2660 Medical Only Coverage Related to the SSI Program (MS/CI) - Medical assistance is available for persons who are aged or disabled and who are not financially eligible for SSI cash benefits. In addition, assistance is also available to children in a state institution.

 

2661 Related to Age - The individual must have attained the age of 65 prior to or within any month for which eligibility is being determined.

 

2662 Related to Disability, Including Blindness - To receive Medicaid coverage based on disability, the individual must be determined blind or disabled according to the Social Security Administration's standards within any month for which eligibility is being determined. To receive MediKan coverage, the individual must meet the MediKan definition of disability.

 

  1. SSA Definition of Disability (Medicaid) - The inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to last for a continuous period of not less than 12 months or result in death.
     
  2. SSA Definition of Blindness (Medicaid) - Central visual acuity of 20/200 or less in the better eye with the use of correcting lens which has lasted, or is expected to last, for a continuous period of not less than 12 months or result in death.
     
  3. MediKan Definition of Disability - A severe impairment which significantly limits physical or mental ability to do basic work activity that is expected to last 12 months or result in death. Basic work activities are those abilities and aptitudes necessary to do most jobs. Examples include:

However, the existence of the severe impairment does not prevent the individual from performing past relevant work or adjusting to other work.

The Social Security Administration will make a determination of disability or blindness as part of the eligibility determination for SSI or SSDI benefits. Individuals receiving either Social Security Disability benefits or SSI based on disability have met the necessary disability standard.

 

Verification of the Social Security decision is required. This can generally be obtained through the EATSS system, but can also be obtained through a notice of entitlement, an SSA-1610 or other SSA document. Receipt of Social Security benefits in general does not automatically indicate the individual meets disability criteria, as some types of SSA benefits are not dependent upon a disability determination (e.g., early retirement or survivor's benefits). Contact with the local SSA office may be needed to determine if a disability decision has been made.

 

2662.1 Disability Levels for Presumptive Disability and MediKan - The state's Presumptive Medical Determination Team (PMDT) along with the Disability Review Team (DRT) will determine if the individual meets the definition of disability or blindness (see above) for purposes of determining eligibility for MediKan and Presumptive Medicaid Disability:

 

Tier 1 Disability: The individual is determined to meet the SSA definition of disability or blindness. For PMD, those who meet the SSA level of disability are considered Tier 1. The Tier 1 determination will evaluate if the impairment(s) meet or equal a listing described in Appendix 1 of CFR 404, Subpart P and will also consider the Medical-Vocational guidelines outlined in Appendix 2 of C.F.R. 404, Subpart P.

 

Tier 2 Disability: The individual is determined to meet the MediKan definition of disability. For MediKan, the disability determination will use the same procedures as the Medicaid determination. This process involves an evaluation of the individual’s impairments related to their ability to work. To receive MediKan, the individual must be determined to have a severe impairment but, because of the person’s ability to work, the individual does not meet SSA criteria. Persons meeting these criteria are considered Tier 2.

The Tier 2 determination considers the individual’s ability to perform past relevant work or adjust to other work. If a severe impairment does not exist, the individual does not meet Tier 2 criteria.

 

Persons must meet Tier 1 disability criteria in order to qualify for Medicaid under Presumptive disability. For MediKan the individual must meet Tier 2 disability criteria. The PMDT will initially consider disability under Tier 1 and, if not met, will then consider disability under Tier 2.


2662.2 Authorization to Determine Disability - A disability determination may only be made by an entity authorized by KDHE-DHCF. A disability determination or certification by another agency is not sufficient to document disability for Medicaid or MediKan. Where a disability determination has been made by another entity, such as the Veterans Administration or Railroad Retirement Board, a SSA determination must be obtained in order to qualify for Medicaid.

 

  1. Social Security - If a final determination of disability or blindness has not been made, the applicant is initially referred to Social Security for a determination. If the individual is potentially eligible for benefits through the Social Security disability insurance program or Supplemental Security Income, SSA will take an application and complete the disability determination. If SSA will not complete the determination because of a reason not related to the disability, the case may be referred to DDS.
     
