5160:1-3-02.9 Medicaid: disability determination process.

 

 

 

5160:1-3-02.9              Medicaid: disability determination process.

 

 

 

(A)This rule addresses the process of determining disability for medicaid eligibility purposes.

 

(B)Definitions.

 

(1)"Administrative  agency,"  for  the  purpose  of  this  rule,  means  the  county department of job and family services (CDJFS).

 

(2)"Continuing disability review" is the process by which the DDA determines whether the individual continues to meet the disability criteria for medicaid eligibility. The DDA will conduct a continuing disability review, in accordance with SSA policy, for an individual who was previously approved for disability or blindness by the DDA but whose initial social security disability application is still pending.

 

(3)"Current medical information" means medical records that originated within eighteen months of the date of initial application or continuing disability review.

 

(4)"Deferred" means that the disability packet contains an incomplete or insufficient amount of current medical information for the DDA to approve, deny or continue the disability or blindness claim.

 

(5)"Disability begin date" means the date the individual is otherwise eligible for medicaid and meets the limiting physical factor.

 

(6)"Disability determination" is the process by which the DDA determines whether the individual meets the social security administration's definition of "blind" or "disabled" for medicaid eligibility. The DDA determines blindness and disability in accordance with SSA policy.

 

(7)"Disability packet" consists of all required forms specified in paragraph (C) of this rule and all available current medical information to support the individual's disability claim. The disability packet is submitted by the administrative agency to the disability determination area (DDA) for a disability determination.

 

(8)"Disability review date" means the date, determined by the DDA, that the individual's current disability approval will expire.

 

(9)"Limiting physical factor" is a non-financial eligibility criterion consisting of a physical or mental characteristic or impairment, or a combination of physical or mental characteristics or impairments, that may limit the individual's ability to work. An individual meets the limiting physical factor by meeting the criteria of age, blindness or disability as set forth in rule 5160:1-3-02 of the Administrative code.

 

 

(10) "SSA disability benefits" are disability benefits provided to an individual and authorized by the social security administration (SSA) under Title II and/or Title XVI of the Social Security Act (as in effect October 1, 2014).

(C)Administrative agency responsibilities. The administrative agency shall:

(1) Determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5160:1-1 through 5160:1-6 of the Administrative Code.

(2) Determine the limiting physical factor is met and shall not submit a disability packet to the DDA when the individual:

(a) Is sixty-five years of age or older; or

(b) Has been approved for SSA disability benefits for the individual's own disability or blindness; or

(c) Has been determined to need a skilled or intermediate level of care (LOC) in accordance with chapter 5160-3 of the Administrative Code. When it is determined that the individual no longer needs a skilled or intermediate LOC, the limiting physical factor is no longer met.

(3) Determine the limiting physical factor is not met and shall submit a disability packet to the DDA for a disability determination when the individual's only potential medicaid eligibility is for a category that requires a disability determination, and the individual:

(a) Alleges  or  appears  to  have  a  physical  or  mental  impairment  or combination of impairments that may limit his or her ability to work;

(b) Alleges or appears to be blind; or

(c) Has an application for SSA disability benefits pending with the SSA.

(4) Determine the limiting physical factor is not met and shall submit a disability packet to the DDA for a disability determination when the individual is potentially eligible for alien emergency medical assistance (AEMA) and requires a disability determination in accordance with rule 5160:1-1-91 of the Administrative Code.

(5) Presume the limiting physical factor is met and shall also submit a disability packet to the DDA for a disability determination when:

(a) The individual or another person who is applying on behalf of the individual alleges, or the individual appears to have at least one of the specific impairments or conditions meeting the presumptive disability

criteria set forth in rule 5160:1-3-02 of the Administrative Code; or

(b) The individual is determined to have a presumptive disability by the SSA and has an application for SSA disability benefits pending.

(6) Upon request, assist the individual with obtaining medical documentation to support the disability or blindness claim, including, if necessary, the use of administrative funds to assist the individual with receiving a medical, psychological or eye examination to determine whether the individual is blind or disabled.

