5101:1-5-20 Disability financial assistance: the determination of a disability.

 

 

 

TO BE RESCINDED

 

5101:1-5-20                 DFA: definitions and determinations of disability.

 

 

 

(A)  If an individual has, appears to have, or alleges to have a physical or mental condition which may limit their ability to work, the CDJFS shall begin developing the medical information necessary for submission to the county medical services section (CMS) for a determination of disability.

 

(B)    Disability for purposes of the DFA program is defined as the inability to do any substantial or gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for not less than nine months. The determination of disability by the CMS is based on SSI disability criteria except for the twelve-month disability requirement.

 

(C)  The disability determination process.

 

(1)   The determination of disability by the CMS is based upon the SSI requirements. The determination of disability by the CMS for potential medicaid may be used to meet the disability determination requirement for the DFA program. The CDJFS should begin the disability determination process by issuing a JFS 07302 "Basic Medical" form to the individual, the individual's legal representative, or to the individual's treating physician for completion by the treating physician. When there may be several treating physicians, a JFS 07302 must be issued to each physician for completion. When an alleged disability or limiting physical factor is a mental impairment, the JFS 07308 "Mental Functional Capacity Assessment" must also be completed, along with the JFS 07302. If a JFS 07302 is sent to a provider for completion, the CDJFS is obligated to pursue and attempt to obtain all available medical evidence and submit the case to the CMS for a determination.

 

(2)    The CDJFS cannot make its own determination of disability based upon the contents of the JFS 07302.

 

(3)   As part of the case development process, the applicant's caseworker (or SSI case manager) must complete fully the JFS 07004 "Social Summary Report for Disability Determination." The caseworker shall send a JFS 07302 and a JFS 07308 (if appropriate) to all treating physicians listed in "Section VIII" of the JFS 07004.

 

(4)    For nonphysician providers listed in "Section VIII" of the JFS 07004, any progress notes, treatment reports, test results and/or other pertinent medical information from these providers should be obtained to augment the medical

 

 

 

information being developed. Caseworker observations of the applicant, listed in "Section X" of the JFS 07004 are a very important source of information for CMS reviewers and should be completed. Caseworkers (or SSI case managers) should obtain any hospital records of the applicant if the individual has been hospitalized or treated in a hospital facility in the three year period prior to the date of the application. If the applicant has not been hospitalized during this period, earlier hospital records should be obtained if the records support the alleged disability.

(5)   When the JFS 07302, JFS 07308, and JFS 07004 have been completed and all readily available medical evidence is gathered, the entire medical case for the individual must be submitted to the CMS for a disability determination. To do this, the JFS 03605 "CDJFS Referral to CMS" must be completed for each medical case being submitted to the CMS. The JFS 03605 must be fully completed. Each case that is submitted to the CMS must be identified by placing the case in a letter-size file folder. The tab of the file folder must include the name (last, first) of the individual and the two-digit county identifier. Cases not containing fully completed and signed required forms as provided in this section and not submitted in the manner previously described will be returned to the CDJFS by the CMS as incomplete.

(6)   There are times during the development of medical information when it may be difficult to obtain the signature of the applicant's treating or consulting physician on the necessary forms and documents. In these situations there may be a nurse or physician assistant or other staff member who has the doctor's "signature authority." Federal regulations and state rules are quite clear that medical evidence from a licensed physician, osteopath, psychologist, and optometrist are the only accepted forms of medical evidence. However, when a physician signature is difficult to obtain and other medical evidence has been gathered which does contain the appropriate signatures, the CDJFS should collect all available medical evidence and submit it to the CMS. The CMS will then weigh all evidence submitted.

(7)    After the CMS has rendered a decision regarding the disability status of the individual, the original medical case submitted to the CMS will be returned to the CDJFS. Medical cases which are approved or deferred by the CMS will be returned immediately. Cases the CMS determined do not meet disability criteria will be retained by the CMS for a period of not less than six months or until the individual has exhausted all state hearing rights. After the individual has exhausted all state hearing rights or after six months have elapsed, the CMS will return the denied case(s) to the CDJFS for filing and maintenance.

(a)     The CDJFS must maintain medical case files in accordance with the

requirements set forth by the county records commissioner or for a period of not less than six years.

(b)    The CDJFS will also review the information provided in this process to determine if an SSI case management referral is appropriate.

(c)       If the CMS determines that the individual meets the disability requirements for DFA, benefits shall be approved if all other eligibility requirements are met.

(d)  Any decision made by the CMS is subject to all hearing and appeal rights in accordance with division level designation 5101:6 of the Administrative Code.

(D)  Individuals who appear to meet medicaid criteria.

(1)     All individuals who appear to meet the aged, blind, or disabled criteria as delineated in rule 5101:1-39-03 of the Administrative Code are to be referred to the social security administration (SSA) to apply for SSI. Additionally, all individuals applying for or in receipt of DFA who appear to meet the blind or disabled criteria delineated in rule 5101:1-39-03 of the Administrative Code shall be referred to the SSI case management program. DFA may be authorized for an individual whose SSI application is pending provided:

(a)   The individual meets all DFA eligibility requirements;

(b)   The individual is not eligible for an interim or advance payment from SSI; and

(c)   The individual complies with the requirements of DFA interim assistance as delineated in rule 5101:1-5-70 of the Administrative Code.

(2)   Each applicant for or recipient of DFA who, in the judgment of the ODJFS or the CDJFS might be eligible for SSI, must, as a condition of eligibility for DFA, apply for SSI if directed by the ODJFS or the CDJFS. The CDJFS shall also require the applicants or recipients, as a condition of eligibility for DFA, to pursue reconsiderations and appeals of the social security administration decisions that deny the individuals SSI benefits.

Effective:                                                     01/01/2005

R.C. 119.032 review dates:                         10/14/2004

CERTIFIED ELECTRONICALLY

Certification

12/20/2004

Date

Promulgated Under:                           111.15

Statutory Authority:                           5115.03

Rule Amplifies:                                  5115.01, 5115.03

Prior Effective Dates:                         9/3/77, 1/1/81, 6/1/84, 9/6/84, 8/1/85, 7/1/87 (Emer.),

8/3/87, 1/1/88, 3/28/88, 4/1/89 (Emer.), 4/24/89,

4/1/90, 10/1/90, 10/1/91 (Emer.), 12/20/91, 4/1/92 (Emer.), 6/30/92, 12/22/92 (Emer.), 3/20/93, 10/30/95, 7/1/98, 07/01/2003