Incapacity Determination - Incapacity Requirements for HEN Referral

Created on: 
Oct 06 2015

INCAPACITY REQUIREMENTS FOR REFERRAL TO THE HOUSING AND ESSENTIAL NEEDS (HEN) PROGRAM

WAC 388-447-0001 What are the incapacity requirements for referral to the housing and essential needs (HEN) program?


 Worker Responsibilities

  1. Determine eligibility for ABD cash assistance and HEN Referral by applying the Concurrent Disability/Incapacity Determination process.
  2. Approve incapacity if the individual is ineligible for ABD and meets the non-Progressive Evaluation Process (PEP) criteria outlined in WAC 388-447-0001 (6) (b) through (i).
  3. If the individual is ineligible for ABD and does not meet the non-PEP criteria outline above, determine incapacity by applying the eight step HEN Referral PEP outlined in WAC 388-447-0030 through 388-447-0100.
  4. If the individual meets any of the incapacity requirements outlined in WAC 388-447-0001 (6) (a) through (i), approve HEN Referral for 12 months.

Incapacity Determination - PEP Step I

Created on: 
Oct 21 2014

Review of Medical Evidence 

WAC 388-447-0030 Progressive evaluation process step I - How does the department review the medical evidence required for an incapacity determination?


Worker Responsibilities

  1. Determine if there is sufficient medical evidence:
    1. Review available medical evidence to determine if it is sufficient to determine incapacity. Sufficient medical evidence must meet all requirements outlined in WAC 388-447-0010.
    2. If the medical evidence is not sufficient to determine incapacity, pend the incapacity determination and request additional medical evidence.
  2. Determine Duration:
    1. If the provider's assigned duration is consistent with the medical evidence provided, accept it.
    2. If the provider fails to assign duration or the provider's assigned duration is not consistent with available objective medical evidence, use reference sources and your professional judgment to assign duration. Clearly document what evidence was used to adjust the duration.
    3. When the provider identifies a condition aschronic, you may consider the condition to meet the 90-day duration requirement even when qualified as episodic or in remission if this determination is consistent with the objective medical evidence.
    EXAMPLE

    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.

  3. PEP Step 1 Determination:
    1. If available medical evidence meets the requirements outlined in WAC 388-447-0010 and the duration supported by objective medical evidence is at least 90 days, proceed to PEP Step 2.
    2. If it is clear the impairment will not last at least 90 days or available medical evidence does not meet the requirements outlined in WAC 388-447-0010, deny incapacity.

Incapacity Determination - PEP Step II

Created on: 
Oct 21 2014

PEP Step II - Determining the Severity of mental Impairments 

NOTE: The DSHS 13-865 Psychological/Psychiatric Evaluation form, DOC 13-450 Behavioral Health Discharge Summary, or typed narrative evaluation may be used to assess mental health impairments.

WAC 388-447-0040 Progressive evaluation process step II - How does the department determine the severity of mental impairments?


Clarifying Information

  1. The Short Clinical Scale is no longer used in the mental health community and has been removed from the psychological evaluation form. Any symptom that affects work function and is listed in the DSM IV or DSM V may be listed by the mental health provider.
  2. Only consider symptoms that have an impact on work function when determining incapacity.
  3. See the learning disabilities and deficits chapter when a learning disorder is diagnosed. Most learning disorders aren't incapacitating.
  4. Don’t consider diagnosis and symptoms of alcohol or substance abuse, or dependence, when determining incapacity through the PEP.
  5. Alcohol and substance use information is requested in order to differentiate between substance use and mental health symptoms, and to provide information for the development of a case plan.
  6. A symptom that was not observed by the evaluator may be considered when determining incapacity accepted if consistent with others symptoms of a diagnosis the evaluator observed.

Incapacity Determination - PEP Step III

Created on: 
Oct 21 2014

PEP Step III--Determining the Severity of Physical Impairments 

WAC 388-447-0050 Progressive evaluation process step III - How does the department determine the severity of physical impairments?


Clarifying Information

Compare the severity rating given by the medical evidence provider with the objective evidence.

  1. When it is consistent, accept it.
  2. When it is not consistent,  raise or lower the rating after consulting medical sources and references. You must have clear and convincing reasons for adjusting a provider's severity rating. Always fully explain your clear and convincing reasons for not accepting the provider's rating in your notes.

Incapacity Determination - PEP Step IV

Created on: 
Oct 21 2014

PEP Step IV--Determining the Severity of Multiple Impairments

WAC 388-447-0060  Progressive evaluation process step IV - How does the department determine the severity of multiple impairments?