(7) Obtain and/or assist the individual in obtaining all available current medical information that pertains to the individual's alleged impairment(s) or combination of impairments, as well as any other information requested by the DDA, and submit it in the disability packet. This includes existing medical information, tests, services or records from other entities such as the SSA, opportunities for Ohioans with disabilities, workers' compensation, etc.

(8) Provide the forms listed in this paragraph to the individual, the individual's legal representative, another person applying on behalf of the individual, or the treating physician(s).

(a) ODM 07302 "Basic Medical" (rev. 07/2014);

(b) ODM 07308 "Mental Functional Capacity Assessment" (rev. 07/2014) when the individual has or appears to have a mental impairment; and

(c) ODM 03606 "Physician Certification of Medication Dependency" (rev.

07/2014) when applicable.

(9) Complete   the   ODM   07004   "Social   Summary   Report   for   Disability Determination" (rev. 07/2014).

(10) Obtain signed copies of form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 07/2014) from the individual for all providers who have or may have current medical information.

(11) Complete the ODM 03605 "CDJFS Referral to DDU" (rev. 07/2014) using current medical information.

(12) Submit the disability packet to the DDA for a disability determination and for a continuing disability review.

(13) When the DDA has deferred a disability determination, and the administrative agency is unable to obtain all of the requested additional medical information, resubmit the initial disability packet and any additional information to the

DDA for a final decision.

(14) Submit the following information to the DDA for the individual's continuing disability review prior to the disability review date:

(a) A new disability packet. The disability packet shall contain all required forms specified in paragraph (C) of this rule and all available current medical information to support the disability claim;

(b) The previously approved disability packet; and

(c) Any other information requested by the DDA.

(D)Individual responsibilities.

(1) When the individual alleges a disability or blindness, the individual shall assist the administrative agency with obtaining all available current medical information that supports the disability or blindness claim.

(2) As a condition of medicaid eligibility, the individual is required to:

(a) Apply for any SSA disability benefits to which the individual may be entitled; and

(b) File a timely appeal of any denial of SSA disability benefits that happens either while the initial disability determination is still being adjudicated or during the individual's disability certification period.

(E)Disability determination area (DDA) responsibilities.

(1) The DDA shall approve, deny or defer disability determinations, and shall notify the administrative agency via the electronic eligibility system.

(2) The DDA shall determine the disability begin date and continuing disability review date for approved disability claims, and shall inform the administrative agency via the electronic eligibility system.

(3) In accordance with paragraph (C)(13) of this rule, when the initial disability packet is resubmitted to the DDA because the administrative agency was unable to obtain the requested additional medical information, the DDA shall make a final decision on the case based upon the information available in the initial disability packet, and shall notify the administrative agency of the decision via the electronic eligibility system.

(F) Medicaid eligibility during initial disability determination.

(1) If the individual meets all other medicaid eligibility criteria and also meets the

limiting physical factor in accordance with paragraph (C)(2) of this rule, the administrative agency shall approve medicaid eligibility, and shall not submit a disability packet to the DDA.

(2) If the individual meets all other medicaid eligibility criteria and also presumptively meets the limiting physical factor in accordance  with paragraph (C)(4) of this rule, the administrative agency shall approve medicaid eligibility and shall also submit a disability packet to the DDA for a disability determination.

(3) If the individual meets all other medicaid eligibility criteria, but has not yet been determined to meet the limiting physical factor, the administrative agency shall not approve medicaid eligibility and shall submit a disability packet to the DDA for a disability determination.

(4) If the SSA denies or does not complete a disability determination due to a non-disability reason, the administrative agency shall submit a disability packet to the DDA for a disability determination.

(a) If the DDA approves the disability, the limiting physical factor is met and the administrative agency shall approve medicaid eligibility.

(b) If the DDA denies the disability, the limiting physical factor is not met and the administrative agency shall not approve medicaid eligibility.

(5) When the individual's SSA application is pending, the administrative agency shall submit a disability packet to the DDA for a disability determination.

(a) If the DDA approves the disability, the limiting physical factor is met and the administrative agency shall approve medicaid eligibility until the earlier of the date SSA makes a decision on the SSA application or the continuing disability review date.

(b) If the DDA denies the disability, the limiting physical factor is not met and the administrative agency shall deny medicaid eligibility until the SSA makes a decision on the SSA application.