  2. Presumptive Medicaid Disability Team (PMDT) and The Disability Review Team (DRT) with the KDHE (for months on or after 09-2006 only) - The DRT, along with the PMDT will make disability decisions for Presumptive Medicaid (see 2666) and MediKan (see 2640) determinations only. These are limited to persons potentially eligible for Social Security benefits. The DDS referral process is used where there is no potential eligibility for SSI or SSDI benefits.;

No verification of the duration of the disability is needed prior to sending a referral to the PMDT. A referral is sent based on the client's statement of disability duration.

  1. Disability Determination Services - DDS makes determinations of blindness or disability only when a disability determination has not, or will not, be made by SSA for reasons unrelated to disability. SSA will not make a disability determination if the individual is not eligible for a cash payment from SSI or SSDI. Reasons for cash ineligibility which would require a DDS referral include: Insufficient work history, excess income or resources, transfer of property penalty. SSA will also not make a disability determination on a deceased individual with no active application on file. Documentation of the SSI/SSDI denial for a reason other than disability is required prior to referring to DDS. See 2662.3 for referral process.
     
  2. Initial Disability Determinations - DDS will determine disability beginning with the first month required for the Medicaid determination. A disability onset date will be established for persons with favorable determinations.
     
  3. Disability Onset Date for Medicaid - DDS will determine an onset date for Medicaid determinations prior to the onset of SSI.

    Example:     Mary T applies for Medicaid on May 10 and requests prior medical. She was approved for SSI with payments beginning May and SI eligibility beginning in April. Disability criteria is met for both May and April. However, because there is no potential for cash benefits in February and March, Social Security will not determine Mary T's disability in those months. A referral is sent to DDS to determine if she meets disability criteria in February and March.
     

2662.3 Referral to Disability Determination Services (DDS) -

 

1. When a referral to DDS is necessary because SSA will not make the determination of disability as described above, the procedure outlined in this section shall be followed. Eligibility staff are is responsible for   securing initial information related to the disability determination and providing the information to DDS. DDS will request additional information prior to rendering a decision. Refer to the Kancare KDHE- Forms for copies of the forms referenced.

  1. Complete sections I and II of the DD-1104 obtaining general information about the individual. If the client does not have an SSN (e.g., undocumented alien applying for SOBRA coverage only), this should be indicated in the space allotted.

    The onset date requested must be noted on the form in Section II. This would normally be the month of application or the 3 months prior to the application month.
     

    If available, attach a copy of the Social Security denial letter to the referral.
     

  2. Complete section I, II and III of DD-1105 obtaining social information as well as employment and medical history. The individual, medical representative or other party (such as a case manager) may complete the form. If someone other than the individual completed the form, the name and relationship of the person should be included on the form. All doctors the applicant has seen since the alleged onset date are to be listed on the form. The applicant may provide a complete list in Section IV or attach additional pages.

  3. The DD-1103 form is used to secure necessary signatures for release of medical information. The client must sign the form unless unable to do so because of the person's medical condition. In these instances, a person authorized to act in his or her behalf may sign the form. Indicate the reason the client is unable to sign. If the form is signed by a mark, a witness must attest to the signature.  The form should also be dated at this time.  The eligibility staff must complete the appropriate section of the form.

 

 

The original DD-1103, DD-1104, and DD-1105 will be submitted to:

Disability Determination Services,

Attn: Case Control,

2820 S.W. Fairlawn, Suite 100,

Topeka, Kansas 66614,

 

for decision and completion of DD-1104, Section III.  The Eligibility Specialist shall retain a copy of each form for the case record.
 

DDS will assume responsibility for securing whatever medical information is necessary to make a disability decision, assuming the applicant and local agency have provided the necessary information on medical providers who have served the applicant. DDS will enter on  DD-1104 the decision (approval or disapproval), date of decision, onset date, review date (diary date) pertinent diagnosis, and any recommended medical procedures that might aid the social service worker in working effectively with the applicant toward maximum health and activity. DDS will return the completed original DD-1104 and DD-1105 with copies of any pertinent medical information to the local office. For the case still pending a decision at the end of 45 days, updated information can be requested directly from Disability Determination Referral Services at (785) 267-4440.
 

