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

 

 

 

Rule Summary and Fiscal Analysis (Part A)

 

Department of Job and Family Services

Agency Name

 

Division of Public Assistance                              Michael Lynch

Division                                                                  Contact

 

OFC- 4200 E. 5th Ave., 2nd fl. J6-02 P.O. Box 183204 Columbus OH 43218-3204

614-466-4605        614-752-8298

Agency Mailing Address (Plus Zip)                                       Phone                     Fax

[e-mail]

Email

5101:1-5-20

Rule Number

NEW

TYPE of rule filing

Rule Title/Tag Line              Disability   financial   assistance:   the   determination   of   a

disability.

RULE SUMMARY

1.  Is the rule being filed for five year review (FYR)? No

2.  Are you proposing this rule as a result of recent legislation? No

3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 111.15

4.  Statute(s) authorizing agency to adopt the rule: 5115.03

5.  Statute(s) the rule, as filed, amplifies or implements: 5115.01, 5115.03

6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

To change policy relating to the administration of the Disability Financial Assistance program and to replace rescinded rule 5101:1-5-20.

7.  If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

This rule describes the disability determination process for the Disability Financial Assistance (DFA) program. The existing rule is being rescinded and replaced with a new rule as more than 50 per cent of the original language has been stricken.

Changes to the rule include: clarified that individuals who applied prior to the effective date of the rule will have their disability determined in accordance with the most recently effective version of the rule; changed the disability determination process to be based solely on a current medical statement from the applicant or recipient's physician and defined what constitutes a current medical statement; established how long a disability determination will remain in effect; established a procedure for conducting a continuing disability review for individuals determined disabled under the proposed and prior rules; and established county agency responsibilities in the disability determination process.

8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This rule incorporates one or more references to the Ohio Revised Code. This question is not applicable to any incorporation by reference to the Ohio Revised Code because such reference is exempt from compliance with RC 121.71 to 121.74 pursuant to RC 121.76(A).

This rule incorporates one or more references to another rule or rules of the Ohio Administrative Code. This question is not applicable to any incorporation by reference to another OAC rule because such reference is exempt from compliance with RC 121.71 to 121.74 pursuant to RC 121.76(A)(3).

The rule incorporates one or more dated references to an ODJFS form or forms. Each cited ODJFS form is dated and is generally available to persons affected by this rule via the "Info Center" link on the ODJFS web site (http://jfs.ohio.gov/) in accordance with 121.75.

9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

Not applicable.

10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material,

provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so. If applicable, indicate each specific paragraph of the rule that has been modified:

This rule is being revise filed to clarify in paragraph (B)(2) the timeframes for when a current medical statement can be dated for it to be valid for continuing disability reviews. Paragraph (E)(2) of this rule was also updated to correct an internal cross-reference.

12.  Five Year Review (FYR) Date:

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

FISCAL ANALYSIS

13.  Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will have no impact on revenues or expenditures.

$0.00

This will have no impact on the current budget.

14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

Not applicable.

15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your

information/estimated costs, e.g. industry, CFR, internal/agency:

No new costs.

16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No

S.B. 2 (129th General Assembly) Questions

18.  Has this rule been filed with the Common Sense Initiative Office pursuant to

R.C. 121.82? No

19.  Specific to this rule, answer the following:

A.) Does this rule require a license, permit, or any other prior authorization to engage in or operate a line of business? No

B.) Does this rule impose a criminal penalty, a civil penalty, or another sanction, or create a cause of action, for failure to comply with its terms? No

C.) Does this rule require specific expenditures or the report of information as a condition of compliance? No

ACTION: Revised                                                DATE: 08/18/2016 9:25 AM

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

MENTAL FUNCTIONAL CAPACITY ASSESSMENT

SECTION I: IDENTIFYING INFORMATION TO BE COMPLETED BY WORKER

Assistance Group Number

Recipient ID

DOB

Sex

County Name

Client Last Name

Client First Name

MI

County Address

Client Address

Client Phone

City

ZIP

City

ZIP

SSN

Caseworker/Case Mgr

Caseload ID

County Phone

SECTION II:

Not Significantly Limited

Moderately Limited

Markedly Limited

Not Rated

Understanding and Memory

1.      The ability to remember locations and work like procedures.

?

?

?

?

2.      The ability to understand and remember very short and simple instructions.

?

?

?

?

3.      The ability to understand and remember detailed instructions.

?

?

?

?

Sustained Concentration and Persistence

1.      The ability to carry out very short and simple instructions.

?

?

?

?

2.      The ability to carry out detailed instructions.

?

?

?

?

3.      The ability to maintain attention and concentration for extended periods.

?

?

?

?

4.      The ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances.

?

?

?

?

5.      The ability to sustain an ordinary routine without special supervision.

?

?

?

?

6.      The ability to work in coordination with or proximity to others without being distracted by them.

?

?

?

?

7.      The ability to make simple work related decisions.

?

?

?

?

8.      The ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods.

?

?

?

?

Social Interaction

1.      The ability to interact appropriately with general public.

?

?

?

?

2.      The ability to ask simple questions or request assistance.

?

?

?

?

3.      The ability to accept instructions and respond appropriately to criticism from supervisors.

?

?

?

?

