To receive Medicaid coverage based on disability, the individual must be determined blind or disabled in accordance with Social Security Administration (SSA) disability standards for any month in which eligibility is determined. To receive MediKan coverage, the individual must meet the MediKan definition of disability.
The presence of a severe impairment alone does not preclude the individual from performing past relevant work or adjusting to other work.
The Social Security Administration determines disability or blindness as part of the eligibility determination for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). Individuals receiving either Social Security Disability benefits or SSI based on disability are considered to have met the disability standard.
Verification of an SSA disability determination is required. Verification may be obtained through electronic data sources or SSA-issued documentation. Receipt of Social Security benefits alone does not automatically indicate the individual meets disability criteria, as some SSA benefits are not based on a disability determination (e.g., early retirement or survivor's benefits). Contact with the local SSA office may be needed to determine whether a disability decision has been made.
The state's Presumptive Medical Disability Team (PMDT), with certification by the Disability Review Team (DRT), determines whether the individual meets disability or blindness criteria for purposes of Presumptive Medicaid (Tier 1) and MediKan (Tier 2) eligibility.
Individuals must meet Tier 1 disability criteria to qualify for Medicaid under Presumptive Disability. To qualify for MediKan, individuals must meet Tier 2 disability criteria. The PMDT will initially consider disability under Tier 1 criteria and, if not met, disability under Tier 2 is evaluated.
An individual meets Tier 1 disability criteria when the impairment satisfies the SSA disability or blindness standards. 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 the Medical-Vocational guidelines in Appendix 2 of C.F.R. 404, Subpart P.
An individual meets Tier 2 disability criteria when the individual has a severe impairment that significantly limits the ability to perform basic work activities but does not meet SSA disability standards due to the ability to perform past relevant work or adjust to other work.
If a severe impairment does not exist, Tier 2 criteria are not met.
A disability determination for Medicaid or MediKan purposes may only be made by an entity authorized by KDHE-DHCF. Disability determinations made by other agencies are not sufficient. Where a disability determination has been made by another entity, such as the Veterans Administration or Railroad Retirement Board, a disability determination by SSA must be obtained in order to qualify for Medicaid.
Verification of the disability duration is not required prior to referral; the referral may be based on the individual’s statement regarding duration.
Example: An individual applies for Medicaid on May 10 and requests prior medical. SSA approved their SSI benefit with payments beginning May, and SSI eligibility beginning in April. Disability criteria are met for both April and May. However, because there is no potential for cash benefits in February and March, SSA will not make a disability determination for the individual in those months. A referral is sent to DDS to determine whether the individual meets the disability criteria in February and March.
When the Social Security Administration (SSA) has not made, or will not make, a disability determination for reasons unrelated to disability, a referral may be made to Disability Determination Services (DDS) to determine whether the individual meets the applicable disability criteria. Eligibility staff are responsible for gathering the required information and submitting the referral to DDS. DDS may request additional information prior to rendering a decision. Refer to the KanCare KDHE- External Forms for copies of the forms referenced in this section.
Eligibility staff must complete the required forms and provide available information regarding the individual’s medical providers and disability history when submitting a referral to DDS.
Sections I and II of the DD-1104 must be completed to provide general identifying information about the individual.
Sections I, II, and III of the DD-1105 must be completed to provide social, employment, and medical history.
The DD-1103 is used to obtain authorization for the release of medical information.
The completed DD-1103, DD-1104, and DD-1105 forms must be submitted to DDS for review and completion of Section III of the DD-1104. Submission must occur through approved agency transmission methods in accordance with established procedures. Copies of submitted forms must be retained in the case file.
DDS is responsible for obtaining additional medical evidence necessary to make a disability determination, provided the applicant and agency have supplied available information regarding medical providers who have treated the individual.
DDS will document the following on the DD-1104:
DDS will return the completed original DD-1104 and DD-1105 with copies of any pertinent medical information to the agency.
The agency will monitor pending DDS referrals and follow up as necessary in accordance with established agency procedures.