When the forms DD-1104 and DD-1105 (including any attachments) have been returned, the Eligibility Specialist will:
 

  1. Complete the proper case action indicated; and

  2. File the original copy of form DD-1104 in the case file for documentation purposes.

 

  

2.  Specific Referrals - The following types of referrals require the inclusion of additional information.

 

a.  SOBRA - A non-qualifying alien may be eligible for emergency Medical services under the SOBRA program (see 2691).  If eligibility will be determined under a disability program, a referral to DDS via the DD-1104 form is required.  The form should clearly indicate that this is a SOBRA referral.  In addition, the referral should include any medical records obtained through the MS-2156 process.

                                                                                                                                                                                                                                                                                                                                                                

b.  Deceased Applicant -  Assistance may be applied on behalf of a deceased individual [see 1411.3(1)].  If eligibility will be determined under a disability program, a referral to DDS via the DD-1104 form is required.  The form should clearly indicate that the individual is deceased, including the date of death.  In addition, the referral should include a copy of the death certificate (if available) and any medical records.                    

                                                                                                                                                                                                                                                                                                                       

c.  Child - There may be instances where a child claiming a disability is not eligible under either poverty level or Caretaker Medical programs.  To consider eligibility under the Medically Needy  program for the child, referral to DDS via the DD-1104 form for a disability determination would be appropriate.  The form should clearly indicate that this is a child referral.

 

In addition, there are instances where the disability status of a non-applicant/recipient child is relevant to the eligibility of another individual.  Even though the child is not seeking assistance, a referral to DDS would be appropriate in order to determine eligibility for the other individual.  

 

For example, an elderly applicant for long term care coverage has funded a special needs trust for a minor grandchild.  In order for this not to be considered an inappropriate transfer subject to penalty (see 5720), the grandchild must meet disability criteria.  If the child has not already been determined disabled through the Social Security Administration (SSA), a disability determination is required.

  

3.  Reconsideration/Appeal -If the DDS decision is negative, the client has a right to request a reconsideration/appeal of that decision.  Eligibility staff shall complete a new DD-1104 and forward to DDS, clearly indicating this is a Reconsideration.  DDS will review the record, including any additional medical evidence presented to reconsider the original disability determination.  The outcome of the reconsideration by DDS will determine the next steps in the process.

 

a.  If disability is approved through the reconsideration process, the agency will be notified and action should be taken to reprocess eligibility based on the disability finding.

 

b.  If the DDS decision upon reconsideration is still negative, the agency shall complete an appeal form and agency summary.  These forms, along with the reconsideration file returned by DDS, shall be submitted to the Administrative Hearing Office (AHO).  The forms should be clearly identified as a DDS appeal case.  A fair hearing will then be scheduled and conducted.  DDS will represent their decision at the hearing.

 

i. If the DDS decision is upheld, no further action on the case is required by the agency.

  

ii.  If the DDS decision is overturned, the original application shall be reinstated and processed based on the applicant meeting disability criteria.

 

See also 1614.1(4) and (5), and 1614.3(9) for additional guidance.  

 

 

4.  Continuation Review - If DDS has made a favorable decision, the DD-1104 returned by DDS to the agency will include the date the disability determination needs to be reviewed in the future.  This is called the diary date.  The eligibility staff shall make a re-referral to DDS on the diary date using the DD-1104.  The re-referral shall include all the previous information used to make the original decision, including the returned DD-1104 and DD-1105 forms.  DDS will then review the client's disability status to determine if he/she continues to meet disability criteria.

  

DDS will complete and return the DD-1104 to the eligibility staff .  If the decision is favorable, eligibility continues.  DDS will include a new diary date indicating when the next disability review will be required.  If the decision is unfavorable, the client no longer meets disability criteria.  Adverse case action may be required.

 

 

 

2662.4 Presumptive Medical Disability Team (PMDT) - A referral to the PMDT is necessary in order to complete a disability determination for Presumptive Disability/Medicaid or MediKan. The eligibility worker is responsible for initiating the PMDT determination and, unless specifically approved by KDHE Policy, the PMDT shall only accept referrals from eligibility staff. The eligibility worker makes a referral to the PMDT by completing steps 1-4 below. Once the referral is received from the eligibility worker, the PMDT will request additional information from the applicant and complete steps 5-11. The eligibility worker then completes Step 12. 

