WAC 182-508-0160 When medical care services benefits end.
(1) The maximum period of eligibility for medical care services (MCS) is twelve months before the agency or the agency's designee must review incapacity. The agency or the agency's designee uses current medical evidence and the expected length of time before the individual will be capable of gainful employment to decide when MCS benefits will end.
(2) The individual's benefits stop at the end of the individual's incapacity period unless the individual provides additional medical evidence that demonstrates during the current incapacity period that there was no material improvement in the individual's impairment. No material improvement means that the individual's impairment continues to meet the progressive evaluation process criteria in WAC 182-508-0015 through 182-508-0110, excluding the requirement that the individual's impairment(s) prevent employment for ninety days.
(3) The medical evidence must meet all of the criteria defined in WAC 182-508-0030.
(4) The agency or the agency's designee uses medical evidence received after the individual's incapacity period had ended when:
(a) The delay was not due to the individual's failure to cooperate; and
(b) The agency or the agency's designee receives the evidence within thirty days of the end of the individual's incapacity period; and
(c) The evidence meets the progressive evaluation process criteria in WAC 182-508-0015 through 182-508-0110.
(5) Even if the individual's condition has not improved, the individual isn't eligible for MCS when:
(a) The agency or the agency's designee receives current medical evidence that doesn't meet the progressive evaluation process criteria in WAC 182-508-0035 through 182-508-0110; and
(b) The agency or the agency's designee's prior decision that the individual's incapacity met the requirements was incorrect because:
(i) The information the agency or the agency's designee had was incorrect or not enough to show incapacity; or
(ii) The agency or the agency's designee didn't apply the rules correctly to the information it had at that time.
When you get information that affects the person's employability.
If there was an error in the previous incapacity determination.
Decide what information is needed to complete the review by examining the person's medical records and treatment progress.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.
NOTE:
Only authorize a new medical evaluation after determining the person’s current chart notes are insufficient to determine incapacity.
3. Send the Notice of Information Required for Incapacity Review, DSHS14-525.
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).
Ensure the Incapacity Review Notice complies fully with the person’s current Equal Access Plan.
Specify the information needed for the review.
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.
When reviewing incapacity, determine if there was an error in the previous incapacity decision . If there was an error:
Assess how the error affected the previous incapacity determination.
Decide if the person remains incapacitated.
Let the Financial Worker know if there is a potential overpayment.
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 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 errorand proceed with reviewing incapacity.
EXAMPLE
A person's incapacity was originally approved per WAC 182-508-0010 (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 182-508-0015 (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
Incapacity was approved based on a physical exam and chest X-ray interpretation by a family physician. A cardiologist conducted a follow-up exam and based on the specialist's findings the person’s impairments aren’t incapacitating and the original decision would have been to deny if the specialist’s information had been available. Explains the details for denial on the DSHS 14-118 sent to financial to close the case.
Receiving Medical Records
NOTE:
When the medical evidence meets criteria WAC 182-508-0160 (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.
There must be current medical evidence supporting continued incapacity before authorizing any MCS 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
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 7.
EXAMPLE
Robert has a chronic mental impairment and was determined to be incapacitated based on global assessment of functioning (GAF) 45 (marked severity). At incapacity review, the psychologist’s evaluation states 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.
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 person is still financially eligible, you must determine if the person is capable of gainful employment.
School Attendance
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
Janet is studying to become a registered nurse. The expectations of the nursing 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 will result in dismissal from the program. In this example, the pressures and demands of attending school aren’t under the control of the client. Janet is able to meet all of the expectations of this school program despite her diagnosis of bipolar disorder, and isn’t incapacitated.
EXAMPLE
Oscar is taking liberal arts courses at a community college. Oscar attends class sporadically due to his anxiety and depression symptoms, but maintains the minimum GPA as required for continued enrollment. In this example, the pressures and demands of attending school are under the control of the client. Oscar's school attendance by itself cannot be the basis for determining that he is employable. Oscar also has physical impairments that limit him to light work and it is determined he meets incapacity requirements at this time, but a referral to DVR may be appropriate.