Upon receipt of the DDS determination, eligibility staff shall complete the eligibility determination using the DDS decision documented on the DD-1104.
The following types of referrals require the inclusion of additional information.
A non-qualifying alien may be eligible for emergency medical services under the SOBRA program (see 2691). When eligibility for a disability-based program must be determined, a DDS referral using the DD-1104 form is required.
The referral must clearly indicate that it is a SOBRA referral and include any medical records obtained through the MS-2156 process.
An application for assistance may be submitted on behalf of a deceased individual (see 1411.3(1)). When eligibility must be determined under a disability-based program, a referral to DDS may be required.
The referral must clearly indicate that the individual is deceased and include the date of death. Available supporting documentation, such a death certificate and medical records, should be included.
In some instances, a child claiming a disability may not qualify under other medical programs, such as poverty level or Caretaker Medical. In these cases, a referral to DDS may be necessary to determine eligibility under the Medically Needy program.
The referral must clearly indicate that this is a child referral.
Referrals may also be required when the disability status of a non-applicant/recipient child affects the eligibility determination of another individual.
Example: An elderly individual applying for long term care coverage establishes a special needs trust for a minor grandchild. To determine whether the trust is exempt from transfer of property penalty provisions (see 5720), the grandchild must meet disability criteria. If the child has not been determined disabled by SSA, a DDS determination may be required.
If DDS issues an unfavorable disability determination, the individual has the right to request a reconsideration of the decision.
The agency must submit a new DD-1104 to DDS clearly identifying the request as a reconsideration. DDS will review the original record along with any additional medical evidence provided.
If disability is approved through the reconsideration process, eligibility must be determined based on the disability finding.
If the reconsideration decision remains unfavorable, the individual may request a fair hearing.
When a fair hearing is requested:
If the hearing decision upholds the DDS determination, no further action by the agency is required.
If the hearing decision overturns the DDS determination, the application must be reinstated and processed based on the disability finding.
See also 1614.1(4) and (5) and (5) and 1614.3(9) for additional guidance.
When DDS makes a favorable disability determination, the DD-1104 returned to the agency will include a review date, also referred to as a “diary date”.
The diary date indicates when the individual’s disability status must be reviewed to determine continued eligibility.
When a review is required, a referral is submitted to DDS to reassess the individual’s disability status. The referral must 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 individual's disability status to determine if the individual continues to meet disability criteria.
DDS will document the review determination on the DD-1104 and return the decision to the agency.
If the determination remains favorable, eligibility may continue and a new diary date is established. If the determination is unfavorable, the individual no longer meets disability criteria, and adverse action may be required.
A disability determination by the Presumptive Medical Disability Team (PMDT) is required for individuals seeking Presumptive Medicaid (Tier 1) or MediKan (Tier 2). The agency determines whether an individual meets the criteria for a referral to the PMDT and initiates the referral when appropriate. Disability determinations (and redeterminations) are made by the PMDT and certified by the Disability Review Team (DRT), unless otherwise specified by policy.
Examples:
A referral to the PMDT requires a declaration of disability by the individual. The declaration may be made on the application for medical assistance or through direct contact with the agency. The declaration must include sufficient information to indicate that the disability may meet minimum program requirements.
Disability is a requirement for both Medicaid disability-based coverage and MediKan. If the individual does not claim a disability or does not respond to the disability-related questions, a referral to the PMDT is not appropriate.
For couples, when only one spouse declares a disability, MediKan eligibility does not exist and any referral to the PMDT would be for Medicaid only.
The agency must determine whether the individual alleges a disability expected to last at least 12 months or result in death. This durational requirement applies to both Medicaid and MediKan. If the durational requirement is not met, a referral to the PMDT is not appropriate.
Example:
An individual reports a temporary injury expected to last six (6) months on the application for medical assistance. Because the durational requirement is not met, no referral to the PMDT is made.
The agency must determine whether the Social Security Administration (SSA) has made a final disability determination. A determination is not considered final if the SSA application is still pending or under appeal.
If SSA has not made a final determination, a referral to the PMDT may be made for Medicaid and, when applicable, MediKan.