 

  1. Determine if Individual is Eligible for Referral to PMDT - To determine if a referral is necessary, the eligibility worker must evaluate all requests for or Medical Assistance.                                                                           
    A referral may be sent for both MediKan and Medicaid, or for Medicaid only. A referral for MediKan only is not appropriate. Individuals who do not meet financial or other criteria for MediKan may be referred for Medicaid only. For MediKan/Medicaid referrals, the PMDT will automatically consider disability under both MediKan and Medicaid. Persons who have met the lifetime limit for MediKan are only referred for Medicaid. A referral for MediKan is not appropriate.

  

2.    The referral must indicate which programs are applicable.

Example 1: Application is received for an individual who has already received 12 months of MediKan coverage. The applicant may not receive MediKan, so the only program considered is Medicaid.

Example 2: Application received for an individual with countable monthly income of $500.00. This is over the income limit for MediKan, so the only program considered is Medicaid.

 

3.    The eligibility worker must ensure the individual has made a declaration of disability that meets the minimal standards. Use the following guidelines and processes for determining if a referral is sent.

 

a.    Statement of Disability - The disability may be claimed on the application or through contact with the individual. The worker must gather additional information regarding the duration of the disability, status of past or current Social Security applications and other medical information. This is communicated to the PMDT as part of the initial referral.

Note: Disability is a requirement for both Medicaid and MediKan. Do not refer if the individual does not claim a disability or does not respond to the questions.

For couples, if only one spouse is reporting a disability, there is no eligibility for MediKan and the referral would be for Medicaid only.
 

b.    Duration - Determine if the individual meets the durational requirements - the disability will last at least 12 months or result in death.

Note: The durational requirements are necessary for both Medicaid and MediKan. Do not refer if this condition is not met.

Example: Client reports on application for medical assistance that he is disabled. He then reports his disability, an arm injury, will only last about 6 months. The durational requirements are not met and therefore, no referral is sent.
 

c.    Status of SSA Disability Application - (see 2662) Determine if a final determination of disability has been made. A determination is not considered final if the application is still pending with Social Security or is in appeal status.

Note: If a final determination has not been made, referral is made for Medicaid and possibly MediKan.

Example: Applicant was denied Social Security last year. Decision was appealed and is currently awaiting a hearing. A final determination has not been made and case is referred to PMDT.
 

d.    Date of Final SSA Determination - Determine if a final determination of disability has been made in the past 12 months (see 2666). If the individual reports more than 12 months have passed since a Social Security denial, the worker shall attempt to verify date of final determination using the EATSS system. However, the referral is not to be delayed while awaiting the verification.

Note: Refer for both Medicaid and possibly MediKan.

Example: Client reports his application for Social Security was denied in 2003 because he wasn't disabled. A TPQY confirms the 2003 denial. Because more than 12 months have passed, the case may be referred to the PMDT. However, the individual must reapply for Social Security in order to be eligible.
 

e.    Final SSA Determination within Past 12 Months - For final determinations made within the past 12 months, determine if the condition has changed or deteriorated since the decision. Client statement regarding the change is adequate.

Note: If a change in condition is reported, refer for both Medicaid and possibly MediKan.

Example: Applicant was denied Social Security 6 months ago due to the level of severity of their disability. Client reports on application that there has been a change in his disability because he was recently diagnosed with hepatitis. Case may be referred to PMDT for both Medicaid and MediKan due to the reported change.

 

4.    Refer To Social Security - Unless verification of a current pending application with Social Security is available, refer the individual to Social Security to make application for SSI or SSDI benefits. Verification of a pending application is required prior to approval, but a referral to PMDT is still appropriate.

5.    Presumptive Medical Disability Determination Questionnaire - This form, ES-3903, will capture medical information associated with the individual applicant and takes the place of the Telephone Consultation. The  ES-3904  will be provided to the applicant by the PMDT upon receipt of the referral.  Providing a signed release is a program requirement.  The release is necessary in order to obtain medical records.  The PMDT must receive the original forms. A self-addressed stamped envelope is included along with instruction to return the information to the PMDT within 12 days. Failure to provide complete information may result in needless delay and/or an unfavorable determination. Applicants needing assistance should be directed to friends, family, and other community resources for assistance. In addition, the form includes language directing the applicant to contact the PMDT at their toll free number (1-888-547-2763) if they have questions about the form. Questionnaire or release forms received directly by the Clearinghouse staff, even if only partially complete, should still be forwarded to the PMDT as part of the referral process. Upon receipt of the questionnaire, the PMDT will review the form and determine if additional information is needed, and contact the applicant if necessary.