(i) If the SSA approves SSA disability benefits, the limiting physical factor is met and the administrative agency shall determine medicaid eligibility based upon the initial medicaid application and continue medicaid eligibility until a medicaid redetermination is required.

(ii) If the SSA denies SSA disability benefits, the limiting physical factor is not met and the administrative agency shall deny medicaid eligibility.

(G)Medicaid eligibility during continuing disability review.

(1) If the individual continues to meet all other medicaid eligibility criteria, the administrative agency shall continue medicaid eligibility while the DDA is conducting a continuing disability review.

(2) If the SSA had previously denied or did not complete a disability determination for a non-disability reason and the DDA had approved the disability, the administrative agency shall submit a new disability packet to the DDA for a continuing disability review.

(a) If the DDA approves the disability, the limiting physical factor is met and the administrative agency shall continue medicaid eligibility.

(b) If the DDA denies the disability, the limiting physical factor is not met and the administrative agency shall terminate medicaid eligibility.

(3) When the individual's initial SSA application is pending at the time of the continuing disability review, the administrative agency shall submit a new disability packet to the DDA.

(a) If the DDA approves the disability, the limiting physical factor is met and the administrative agency shall continue medicaid eligibility until the earlier of the date the SSA makes a decision on the SSA application or the next continuing disability review date.

(b) If the DDA denies the disability, the limiting physical factor is not met and the administrative agency shall terminate medicaid eligibility.

(4) If the individual's SSA application is in an appeal at the time of the continuing disability review, the administrative agency shall continue medicaid eligibility through the SSA appeals council review process, in accordance with paragraph (I) of this rule.

(H) Reapplication for medicaid. When an individual is terminated from medicaid and reapplies:

(1) Within twelve months after the disability begin date, the limiting physical factor is met. The administrative agency shall not submit a new disability packet to the DDA. The administrative agency shall apply the existing disability review date, in accordance with paragraph (G) of this rule.

(2) Beyond twelve months of the disability begin date, the limiting physical factor is not met. The administrative agency shall submit a new disability packet to the DDA for a new disability determination, in accordance with paragraphs (C) through (F) of this rule.

(I)Medicaid eligibility when SSA denials are appealed.

(1) When the SSA makes a decision denying SSA disability benefits, the individual has a right to appeal the SSA decision.

(2) The SSA appeal consists of three levels of administrative review that must be requested within sixty-five days and at the proper level. The levels of administrative review are reconsideration, administrative law judge (ALJ) hearing, and appeals council review. If an individual is still dissatisfied at the conclusion of the appeals council review, he or she may request judicial review by filing an action in federal court.

(3) If the individual appeals SSA decisions timely, the administrative agency shall continue medicaid eligibility through the date the final decision is issued by the appeals council.

(4) If the individual does not appeal the SSA decision, medicaid eligibility shall continue through the sixty-fifth day from the date of the adverse SSA disability decision. After the sixty-fifth day, the limiting physical factor is no longer met, and medicaid eligibility under the aged, blind and disabled category shall be terminated.

(5) If the individual fails to appeal the SSA decision timely, but is later permitted by the SSA to appeal for good cause shown, the administrative agency shall restore medicaid eligibility back to the date of medicaid termination.

Replaces:                                                              5160:1-3-03

Effective:                                                             02/23/2015

Five Year Review (FYR) Dates:                         02/23/2020

CERTIFIED ELECTRONICALLY

Certification

02/13/2015

Date

Promulgated Under:                           111.15

Statutory Authority:                           5160.02, 5163.02

Rule Amplifies:                                  5160.02, 5163.02

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

1/1/88 (Emer.), 3/28/88, 10/1/88 (Emer.), 12/20/88,

4/1/90, 10/1/91 (Emer.), 12/1/91, 12/2/91, 12/20/91,

1/1/92 (Emer.), 3/20/92, 12/22/92 (Emer.), 1/1/93 (Emer.), 2/11/93, 3/20/93, 9/1/93, 8/1/95 (Emer.), 10/30/95, 4/1/99, 10/1/02, 11/25/02, 1/1/05