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

Revised on: March 28, 2018

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


Clarifying Information

  1. Any symptom that affects work function and is contained in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) 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.
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.

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 Program Eligibility Ends

Revised on: March 28, 2018

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).

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 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 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 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.

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 client does not qualify, deny incapacity. Document how the error makes the person ineligible.

 

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.

EXAMPLE: At Jenny’s incapacity review, the Disability Specialist denied ABD and reapproved the HEN Referral program 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 we received the evidence within 30 days of the ABD denial, the Disability Specialist completed a new SEP to determine ABD eligibility in line with the Concurrent Disability/ Incapacity Determination Process.

 

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).

Incapacity Determination - Acceptable Medical Evidence

Revised on: March 23, 2018

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?


 Clarifying Information- WAC 388-447-0005

  1. A diagnosis of a medically determinable impairment must be from an “acceptable medical source” as defined in WAC 388-447-0005. The diagnosis must be supported by objective medical evidence described in WAC 388-447-0010 and be based on an examination within 5 years of the application date.
  2. After a diagnosis is established, we can use “supplemental medical evidence” as current evidence.
  3. Once we have a diagnosis and current medical evidence, we may include “other evidence” as supporting documentation.

Clarifying Information- WAC 388-447-0010

  1. We use symptoms and a diagnosis of a substance use disorder (SUD) when determining incapacity.

    1. An SUD is classified as a mental disorder and must be contained in the current Diagnostic and Statistical Manual of Mental Disorders (DSM).

    2. A diagnosis of an SUD must be from an “acceptable medical source” listed in WAC 388-447-0005.

      1. 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.

    3. 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.

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

Created on: 
Oct 21 2014

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.