6.   Receipt by the PMDT - All cases referred to the PMDT will be logged. Documentation and tracking of cases pending with the PMDT will be recorded in the PMDT Central Data Base. The data base is only accessible by designated KDHE-DHCF staff. All policies and procedures used by the PMDT to determine disability are located in the PMDT Procedures Manual.

7.    Assign to Case Development Specialist (CDS) - Upon receipt of the PMD referral, questionnaire, and HIPAA release forms the case will be assigned to a CDS. The CDS will be responsible for requesting medical evidence, scheduling any consult examinations and preparing the disability file for the Disability Examiner.
 

8.    Review by Disability Examiner -Following development of the medical evidence, the disability examiner will review the information and determine if there is sufficient evidence to send the case on to the Disability Review Team for a final determination. The disability examiner will prepare the file for review by the DRT.
 

9.    Review by the Disability Review Team - All persons determined disabled by the PMDT must be certified through the Disability Review Team. The DRT consists of a trained disability examiner and physician (or psychologist for evaluation of mental disabilities). The team will evaluate the medical evidence, including vocational and other non-medical information, and make a determination of the individual's status. KDHE-DHCF currently contracts with Disability Determination Services (DDS) for services provided by the Disability Review Team.
 

10. Notification to PMDT - The DRT will notify the PMDT of the outcome of the disability determination. The information will be recorded by the PMDT.
 

11. Notification to the Eligibility Worker - The PMDT will send final notification regarding the disability determination to eligibility staff.
 

Final Determination and Notification to the Applicant/Recipient - Using the disability information from the PMDT, the eligibility worker is responsible for making the final determination regarding the individual's eligibility. The eligibility worker is also responsible for meeting the notice requirements (see 1430).
 

 2662.5 Failure to Cooperate with the PMDT -  Persons applying for Medical Assistance must cooperate with the PMDT in determining disability. Failure to cooperate with any of the following PMDT activities results in non-cooperation and subsequent negative action. In each situation, the PMDT will notify the case worker of non-cooperation with the specific reason. The eligibility worker shall take negative action based on failure to cooperate with the PMDT.

  1. ES-3903, - This form must be completed to the best of the client’s ability as part of the PMDT's disability determination. The questionnaire along with the  ES-3904 must be received by PMDT.
     
  2. Medical Evaluation - Medical Evaluation - If sufficient evidence is not available to develop the disability case, the PMDT may determine a medical evaluation is necessary. The PMDT is responsible for scheduling the appointment with a contracted medical provider. The PMDT will remind the applicant/recipient prior to the appointment. If the applicant/recipient fails to keep the appointment, it shall be considered non-cooperation. A second appointment will not automatically be rescheduled.
     
  3. Medical Records - The PMDT will request medical records as part of the disability determination. Although the signed release of information will generally be sufficient to obtain the records, the applicant/recipient may be asked to assist with the process. Failure to follow through with a request to assist with obtaining medical records is considered non-cooperation.  

 

NOTE: If the individual contacts the agency within 90 days of the original application date to reschedule a missed appointment or to cooperate, the application may be reactivated per 1414.2 (3). Requests for rescheduling may be made directly with the PMDT or through the caseworker. Communication between the entities is necessary.

 

2662.6 Changes During the Disability Determination - If either the PMDT or the eligibility worker become aware of changes which could impact the determination, the party receiving the information is responsible for notifying the other entity of the change. This includes general changes, such as a change in address, phone number, living arrangement, conservator, etc., as well as changes in eligibility or process which could result in ineligibility. The eligibility worker must notify the PMDT if a determination is made on the case for reasons other than disability.

  

2662.7 Persons with Drug Addiction or Alcoholism - Based on the drug addiction and alcoholism provisions of the OASDI program, OASDI benefits are not available to individuals whose drug addiction or alcoholism is material to the determination of disability (i.e., would not be found disabled if the drug abuse and/or alcohol abuse were to stop). These provisions became effective as of March 29, 1996. Medical eligibility under the MS program shall not be provided in such instances. However, OASDI beneficiaries whose benefits are terminated due to these provisions and who are medical recipients shall continue to be eligible for Medicaid if they timely appeal the SSA decision and are otherwise eligible except for the disability determination. Such eligibility continues throughout the appeal process. Verification from SSA that the appeal was filed timely is required.

