WAC 388-448-0160 When do my general assistance benefits end?
The maximum period of eligibility for general assistance is twelve months before we must review additional medical evidence. We use medical evidence and the expected length of time before you are capable of gainful employment to decide when your benefits will end.
Your benefits stop at the end of your incapacity period unless you provide additional medical evidence that demonstrates during your current incapacity period that there was no material improvement in your impairment. No material improvement means that your impairment continues to meet the progressive evaluation process criteria in WAC 388-448-0010 through WAC 388-448-0110, excluding the requirement that your impairment(s) prevent employment for ninety days.
Additional medical evidence must meet all of the criteria defined in WAC 388-448-0030.
We use additional medical evidence received after your incapacity period had ended when:
(a) The delay was not due to your failure to cooperate; and
(b) We receive the evidence within thirty days of the end of your incapacity period; and
All Social Workers working with individuals who are potentially eligible for SSI must ensure the IARA is signed, dated, and filed timely with the Social Security Administration.
Send the Notice of Information Required for Incapacity Review, DSHS 14-217, to the person. You must:
Send the 14-217 between six and seven weeks prior to the incapacity review date (around the 10th of the month prior to the incapacity review month),
Specify the information needed for the review, and
Include a deadline for providing the information. The deadline is the 10th of the month of incapacity review, or the first business day following the 10th if the 10th of the month falls on a holiday or weekend.
If the person has seen the provider within 45 days prior to the month of incapacity review, obtain copies of chart notes and a narrative summary.
Authorize a new medical evaluation if the person's medical records are insufficient to complete the PEP.
When reviewing incapacity, determine if there was a previous error. If there was an error:
Assess how the error affected the previous incapacity determination,
Decide if the person remains incapacitated, and
Let the Financial Worker know if there is a potential overpayment.
When you discover that an error was made in a prior incapacity decision and the person should not have been previously approved AND the 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.Previous Error
EXAMPLE
A person's incapacity was originally approved per WAC 388-448-0001 (2) (in-patient to out-patient treatment for mental disorder). When reviewing the case and preparing to notify the person about the need for an incapacity review, you discover that the diagnosis was "drug-induced psychosis" and the discharge plan was for chemical dependency follow-up care at the local community health agency. The agency provides both behavioral health and chemical dependency treatment. The rule was applied in error because the person was not participating in out-patient mental health treatment and the person is ineligible per WAC 388-448-0010 (4) as their incapacity is solely related to substance abuse. Explain on the 14-118 the reason for the denial and indicate to the Financial Worker that there may be an overpayment.
EXAMPLE
At incapacity review, you discover that the previous PEP incorrectly approved incapacity at Step 5 when the person did not meet the social factors criteria. The correct action would have been to refer the case to the Administrative Review Team (ART). The current findings identify the same impairment and the functional limitations do meet the WAC for approval at Step 5. It is not possible to determine what the ART might have decided and the case currently qualifies with no indication of material improvement. Document that an error was found but do not deny for previous error. Continue the PEP to determine if the person is currently incapacitated. There is no potential overpayment established.
EXAMPLE
Incapacity was approved based on a physical exam and chest X-ray interpretation by family physician. A cardiologist conducted a follow-up exam. You use the specialist's additional findings and evaluation of the previous evidence to complete a new PEP. The decision is that the impairment currently is not incapacitating and the original decision would have been to deny if the additional information had been available at that time. "Previous error" does not mean that mistakes were made in the original decision, only that the outcome would have been to deny incapacity if the additional facts had been available at the time. The Social Worker explains these details on the DSHS 14-118 sent to financial to close the case, but there is no potential overpayment established.
Receiving Medical Records
NOTE:
When the medical evidence meets criteria WAC 388-448-0160 (4) (a-c) above, benefits are re-opened to the first of the month after incapacity ended. There will NOT be a loss of benefits to the person in this situation.
Decide if the medical evidence provided is:
From an acceptable source of primary medical evidence;
Based on an evaluation of the medical condition within 45 days of the incapacity review, and
There must be current medical evidence supporting continued incapacity before authorizing any GA benefits beyond the review month.
When you receive medical evidence, complete the incapacity review before the 15th so that if there is a denial the person receives adequate notice.
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.
A decision denying incapacity at review means there is material improvement.
When there is no material improvement in the person's incapacity, use the information provided for the review or medical treatment references to decide the next incapacity review date.
EXAMPLE
Susan submits a psychological evaluation for her incapacity review that shows the global illness severity rating on the short clinical rating scale decreased from "marked" to "moderate" and four out of five of the other symptoms previously rated "moderate" are now rated "mild." The narrative comments are that Susan is taking and responding to medication but has yet to show significant improvement in functioning. A comparison of the cognitive and social functional limitation scores between the current and previous evaluations shows only a slight improvement in functioning (score was 16 and is now 15) and continues to meet criteria to approve at Step 5. In this case, material improvement has not been established.
EXAMPLE
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.
EXAMPLE
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 6.
EXAMPLE
Robert has a mental impairment previously confirmed as chronic and of "marked" severity. His case plan was to participate in mental health treatment and vocational rehabilitation. At incapacity review, the therapist's evaluation is that Robert's condition remains chronic but his symptoms and behavior have been stabilized to a global severity of "moderate" with two mild and three moderate limitations on social functioning. However, Robert left school in the 10th grade and has no relevant work experience. His vocational counselor states that Robert needs three more months of skills training to finish his rehabilitation plan and meet employer requirements. While the medical evidence indicates some improvement in his impairment, material improvement has not been shown.
If you become aware that the person has returned to work, obtain the following information:
Name of employer,
Employment start date, and
Job title and specific duties.
Notify financial services of the person's employment.
