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

 

 

 

5101:1-5-20                 DADFA:  definitions  and  determinations  of  disability  and medication dependency.

 

 

 

(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 CDHSCDJFS 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 DADFA program other than disability due to medication dependency, 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)An individual is determined to be medication dependent when a licensed physician has certified that the person is under ongoing treatment for a chronic medical condition requiring continuous prescription medication for a long-term, indefinite period of time and for whom the loss of such medication would result in a significant risk of a medical emergency and loss of employability which will last for at least nine months. The CDHS shall verify the individual's medication dependency with a completed ODHS 3606 "Physician Certification of Medication Dependency for the Disability Assistance Program" provided by the individual's physician and verification of prescription history.

 

(1)The prescription history can be verified by pharmacy records or through existing medical records. In the event that verification of prescription history is not available, the CDHS must secure a statement from the individual, physician, or pharmacy explaining why the prescription history is not available.

 

(2)In those situations in which the individual has recently been diagnosed with a chronic medical condition, the CDHS shall accept a minimal, or very recent prescription history as appropriate documentation.

 

(3)The CDHS shall not deny DA benefits to the individual if the prescription history is not available. However, documentation shall be maintained in the assistance group record regarding the absence of prescription history.

 

(4)At reapplication for assistance groups that have been approved for DA based upon the medication dependent criteria, the CDHS shall review whether the condition continues to exist by obtaining another ODHS 3606.

 

(D)Indication of disability.

 

(1)The  CDHS  shall  evaluate  the  information  provided  on  the  ODHS  3603 "Prescription History" to determine if a disability determination through the

 

 

county medical services (CMS) section should be pursued in addition to the medication dependency determination. While the individual may meet the criteria set forth in paragraph (C) of this rule and be approved for DA medical assistance, the CDHS shall continue to develop medical evidence as delineated in paragraph (E) of this rule, when appropriate.

(2) If the CDHS believes a medication dependent individual may also be disabled, the CDHS shall also issue an ODHS 7302 "Basic Medical Form" and an ODHS 7308 "Mental Functional Capacity Assessment" form and begin developing medical case information for submission to the CMS for a formal determination of disability.

(3) If an individual who has been determined medication dependent is to have a medical case submitted to the CMS, a copy of the ODHS 3606 "Physician Certification of Medication Dependency for the Disability Assistance Program" should be included in the medical case submitted to the CMS.

(E)(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 DADFA program. The CDHSCDJFS should begin the disability determination process by issuing ana ODHS 7302JFS 07302 "Basic Medical" form 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, ana ODHS 7302JFS 07302 must be issued to each physician for completion. When an alleged disability or limiting physical factor is a mental impairment, the ODHS 7308JFS 07308 "Mental Functional Capacity  Assessment"  must  also  be  completed,  along  with  the  ODHS

7302JFS  07302.  If  ana

ODHS  7302JFS  07302  is  sent  to  a  provider  for

completion, the CDHSCDJFS is obligated to pursue and attempt to obtain all available medical evidence and submit the case to the CMS for a determination.

(2)   The CDHSCDJFS cannot make its own determination of disability based upon the contents of the ODHS 7302JFS 07302.

(3)   As part of the case development process, the applicant's caseworker (or SSI case manager) must complete fully the ODHS 7004JFS 07004 "social summarySocial Summary Report for Disability Determination." The caseworker shall send ana ODHS 7302JFS 07302 and ana ODHS 7308 JFS 07308 (if appropriate) to all treating physicians listed in "Section VIII" of the ODHS 7004JFS 07004.

(4)     For nonphysician providers listed in "Section VIII" of the ODHS 7004JFS 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 ODHS 7004JFS 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 ODHS 7302JFS 07302, ODHS 7308JFS 07308, and ODHS 7004JFS 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 ODHS 3605JFS 03605 "CDHSCDJFS Referral to CMS" must be completed for each medical case being submitted to the CMS. The ODHS 3605JFS 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 CDHSCDJFS 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 CDHSCDJFS should collect all available medical evidence and submit it to the CMS. The CMS will then weigh all evidence submitted. With respect to the ODHS 3606, however, the administrative rules are quite clear. This form must be signed by an MD or DO.

(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 CDHSCDJFS. 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 CDHSCDJFS for filing and maintenance.

(a)    The CDHSCDJFS 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 CDHSCDJFS 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 DADFA, 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 Chapters 5101:6-1 to 5101:6-9 division level designation 5101:6 of the Administrative Code.

(8) When the CDHS has issued an ODHS 7302 and no ODHS 3606, the caseworker should review the ODHS 7302 upon its return, paying particular attention to "Section C" (history of these problems) of the ODHS 7302. This section will contain information regarding medications prescribed to the applicant. If the physician notes any prescribed medications, the CDHS must issue an ODHS 3606 to the applicant's treating physician for completion. When a medical case is submitted to the CMS for a disability determination and there is evidence of prescribed medications but there is no completed ODHS 3606 and the case is subsequently deferred for additional information or denied, the CMS will note on the ODHS 3600 "County Medical Services Section Disability Determination" form that the CDHS should explore medication dependency eligibility for the individual.

(F)(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 DADFA 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. DADFA  may  be  authorized  for  an  individual  whose  SSI  application  is

pending provided:

(a)   The individual meets all DADFA 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  DADFA  interim assistance as delineated in rule 5101:1-5-70 of the Administrative Code.

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

(3) The CDHS shall require individuals who, in the judgment of the SSI case manager, are or may be blind or disabled, to apply for medicaid.

(4) Individuals under sixty-five who are not permanently incapacitated in the context of the definition of disability found in rule 5101:1-39-03 of the Administrative Code should not be routinely referred to SSI. However, any individual who applies for and/or receives public assistance who claims an incapacity that has already existed for twelve months or is expected to last for twelve months is to be referred to the SSA for a determination of SSI eligibility. Additionally, an individual applying for or in receipt of DA who claims an incapacity that has already existed for twelve months or is expected to last for twelve months is to be referred to the SSI case management program.

Effective:                                09/30/2003

R.C. 119.032 review dates:    07/03/2003 and 09/01/2008

CERTIFIED ELECTRONICALLY

Certification

09/12/2003

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, 7/1/03 (Emer.)