Worker Responsibilities

Document the cumulative effect (or lack of effect) that multiple impairments have on the basic work activities.

Incapacity Determination - PEP Step V

Created on: 
Oct 21 2014

PEP Step V--Determining Level of Function of Mentally Impaired Individuals in a Work Environment

WAC 388-447-0070 Progressive evaluation process step V - How does the department determine the impact of a mental impairment on my ability to function in a work environment?


Clarifying Information

  1. Cognitive and Social Factors:

    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.

  2. Mental Status Examinations (MSE):

    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.

    1. A standardized MSE includes a series of specific questions designed to assess memory, thought process and content, perception, attention and concentration, judgment, intelligence, insight, and orientation. A standardized MSE should usually be given where psychotic or cognitive problems are indicated in the psychological/psychiatric evaluation. While the Folstein is the most common, many standardized MSE's are available.
    2. A non standardized MSE is not numerically rated and may be documented by indicating the degree to which a person is oriented (e.g.. "O x 3" means a person is normal in the "three spheres" of time, place, and person - or fully oriented) along with more comprehensive observations including assessment of appearance, movement and behavior, affect, mood, speech, thought content and process, cognition, judgment, and insight.
    3. The MSE must be conducted by an authorized provider and included within the psychological/psychiatric evaluation or attached as an addendum.
    4. When used in conjunction with the evaluation, the MSE provides objective information, which should be consistent with the diagnoses and ratings contained in the psychological/psychiatric evaluation.
      1. If the ratings on the psychological/psychiatric evaluation are inconsistent with the MSE, contact the provider for clarification before proceeding.
      2. Some mental status exams use a numeric rating system. For example, a score of 24 or more on the Folstein Mini Mental Status Examination is considered normal.
    EXAMPLE:

    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.

Worker Responsibilities

  1. Ensure an objective MSE accompanies or is included with the psychological/psychiatric evaluation.
  2. If the MSE is not consistent with the evaluation, obtain clarification from the provider.

Incapacity Determination - PEP Step VI

Created on: 
Oct 21 2014

Determining Level of Function of Physically Impaired Individuals in a Work Environment 

WAC 388-447-0080 Progressive evaluation process step VI - How does the department determine the impact of a physical impairment on my ability to function in a work setting?


Clarifying Information

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:

  • Restrictions in seeing or hearing,
  • Allergies,
  • Restrictions in operating dangerous machinery or driving, and
  • Restrictions in working at heights due to dizziness.

Incapacity Determination - PEP Step VII

Created on: 
Oct 21 2014

Evaluating a Client's Capacity to Perform Relevant Past Work

WAC 388-447-0090 Progressive evaluation process step VII - How does the department determine ability to perform past work?


Worker Responsibilities

  1. Enter the age rounded to the nearest full year.
  2. Enter each job from the Social Service Intake, or other available source, considered to be relevant past work.
  3. Use O*NET to get exertion and skill levels for the jobs the client has held.  According to the Department of Labor, O*Net has replaced the Dictionary of Occupational Titles.
  4. Compare the physical and mental requirements for each job with the person's current functional abilities, as identified in Steps V and VI.  If mental or non-exertional physical limitations prevent an individual from performing a job they were formerly capable of doing, indicate that the person cannot do this job and document the specific reason.
    EXAMPLE: A client is advised not to work in high places because of a seizure disorder.  This would prevent the client from returning to past work as a roofer, but the client could perform past work as a retail clerk.
  5. Deny incapacity when a person has recently completed a vocational training or gained work skills that they can currently use to perform a job.
  6. Deny incapacity when a person is able to do relevant past work performed within the past 5 years.
  7. Approve incapacity when a person is 55 years old or older and is unable to perform relevant past work, or has no relevant past work.

Incapacity Determination - PEP Step VIII

Created on: 
Oct 21 2014

Evaluating a Client's Capacity to Perform Other Work.

WAC 388-447-0100 Progressive evaluation process step VIII - How does the department determine ability to perform other work?


Clarifying Information

  1. Completion of high school by attendance in a special education curriculum in the basic academic classes of math, English and writing is considered limited education.  Classes for non-academic reasons such as speech therapy and interpersonal relationships are not to be considered special education or limited schooling.
  2. High school education and above includes a non-English education if it otherwise meets the standards of a U.S.high school education.
  3. Approve incapacity if the individual meets the criteria in the tables in WAC 388-447-0100.