If the amount of earnings after allowable deductions exceeds the payment standard, financial services will determine that the person is financially ineligible for GA benefits and they will send a termination notice to the person.
If the person is still financially eligible, you must determine if the person is gainfully employed as defined in WAC 388-448-0010 (1). Focus on the person's ability to meet the job duties as expected over time. Special circumstances means the person did not have to compete for the job or the employer goes beyond what would be considered reasonable accommodation under the Americans with Disabilities Act to enable the person to get or keep the job.
If you decide the person is gainfully employed or has the capability for gainful employment, deny incapacity.
Full Time School Attendance
NOTE:
Full-time school attendance does not by itself mean a person is capable of gainful employment. The pressures and demands of attending school are usually under the control of the student while the pressures and demands of a job are usually under the control of the employer.
Assess the mental and physical demands of the school program and compare these to the mental and physical requirements of employment with the individual's medical profile.
Resolve any conflicts between these with the medical treatment provider, and document the conversation.
After assessing the person's capabilities, alter the incapacity decision, case plan, and treatment and referral monitoring as appropriate.
EXAMPLE
During Janet's incapacity review, her Social Worker discovers that she is enrolled in college studying to become a registered nurse. The expectations of the program include attendance at and participation in lab three full days per week, class attendance two full days per week, with an expected level of performance for both lab and class work. Failure to meet the expectations would result in Janet's dismissal from the program. In this example, the pressures and demands of attending school are not under the control of the student. Janet is able to meet all of the expectations of this school program, and could be considered to be employable.
The next step in this case is to compare the demands of the program with her medical profile. Janet has a diagnosis of bipolar disorder. Her cognitive factor limitations (ability to learn new tasks, exercise judgment and make decisions, and perform routine tasks) were rated moderate and marked during her most recent psychological evaluation. This profile is inconsistent with her successful performance in the nursing program.
The information regarding her progress in the nursing program was shared with the medical provider. The provider agreed that Janet's school performance indicated higher ability to function than previously expected and that she is capable of being employed.
Incapacity should be denied in this case.
EXAMPLE
Oscar is enrolled in the local community college, taking liberal arts courses including history, English, and basic math. The expectations of the college program are that he maintains a certain GPA level in order to continue enrollment. Oscar attends class sporadically, takes his exams, and maintains the minimum GPA as required for continued enrollment. Poor performance in classes will not result in Oscar's dismissal. In this example, the pressures and demands of attending school are under the control of the student. Oscar's school attendance by itself cannot be the basis for determining that he is employable.
The next step is to compare the person's school attendance and performance with his medical profile. Oscar's psychological evaluation reflects diagnoses of anxiety disorder and depression. The cognitive factors are rated mild to moderate with social factors rated moderate to marked. His medical profile appears to be consistent with his level of performance at the community college. It is decided that Oscar is not employable.
However, at this point, you should review the case plan to determine whether Oscar should be required to receive training or services that would lead to employment. Vocational education or DVR services may be appropriate at this time. Modify the case plan accordingly.
During the previously established incapacity period, GA benefits may stop because of other eligibility changes such as leaving the state, becoming incarcerated, etc. You need to decide whether to use a previous determination to establish incapacity, or to request additional medical evidence for a new incapacity decision.
Assess whether the person presents the same impairment(s) as before.
When the presenting impairments are the same, consider the possibility of significant change in the impairment or its effects since the previous decision.
When the previous impairments are the same, and there is no indication of a possibility of significant change, accept the previously established incapacity period.
When there is an indication of significant change or a new impairment, obtain new medical evidence for new incapacity decision.
EXAMPLE
Melissa was previously approved for GA-U for a period of six months, based on a diagnosis of depression. Her assistance was closed two weeks after approval because she left the state. She has now returned to the state, and there were two months left of her incapacity period. She has reapplied and is financially eligible. During your interview with Melissa, she relates that she has been taking her medication, paid for by her mother. She indicates she is feeling somewhat better, but is still depressed. In this case, because indications are that there has been some improvement, you should obtain a new psychological evaluation to decide if she is incapacitated.
EXAMPLE
Bob was previously approved for GA-U benefits and then GA-X. His incapacitating conditions were degenerative disc disease and cirrhosis of the liver. Bob was working with the SSI facilitator, but then was in jail for 6 months. He has now been released from jail and returns to the CSO to reapply for benefits. He has 6 months left in his initial incapacity eligibility period. He has been determined financially eligible for General Assistance. During the interview, you discover that he has not had any treatment for his impairments while in jail, and has not received any training. Use the previous Incapacity Decision to approve incapacity for 6 months.
WAC 388-448-0180
WAC 388-448-0180
Effective May 1, 2004
WAC 388-448-0180 How do we redetermine your eligibility when we decide you are eligible for general assistance expedited Medicaid (GAX)?
The maximum period of eligibility for GAX is twelve months before we must review additional medical evidence. If you remain on GAX at the end of the twelve-month period, we determine your eligibility using current medical evidence.
If your application for SSI is denied, and the denial is upheld by an SSI/SSA administrative hearing before the end of the twelve-month incapacity period, we change your program eligibility from GAX to GA and adjust the incapacity review date to be sixty days after the administrative hearing date.
Use DSHS 14-118, Incapacity Decision to notify financial services of the decision.
For incapacity approvals:
Create a new GA Case Plan and give a copy to the person. For the most effective plan, meet with or phone the person to assess what the new plan should be.
Complete the 14-332, Disability Assessment. Within ICMS, the Disability Assessment may be completed at the end of the PEP or by itself. If it indicates need for a GAX / SSI facilitation referral, follow the procedures in SSI Facilitation section D.General Assistance - Expedited Medicaid.
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Modification Date: July 25, 2008
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