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.