Incapacity Determination - When HEN Referral Eligibility Ends

Created on: 
Dec 01 2015

 

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, 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).

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. However, 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 incapacity requirements outlined in WAC 388-447-0001 (6) (a) through (f) at review.

 

b. "No current medical evidence" means the individual 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 HEN Referral is denied at incapacity review, the disability specialist approves HEN Referral back to the first of the month (not the date medical evidence was received) when: Medical evidence is received within thirty (30) days of the end of the HEN Referral authorization period (in ACES); the delay was not due to the individual’s failure to cooperate; and the medical evidence meets incapacity requirements defined in WAC 388-447-0001.

2. HEN Referral 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.

NOTE: When the disability specialist discovers that an error was made in a prior incapacity decision and the client 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.

3. HEN Referral eligibility ends when the client is found eligible for ABD through the SEP process.

NOTE: While an individual is active on the HEN Referral Program, the disability specialist may conduct a new SEP in the following situations:

a. At the end of the 12 month HEN Referral authorization (incapacity review)

b. 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

c. When additional medical evidence is received within 30 days from an initial ABD denial/ HEN Referral 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 acceptable medical source per WAC 388-449-0010. Due to Standard of Promptness the disability specialist processed the case on 9/15 which denied ABD (due to lack of acceptable medical source) and approved the client for a HEN Referral .

On 10/10 the disability specialist received additional medical evidence that was signed by an 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.

EXAMPLE: At her incapacity review, Jenny was denied ABD and again found eligible for a HEN Referral, for a period of 12 months, based on a completed SEP. Two weeks later, the disability specialist received additional medical evidence indicating potential eligibility for ABD. Because the evidence was received within 30 days of the ABD denial, the disability specialist completed a new SEP to determine ABD eligibility in line with Concurrent Disability/ Incapacity Determination Process.

4. HEN Referral eligibility ends in the event that the client turns age 65, as they are now eligible for ABD per WAC 388-400-0060 (1)(a)(i).

Incapacity Determination - Required Medical Evidence

Created on: 
Oct 21 2014

Purpose: 

This chapter describes medical evidence required for HEN Referral incapacity determinations.

WAC 388-447-0010 What medical evidence do I need to provide?


Clarifying Information 

1. Per WAC 388-447-0010 (5), the Department will cover the cost of obtaining medical evidence necessary to determine incapacity following our published fee schedule if the applicant/recipient is unable to obtain necessary evidence without incurring a cost.

Incapacity Determination - Acceptable Medical Evidence

Purpose:

This section describes acceptable sources of medical evidence for HEN Referral incapacity determinations.

WAC 388-447-0005 What evidence does the department consider to determine incapacity?


 Clarifying Information

  1. Supplemental Medical Evidence may be used to help better understand the client's incapacities and make well-informed incapacity decisions. Supplemental Medical Evidence does not replace Objective Medical Evidence (OME). OME must still be obtained for the Progressive Evaluation Process.

Incapacity Determination - Assignment of Severity Ratings

How Severity Ratings are Assigned for HEN Referral Incapacity 

Clarifying Information

  1. When the provider does not give a severity rating:
    1. Review the medical evidence. Use reference sources, facts present in the medical evidence, and your professional judgment to assign a severity rating that is consistent with the objective medical evidence and severity definitions in WAC 388-447-0020 and 388-447-0040; or
    2. Refer the case to a Medical Consultant for assistance with interpreting the medical information.
  2. When the severity rating given by the provider is supported by the objective findings, accept the rating.
  3. You may adjust the provider's ratings if you have clear and convincing reasons why the rating should be adjusted (e.g. rating is not consistent with the objective medical evidence). If the adjusted rating results in the person having only one impairment with a severity rating less than three, deny incapacity at Step 1 (see WAC388-447-0030).