 

2662.8 Effect of Loss of SSA/SSI Eligibility on Disability Determination - For medical eligibility determination purposes, a prior determination of disability by the SSA is not considered void if an SSA or SSI benefit is stopped for reasons other than cessation of disability. See also 2662.2 above regarding cessation of benefits for persons with drug addiction or alcoholism. However, persons whose benefits are terminated due to loss of disability status and who timely appeal the SSA decision (defined as within 90 days of notification of termination) shall continue to be eligible for medical assistance if they are otherwise eligible except for the disability decision. Such eligibility continues throughout the appeal process. Verification from SSA that the appeal was timely filed is required.

 

For ongoing SI cases in which SSI benefits have been terminated due to financial reasons (i.e., excess income or resources) and the client is not otherwise eligible for OASDI disability benefits, continuing eligibility under the MS program should be reviewed.

 

If an MS case is established, a referral to DDS (via the DD-1103, DD-1104  and DD-1105) is required primarily so that a continuing disability review period can be initiated. The referral form should note the reason for the referral. MS eligibility can be determined and medical benefits provided while the DDS decision is pending. If disability status is denied, eligibility shall be terminated based on timely and adequate notice requirements. If disability status is approved, the case shall be re-referred to DDS on a periodic basis (based on the review date specified in DDS) provided the client does not attain eligibility for OASDI or SSI benefits in the interim. This provision is not applicable to persons who meet one of the protected group criteria of 2680, qualify for QWD status per 2674, or who are eligible under the 1619(b) provisions as referenced in 2634.

 

2662.9 Impact of Social Security Determination - The outcome of the disability determination made by PMDT is binding until Social Security reaches a final determination.


If a Tier 1 disability is established, the consumer is considered disabled until SSA reaches a final determination. If Social Security affirms the disability, assistance may continue if all other eligibility factors continue to be met. If Social Security denies disability, categorical assistance is terminated under the disability category.


If a Tier 1 disability is not established, the application for disability based Medicaid is denied. The application can be reconsidered if new information is presented during the 90 day application time frame (see KEESM 1413). If the consumer is approved for SSI based on the Social Security application associated with the PMDT, assistance may be provided effective with the Protected Filing Date if all other eligibility factors are met. Cooperation with Social Security disability is required.

 

2662.10 Protected Filing Dates - The date an application for medical assistance is made is considered the Protected Filing Date if a determination of medical assistance cannot be made because a final determination for Supplemental Security Income (SSI) has not been issued. The initial application date is active as long as the individual cooperates with the medical assistance determination and the SSI application is pending an initial determination or is in appeal status. Verification of a timely appeal is required. Failure to cooperate with MediKan criteria does not impact the medical protected filing date.

 

If SSA finds the individual is disabled and eligible for SSI payment, Medicaid coverage is potentially available back to the protected filing date, or three prior months if prior medical assistance was requested, as long as the onset date is on or before the medical assistance start date. Medicaid coverage must also be established back to the protected filing date for MediKan recipients. Persons who are receiving Presumptive Medicaid Disability coverage are converted to another type of Medicaid. In order to qualify for coverage back to the Protected Filing Date, the consumer must report the outcome to the agency within 10 days of receiving payment/notification (whichever is later).

 

Note: The Protected Filing Date is only applicable to SSI recipients. The Protected Filing Date is not applicable to persons who qualify only for Social Security Disability benefits. In addition, when a referral has been made to Disability Determination Services (DDS) because SSA will not make a disability determination as indicated in 2662.2(3), a final decision for purposes of this section is the decision made by DDS. See also the Note in 2663.6.

 

If SSA finds the individual is not disabled, coverage is denied unless the applicant qualifies under another Medicaid program. However, the protected filing date is still alive for persons who file a timely appeal of Social Security decision if SSI coverage is ultimately approved. In addition, the protected filing date is applicable to persons who are not eligible for PMD benefits, but have been cooperative with the PMD. The protected filing date ends if the individual fails to cooperate with the PMD process.