Incapacity Determination - When HEN Referral eligibility ends
DSHS Home Page
 
Search     for:


Incapacity Determination - When HEN Referral eligibility ends


Revised December 31, 2013



WAC 388-447-0110When does my eligibility for referral to the housing and essential needs (HEN) program end?

WAC 388-447-0110

WAC 388-447-0110

Effective January 1, 2014

WAC 388-447-0110 When does my eligibility for referral to the housing and essential needs (HEN) program end?

  1. If we determine you are incapacitated and you meet the eligibility requirements in WAC 388-400-0070, you are eligible for referral to the housing and essential needs (HEN) program for a maximum period of twelve months. This is your incapacity authorization period.
  2. Your HEN referral eligibility stops at the end of your incapacity authorization period unless you provide current medical evidence that demonstrates there was no material improvement in your impairment. No material improvement means that your impairment continues to meet the incapacity criteria detailed in WAC 388-447-0001.
  3. The medical evidence must meet the criteria defined in WAC 388-447-0010.
  4. We use medical evidence received after your incapacity authorization period has ended when:
    1. The delay was not due to your failure to cooperate;
    2. We receive the evidence within thirty days of the end of your incapacity authorization period; and
    3. The evidence meets the incapacity criteria in WAC 388-447-0001.
  5. Even if your condition has not improved, you aren't eligible for referral to the HEN program when:
    1. We receive current medical evidence that doesn't meet the incapacity criteria in WAC 388-447-0001; or
    2. We determine the prior decision that your condition met incapacity requirements was incorrect because:
      1. The information we had was incorrect or not enough to show incapacity; or
      2. We didn't apply the rules correctly to the information we had at that time.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Worker Responsibilities

1. Authorize incapacity for 12 months for all individuals who meet the incapacity requirements outlined in WAC 388-447-0001 (6) (a) through (f). Review incapacity at the end of the 12 months incapacity authorization period.


NOTE:

Only authorize a new medical evaluation after determining the person’s current chart notes are insufficient to determine incapacity.


     2. Send the Notice of Information Required for Incapacity Review, DSHS14-525.

a.  Provide Adequate Notice: Send the 14-525 between six and eight weeks prior to the incapacity review date (around the 10th of the month prior to the incapacity review month).

b.  Ensure the Incapacity Review Notice complies fully with the person’s current Equal Access Plan. 

c.  Specify the information needed for the review.

d.  Establish the deadline for the person to provide current medical evidence as the 10th of the month of incapacity review, or the first business day following the 10th if the 10th falls on a holiday or weekend.


NOTE: Benefits cannot be terminated unless adequate notice is provided. Adequate Notice includes both a timely 14-525 and full compliance with the person’s current Equal Access Accommodation Plan.

EXAMPLE

Jerry transfers into the CSO during his Incapacity Review month. The worker reviews the case record and discovers Jerry was not sent a 14-525 and therefore did not receive adequate notice. After reviewing his case record and Equal Access plan. the worker sends Jerry an appropriate 14-525, The worker notifies financial that a one month extension is necessary due to lack of adequate notice using the 14-118.


Review Incapacity

1. HEN Referral eligibility ends at the end of the incapacity authorization period if current objective medical evidence shows there has been material improvement to the individual's impairment, if there was a previous error, or if there is no current medical evidence:

a. "Material improvement" means the impairment no longer meets the incapacity requirements outlined in WAC 388-447-0001 (6) (a) through (f).

b. "Previous error" means that the previous incapacity termination was incorrect because:

i. The information we had was incorrect or not sufficient to determine incapacity; or

ii. Program rules were not applied correctly based on the information available at the time.

c. "No current medical evidence" means the individual failed to provide the medical evidence necessary to determine incapacity outlined in WAC 388-447-0010.


No Material Improvement


NOTE:

Willie was previously determined incapacitated based on a physical impairment with a "moderate" severity rating. The new medical evaluation indicates that condition has healed so impairment no longer exists, but Willie has another, previously unclaimed physical problem. The second impairment has a "moderate" severity rating but does not qualify Willie according to the PEP. There is material improvement because there is no impairment that meets PEP criteria at review.


NOTE:

Karen has a physical impairment that permanently limits her to light work. She has successfully completed vocational rehabilitation and the vocational counselor verified Karen is now able to perform some light work jobs. While Karen's physical impairment will not change, material improvement is established through denial of incapacity at Step 7.


Previous Error


NOTE: "Previous error" does not necessarily mean that mistakes were made in the original decision, rather the outcome would have been to deny incapacity if all relevant information had been available and reviewed at the time of the decision.

When you discover that an error was made in a prior incapacity decision and the person should not have been previously approved,  AND the current available evidence indicates that the person does not qualify, deny incapacity. Document how the error makes the person ineligible. If the available medical evidence does not clearly indicate a lack of incapacity, document the error and proceed with reviewing incapacity.

No Current Medical


NOTE: There must be current medical evidence supporting continued incapacity before authorizing any MCS benefits beyond the review month.

  1. When you receive medical evidence, complete the incapacity review before the 15th so that if there is a denial the person receives adequate notice.
  2. If no current medical evidence is received by the first business day following the due date for medical evidence (usually the 11th or the first business day following), issue a 14-118 to deny incapacity.
Modification Date: December 31, 2013