4.      The ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes.

?

?

?

?

5.      The ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness.

?

?

?

?

Adaptation

1.      The ability to respond appropriately to changes in the work setting.

?

?

?

?

2.      The ability to be aware of normal hazards and take appropriate precautions.

?

?

?

?

3.      The ability to travel in unfamiliar places or use public transportation.

?

?

?

?

4.      The ability to set realistic goals or make plans independently of others.

?

?

?

?

Are you the client's primary care physician?     ? Yes     ? No

After taking the appropriate history and performing the relevant physical examination, do you believe the client is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than nine months? ? Yes   ? No

Will disclosure of this information to the client have an adverse effect?  ? Yes     ? No

I hereby certify under penalty of law that the above information is a true and accurate description of my patient's medical condition at this time to the best of my knowledge. I understand that I may be reported to the State Medical Board and/or be subject to criminal or civil prosecution should I knowingly make false or misleading statements or provide altered or false documentation that results in my patient being inappropriately determined to be eligible for the Disability Financial Assistance program.

Physician's Signature

Date of Last Exam

Physician's Name (Please print)

Specialty

JFS 07308 (10/2016)                                                                                                                                                                                                                   Page 1 of 2

Address
City	State	Zip	Physician's Phone
Client Last Name	Client First Name	MI	Recipient ID

JFS 07308 (10/2016)                                                                                                                                                                                                                   Page 2 of 2

ACTION: Revised

BASIC MEDIC

ADLATE: 08/18/2016 9:25 AM

Page 1 of 2

SECTION I: IDENTIFYING INFORMATION TO BE COMPLETED BY WORKER

Assistance Group Number

Recipient ID

DOB

Sex

County Name

Client Last Name

Client First Name

MI

County Address

Client Address

Client Phone

City

ZIP

City

ZIP

SSN

Caseworker/Case Mgr

Caseload ID

County Phone

SECTION II: TO BE COMPLETED BY PHYSICIAN

Are you the individual's primary care physician?  ? Yes    ? No

Physical Examination / Vital Signs:

Height:                                              Weight:                       Pulse Rate:                    Blood Pressure:                                       Respiratory Rate:

HEENT:                                                                                                              Abdomen:

Chest:                                                                                                                Heart:

Extremities                                                                                                         Neurological:

Visual Acuity:                                   OS:                                            OD:

ROM                                               Spine:                                         Joints:

A. Pregnancy verification only                                            Date of test:                                        Expected date of delivery:

B. Describe the client's medical conditions (physical and mental) [Include appropriate ICD-9CM and/or DSM-IIIR codes(s)]

C. History of these problems (Onset, duration, treatment, prescribed medications, prognosis, etc.)

D. Health Status: ? Improving ? Improving Without Tx ? Improving With Tx ? Good/Stable With Tx ? Poor But Stable ? Deteriorating

E. Physical/psychological/psychiatric findings (Please also complete G and/or JFS form[new form number]for Mental Impairments as appropriate):

F: Are additional studies or treatment indicated? If yes, specify.

JFS 07302 (10/2016)

BASIC MEDICAL Page 2 of 2
Client Last Name	Client First Name		MI	Recipient ID		SSN
Considering the combined effects of the medical conditions noted above, please answer the following:
G. Physical Functional Capacity Assessment
				No	Yes	Hours
1. Are standing/walking affected?
If yes, how many hours in an 8-hour workday can patient stand/walk?
How many hours without interruption?
2. Is sitting affected?
If yes, how many hours in an 8-hour workday can patient sit?
How many hours without interruption?
3. Are lifting/carrying affected?
If yes, up to how many pounds can patient lift/carry frequently? (up to 2/3 of 8 hour day)
? Up to 5 lbs.                             ? 6-10 lbs                 ? 11-20 lbs                      ? 21-25 lbs.                         ? 26-50 lbs                             ? 51-100 lbs.
If yes, up to how many pounds can patient lift/carry occasionally? (up to 1/3 of 7 hour day)
? Up to 5 lbs.                             ? 6-10 lbs                 ? 11-20 lbs                      ? 21-25 lbs.                         ? 26-50 lbs                             ? 51-100 lbs.
				None	Not Significantly Limited	Moderately Limited	Markedly Limited	Extremely Limited
4. Are the following functions affected?  If so, how?
Pushing/pulling
Bending
Reaching
Handling
Repetitive foot movements
Seeing
Hearing
Speaking
5. What observations and/or medical evidence led to your findings in questions G1 - G4? Please provide examples of specific physical limitations:
After taking the appropriate history and performing the relevant physical examination, do you believe the individual is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than nine months?  ?Yes    ? No
Will disclosure of this information to the client have an adverse effect?             ? Yes     ? No
I hereby certify under penalty of law that the above information is a true and accurate description of my patient's medical condition at this time to the best of my knowledge. I understand that I may be reported to the State Medical Board and/or be subject to criminal or civil prosecution should I knowingly make false or misleading statements or provide altered or false documentation that results in my patient being inappropriately determined to be eligible for the Disability Financial Assistance program.
Physician's Signature		Date of Last Exam
Physician's Name(Please print)                                                                                                  Specialty
Address
City		State		ZIP			Physician's Phone

JFS 07302 (10/2016)