Incapacity Determination - Chemical Dependency

How alcohol or drug dependence affects an individual's eligibility for medical care services

Clarifying Information

House bill 2082 passed into law and mandates:

  1. Persons who are primarily incapacitated due to alcohol or drug addiction are ineligible for ABD cash and MCS benefits.
  2. Persons who meet incapacity requirements, and who are assessed as in need of drug or alcohol treatment (CD), must participate in treatment as a condition of eligibility for ABD cash, PWA cash, and MCS medical.
  3. The CD treatment requirements and good cause reasons listed in WAC 182-508-0220 are defined in state law (RCW 74.04.005).
  4. An “indication” of chemical dependency includes:
    • A notation of alcohol on breath (AOB) by a medical provider, DSHS staff, or in ACES case notes.
    • Medical or mental health chart notes counseling a client on substance use.
    • Recent legal problems associated with substance use (DUI, etc.)
    • The person states verbally or in writing that they use an illegal substance in any quantity.
    • Concern of the person’s substance use is expressed by family members, friends, etc.
  5. See the Alcohol and Substance Abuse chapter for more information on signs of chemical dependency or abuse.
  6. Chemical dependency assessments are valid for 6 months. If a person is assessed as dependent, no additional assessments are needed for 6 months.

Worker Responsibilities

  1. Determine if a person has an incapacitating impairment that is separate from chemical dependency or abuse per WAC 182-508-0030.
  2. If the person is primarily incapacitated by chemical dependency:
    1. Deny incapacity for applicants and recipients of MCS. 
    2. Encourage the person to engage in CD treatment and provide chemical dependency resource information.
    NOTE: Don’t request a chemical dependency assessment to support an incapacity decision of no clear differentiation. Only refer persons primarily incapacitated by alcohol or drugs for an assessment if they indicate they want to pursue treatment.
  3. If it can be established that a person has a separate incapacitating impairment, and there is an indication of substance abuse or addiction, approve incapacity, and open the ICMS screen “chemical dependency”. Send a form 14-527 MCS Plan letter requiring the client: 1. Sign a DBHR release of information form 14-314. 2. Complete a chemical dependency assessment.
  4. If the person is assessed as dependent and in need of chemical dependency treatment, update the 14-527 MCS plan to require the person to participate and complete treatment as recommended by the certified chemical dependency professional (CDP).
  5. If assessed as dependent, but treatment isn’t recommended because the person isn’t amenable to treatment – this means the person has refused treatment. Send a 14-528 good cause letter and terminate benefits if the person does provide proof a good cause reason listed in WAC 182-508-0220.
  6. Communicate with the CDP if questions arise regarding the level of treatment the person is capable of participating in or if the person has special needs such as a dual diagnosis placement.
  7. If the person is assessed as needing inpatient treatment, but medical treatment prevents the person from entering into inpatient treatment, contact the chemical dependency counselor to request the assessment be updated to recommend outpatient treatment.
EXAMPLE Mike was assessed as dependent with a recommendation for 90 days of inpatient treatment. He was scheduled to enter treatment on September 5th. He calls his social worker and requests he be sent to outpatient treatment because he has visitation with his children on the weekends. The social worker explains Mike must comply with the inpatient treatment requirement. The treatment requirement won’t be changed and Mike will not have good cause if he fails to participate.

Tracking Assessment and CD Treatment

  1. Tracking and verification of compliance with CD assessment through completion of treatment is mandatory for every MCS client with an indication of chemical dependency. You must have a signed form 14-314
  2. Document all tracking and verification actions in the ICMS chemical dependency screen and case notes.
  3. Treatment monitoring and protective payees are mandatory for clients assessed as dependent.

