Dale is diagnosed with chronic rapid-cycling bipolar disorder. The most significant impairment on work activities is due to psychotic symptoms which, according to his psychiatrist, are episodic in nature. Although not currently psychotic, he has had 3 major psychotic episodes within the last 2 months. He has not yet been stabilized on medication. Accept this as meeting the 90-day duration requirement.
Revised on: March 28, 2018
PEP Step III--Determining the Severity of Physical Impairments
Compare the severity rating given by the medical evidence provider with the objective evidence.
PEP Step IV--Determining the Severity of Multiple Impairments
Document the cumulative effect (or lack of effect) that multiple impairments have on the basic work activities.
PEP Step V--Determining Level of Function of Mentally Impaired Individuals in a Work Environment
Approvals at PEP step V based on cognitive and social factors are intended for individuals who are unable to perform the basic work functions necessary to learn the basic skills of a job, perform to an employer’s expectations, or behave in a manner acceptable in a work place.
The purpose of a Mental Status Examination (MSE) is to assess the presence and extent of a person's mental impairment. The MSE may suggest specific areas for further testing or specific types of required tests. There are standardized and non-standardized Mental Status Examinations.
The cognitive ratings on the DSHS13-865 are marked to indicate the client cannot follow simple one and two-step instructions. However, the client had no difficulty following instructions specifically developed to test this function - folding a piece of paper and placing it on the floor. Contact the provider and request clarification. The two pieces of information must be consistent to accurately reflect the status of the person being evaluated.
Determining Level of Function of Physically Impaired Individuals in a Work Environment
Consideration of exertionally-related or non-exertional limitations may be crucial either in eliminating specific types of past work or in accurately assigning the level of work the person can currently perform. Non-exertion limitations may include:
Evaluating a Client's Capacity to Perform Relevant Past Work
Evaluating a Client's Capacity to Perform Other Work.
Revised on: February 23, 2023
1. HEN Referral program eligibility ends at the end of the incapacity authorization period if current objective medical evidence shows there has been material improvement to the client's impairment, 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. "No current medical evidence" means the client failed to provide the medical evidence necessary to determine incapacity outlined in WAC 388-447-0010.
i. When the Disability Specialist receives medical evidence, they complete the incapacity review before the 15th whenever possible, to ensure the client receives advance notice in the event of a denial.
ii. 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), the Disability Specialist issues a 14-118 to deny incapacity.
NOTE: If medical evidence is received after the end of the month in which the incapacity review is due, the disability specialist notifies the client that they must reapply for ABD and complete a financial eligibility interview. If the client meets Disability or Incapacity criteria based on medical evidence received prior to the new application, the approval date goes to the date financial eligibility was determined.
EXAMPLE: Jamie has an incapacity review for HEN Referral due 1/31. They submit medical evidence on 2/8. The disability specialist notifies them that they need to reapply for benefits. A new application is received 2/16 and the financial eligibility interview is completed. The Disability Specialist completes a new SEP approves HEN Referral starting 2/16.
2. HEN Referral program eligibility ends if there was a previous error.
a. "Previous error" means that the previous incapacity determination was incorrect because:
i. The information the department 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.
3. HEN Referral program eligibility ends when the client is found eligible for ABD through the SEP process.
a. While a client is active on the HEN Referral program, the Disability Specialist may conduct a new SEP in the following situations:
i. At the end of the 12 month HEN Referral program authorization (incapacity review);
ii. When the client has reapplied for the ABD cash program, and has been referred by financial to the Disability Specialist for a new disability determination; or
iii. When additional medical evidence is received within 30 days from an initial ABD denial/ HEN Referral program approval.
EXAMPLE: Doug applied for ABD cash benefits on 8/1 and completed an intake with a Disability Specialist that same day. The medical evidence received and reviewed by the Disability Specialist was not signed by an ABD “acceptable medical source” per WAC 388-449-0010. Due to Standard of Promptness the Disability Specialist processed the case on 9/15. The case denied ABD (due to lack of “acceptable medical source”), but met all eligibility requirements under WAC 388-400-0070, and approved the client for the HEN Referral program.
On 10/10 the Disability Specialist received additional medical evidence that was signed by an ABD “acceptable medical source.” Because the new medical information was received within the 30 day reconsideration period from the initial ABD denial (WAC 388-406-0065), the Disability Specialist completed a new SEP which subsequently found the client eligible for ABD.
4. HEN Referral program eligibility ends when the client turns age 65, as they are now eligible for ABD per WAC 388-400-0060 (1)(a)(i).
Revised on: March 23, 2018
We use symptoms and a diagnosis of a substance use disorder (SUD) when determining incapacity.
An SUD is classified as a mental disorder and must be contained in the current Diagnostic and Statistical Manual of Mental Disorders (DSM).
A diagnosis of an SUD must be from an “acceptable medical source” listed in WAC 388-447-0005.
Once an “acceptable medical source” has established a diagnosis, the Disability Specialist can use “supplemental medical evidence” (e.g. from a chemical dependency professional) and “other evidence” (e.g. public and private agencies, personal observation, etc.) as supporting documentation as needed.
In addition to a diagnosis of a SUD, a client must meet all requirements under WAC 388-400-0070 (e.g. determined incapacitated via the PEP) to be eligible for the HEN Referral Program.
Revised January 14, 2014
INCAPACITY AND MEDICAL EVIDENCE REQUIREMENTS
WAC 388-447-0001 What are the incapacity requirements for referral to the Housing and Essential Needs (HEN) program?
WAC 388-447-0005 What evidence does the department consider to determine incapacity?
WAC 388-447-0010 What medical evidence do I need to provide?
WAC 388-447-0020 How does the department assign severity ratings to my impairments?
PROGRESSIVE EVALUATION PROCESS
WAC 388-447-0030 PEP Step I - How does the department review the medical evidence for an incapacity determination?
WAC 388-447-0040 PEP Step II - How does the department determine the severity or mental impairments?
WAC 388-447-0050 PEP Step III - How does the department determine the severity of physical impairments
WAC 388-447-0060 PEP Step IV - How does the department determine the severity of multiple impairments?
WAC 388-447-0070 PEP Step V - How does the department determine the impact of a physical impairment on my ability to function in a work setting?
WAC 388-447-0080 PEP Step VI - How does the department determine the impact of a physical impairment on my ability to function in a work setting?
WAC 388-447-0090 PEP Step VII - How does the department determine ability to perform past work?
WAC 388-447-0100 PEP Step VIII - How does the department determine ability to perform other work?
TERMINATION OF HEN REFERRAL
WAC 388-447-0110 When does my eligibility for referral to the Housing and Essential Needs (HEN) program end?
1. Review incapacity at the end of the 12 month incapacity authorization period.