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.
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.
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.
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.
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.
The original Disability Determination Request Medical Assistance Case, Disability Determination Data/Report Medical Assistance Case, and Authorization to Disclose Information to KDHE-DDS's will be submitted to:
Disability Determination Services,
Attn: Case Control,
2820 S.W. Fairlawn, Suite 100,
Topeka, Kansas 66614,
for decision and completion of Disability
Determination Request Medical Assistance Case, 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 Disability
Determination Request Medical Assistance Case 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
Disability
Determination Request Medical Assistance Case, and form Disability
Determination Data/Report Medical Assistance Case, 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 Disability
Determination Request Medical Assistance Case and Disability
Determination Data/Report Medical Assistance Case (including any attachments)
have been returned, the Eligibility Specialist will:
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 Disability Determination Request Medical Assistance Case 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 Medical Review of Emergency Services for SOBRA 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 Disability Determination Request Medical Assistance Case 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 Disability Determination Request Medical Assistance Case 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 Disability Determination Request Medical Assistance Case 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 Disability Determination Request Medical Assistance Case 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 Disability Determination Request Medical Assistance Case. The re-referral shall include all the previous information used to make the original decision, including the returned Disability Determination Request Medical Assistance Case and Disability Determination Data/Report Medical Assistance Case 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 Disability Determination Request Medical Assistance Case 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 ES, the PMDT will obtain additional information by
requesting additional information from the applicant and completing steps
5-12. The eligibility worker then completes Step 13.
Persons who have met the lifetime limit for MediKan are only referred for Medicaid. A referral for MediKan is not appropriate.
The referral should indicate
if the consumer is requesting prior medical. If so, include the first
prior medical month in the referral.
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.
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.
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.
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.
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.
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 severity level of 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, , will
capture medical information associated with the individual applicant and
takes the place of the Telephone Consultation. This form HIPAA
Compliant Authorization to Disclose Information to KDHE and the ES-3909
Instructional Cover Letter will be provided to the applicant by the PMDT
upon receipt of the referral. A self-addressed stamped envelope is included
along with instruction to return the information to the PMDT within 15
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 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.
Obtain One Original of the HIPAA Compliant Authorization to Disclose
Information to KDHE -
This release is necessary in order to obtain medical records. The release must be signed.
The PMDT shall request the form along with the Presumptive
Medical Disability Questionnaire and Applicant
Instructions for The Presumptive Medical Disability Process as instructed
in item (4). The PMDT must receive the original forms.
If the eligibility worker obtains the forms from the client, fax it to
the PMDT. The original is sent to the PMDT. Providing a signed release
is a program requirement.
7. 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.
8.
Assign to Case Development Specialist - Upon receipt of the ES-3901,
the case will be assigned to a CDS. The eligibility worker will be responsible
for requesting medical evidence, scheduling any consult examinations and
preparing the disability file for the Disability Examiner.
9.
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.
10.
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. The PMDT's DE may also serve as the DE for
the DRT.
11.
Notification to PMDT - The DRT will notify the PMDT of the outcome
of the disability determination. The information will be recorded by the
PMDT.
12.
Notification to the Eligibility Worker - The PMDT will send final
notification regarding the disability determination to eligibility staff.
13.
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
via the ES-3906, Notification of Changes, of non-cooperation with the
specific reason. The eligibility worker shall take negative action based
on failure to cooperate with the PMDT.
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 a contributing factor 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 Authorization to Disclose Information to KDHE-DDS, Disability Determination Request Medical Assistance Case, and Disability Determination Data/Report Medical Assistance Case) 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.