Non compliance and good cause

  1. Send form 14-528 MCS Good Cause letter when verification of CD treatment compliance isn’t received, or if we receive information that the person didn’t complete treatment as recommended.
  2. If there is no response to the good cause letter, assume refusal to cooperate without good cause.
  3. Good cause for non compliance is defined in WAC 182-508-0220. All good cause reasons for failing to participate in CD treatment are temporary. Engage the person in treatment as soon as possible. These are the only acceptable reasons for refusing or failing to complete a chemical dependency assessment or treatment.
    1. We determine physical or mental health impairment, or treatment, prevents participation in treatment:
      1. Based on a review of objective medical information and treatment recommendations.
      2. Impairments must be severe or acute - person can’t ambulate, they are hospitalized or mental health is so unstable as to preclude any participation at this time.
      3. Communicate with the medical or mental health provider regarding status of the person’s condition and engage the person in treatment as soon as possible.
      4. Communicate with the chemical dependency provider about the special physical or mental health needs of the person to see if the person can be accommodated or treated effectively.
    2. Outpatient treatment isn’t available in the county you live in. Cooperating with waiting list procedures is cooperating with treatment. (Must make an assessment appointment and agree to be placed on a waiting list if necessary).
    3. Inpatient chemical dependency treatment. Cooperating with waiting list procedures is cooperating with treatment. (Must make an assessment appointment and agree to be placed on a waiting list if necessary).
  4. Take action on a person’s non-compliance immediately. Don’t wait until the incapacity review.
  5. Terminate assistance using a 14-118 when there isn’t good cause for non compliance.
EXAMPLE Shannon was assessed as dependent with a recommendation for 90 days of inpatient treatment. She was assigned a bed date of August 10th. The social worker did not receive notice that Shannon entered treatment on the 10th and sent a 14-528 good cause letter. Shannon called her social worker and explained that she had been scheduled for knee surgery on September 9th. Shannon provides verification of her surgery date, and the ISW contacts the CD counselor to request the treatment recommendation be changed to outpatient treatment. Her case is changed to require compliance with outpatient treatment. Shannon demonstrated good cause for failing to participate in in-patient treatment, but she must now participate in outpatient treatment.
EXAMPLE Roger was assessed as dependent with a recommendation for 90 days of inpatient treatment. He was scheduled to enter treatment on October 8th. The social worker did not receive notice that Roger entered treatment on the 10th and sent a 14-528 good cause letter. Roger calls his social worker and states he did not enter inpatient treatment because he could not find anyone to take care of his house. Roger doesn’t have good cause for failing to participate or a valid reason for changing the assessment recommendation.
EXAMPLE Sandy was assessed as dependent with a recommendation of outpatient treatment. She was scheduled to start treatment on September 10th. The social worker did not receive notice that Shannon started treatment and sent a 14-528 good cause letter. Sandy called her social worker and explained that she had physical therapy appointments she needed to attend. Sandy provides verification of her physical therapy appointments. They don’t conflict with the CD treatment sessions and that the PT appointments can be rescheduled if a conflict arises. Sandy has not demonstrated good cause for failing to participate in CD treatment and her benefits end September 30th.

Incapacity Determination - Housing and Essential Needs (HEN) Referral- WAC Index

Created on: 
Oct 21 2014

Information and Referral (I&R)

Purpose:

How to provide individuals contacting the department for services with information and referrals to community resources.


Guidelines

1. Information and Referral (I & R) is a service available to all persons who request it from the department regardless of how they make such a request.

2. Resources available to assist the client will vary depending on whether the client is currently receiving services from DSHS.

3. Any staff person can refer the client to a Social Worker for I & R assistance if the staff person cannot directly assist the client by providing either the requested information or referral.

4. Staff should make referrals in an efficient manner that connects the person directly with the resource and eliminates any unnecessary steps or time.

NOTE: Information about local community resources can be found on the web at the Access Washington Resource Directory.

Worker Responsibilities

  1. Discuss the person’s needs with them.
  2. Determine if there are resources within the department or community to meet the client’s needs and make an appropriate referral.
  3. If the person appears to be able to make their own appointment with the resource, give them the information they need to do so. If it appears the person needs help to connect with the resource, provide them with appropriate assistance.
  4. Document the information that you gave to the person (if appropriate) or referrals that were made on the person’s behalf. Make the documentation in the system associated with the program from which the person is receiving services. For example:
Program System
TANF / SFA, RCA, food assistance only ACES, eJAS
ABD cash, MCS ICMS
Non-Recipients Barcode
EXAMPLE

Mary reports family violence issues and requests information and services from the receptionist. The receptionist immediately refers the client to a Social Service Specialist who:

  1. Determines if Mary or her children are in immediate danger.
  2. Conducts an assessment and makes appropriate referrals including to the Family Violence Advocate in the local office.
  3. Based upon the outcome of the assessment either:
    1. Give Mary the information n to assist her with her needs (if it appears she can follow through with needed resources); or
    2. Complete a referral form including the name, address, phone number, directions etc. so that the client can get to the resources on her own.
EXAMPLE

Henry reports his family has no food. His family has applied for food assistance and has an expedited appointment in 3 days. staff may:

  1. Providing Henry with information about local food banks.
  2. Check the Access Washington Resource Directory for information about local food banks and give Henry the address and days and times the food bank is open.
  3. Provide local contacts (such as churches) to assist Henry with obtaining food.

Incapacity Determination - Review of Incapacity

Created on: 
Dec 01 2015

Worker Responsibilities

1. Review incapacity at the end of the 12 month incapacity authorization period. 

  1.  Send the Notice of Information Required for Incapacity Review, DSHS 14-525.
  2. 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).
  3. Ensure the Incapacity Review Notice complies fully with the person’s current Equal Access Plan.
  4. Specify the information needed for the review.
  5. 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.