Example:
An individual was denied SSA disability benefits and timely appealed the decision and is currently awaiting a hearing. Because the SSA determination is not final, a referral to the PMDT is appropriate.
When an individual reports that a final SSA disability determination occurred more than 12 months prior, the case may be referred to the PMDT. Verification of the date of the SSA determination should be attempted but must not delay the PMDT referral.
Example:
The applicant reports that Social Security denied their application 18 months prior because of not meeting disability criteria. The EATSS interface confirms the denial. Because more than 12 months have passed since the final SSA determination, a new referral to PMDT is appropriate. The individual must also be referred to reapply for disability benefits with the SSA.
When SSA has made a final disability determination within the past 12 months , a referral to the PMDT is only appropriate if the individual reports a change in condition or a new disability. The individual’s statement regarding the change is sufficient for referral purposes.
Example:
The applicant was denied by Social Security 6 months ago as their medical condition did not meet SSA disability standards. However, they report on their Medicaid application that the medical condition has worsened. Because a new or worsening condition has been reported, a referral to the PMDT is appropriate. The individual must also be referred to reapply for disability benefits with the SSA.
Unless verification of a pending SSA disability application verified, the individual must be advised to apply for SSA disability benefits. Verification of a pending SSA application is required prior to MediKan approval. However, medical assistance under Medicaid may not be denied solely because the individual has not applied (or provided verification of applying) for SSA benefits, in accordance with 2124.
The agency collects medical information necessary for a PMDT disability determination using the following forms:
Completion of the required questionnaire and receipt of the original, validly signed release of information are program requirements. These forms allow the PMDT to obtain medical records and complete the disability determination.
Failure to provide requested information may delay the disability determination or result in an unfavorable determination.
Individuals 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. Questionnaires or release forms received, even if only partially complete, should still be forwarded to the PMDT as part of the referral process. Upon receipt of the questionnaire and HIPAA release, the PMDT will review the form and determine if additional information is needed and contact the applicant if necessary.
The PMDT develops the disability case and evaluates medical evidence. All disability determinations must be certified by the Disability Review Team (DRT), which consists of qualified medical and disability professionals. The DRT evaluates medical, vocational, and other relevant evidence and makes the final disability determination. Disability determination services may be provided through a contractual arrangement with Disability Determination Services (DDS).
The PMDT records and maintains disability determination outcomes and reviews disability statuses when deemed appropriate by the agency. Eligibility staff uses the disability determination to complete the Medicaid eligibility determination and issue required notices in accordance with 1430.
Individuals seeking medical assistance based on disability must cooperate with the PMDT in completing the disability determination. Failure to cooperate may result in adverse action when cooperation is required to establish eligibility.
Non-cooperation includes, but is not limited to:
When non-cooperation occurs, the PMDT notifies Eligibility staff, who then determines the appropriate action in accordance with applicable eligibility and notice requirements.
NOTE: If the individual contacts the agency within 90 days of the original application date and cooperates or requests rescheduling, the application may be reactivated in accordance with 1414.2 (3).
When either the Clearinghouse or the Presumptive Medical Disability Team (PMDT) becomes aware of a change that may affect a pending disability determination, the change must be shared to ensure the determination is based on current and accurate information. Changes include, but are not limited to, updates in contact information, living arrangements, legal representation, eligibility, or other circumstances that may affect eligibility or the disability determination. Changes that may affect the need for a continuing disability review must be shared in accordance with 2662.7.
If an eligibility determination is made on the case for reasons unrelated to disability while the disability determination is pending, the PMDT must be notified.
NOTE: A PMDT referral remains valid for up to 12 months. When coverage under PMDT is maintained without a break, staff must not initiate a new PMDT referral at review if the individual remains otherwise eligible and the disability determination is still pending with SSA. If SSA issues a final determination that the individual does not meet disability criteria, the individual is denied or discontinued due to no longer meeting program requirements. (See 2663.4 and 2663.6)
If the individual later reapplies for SSA disability benefits after a final denial, this does not automatically continue prior PMDT eligibility. A new Medicaid application is required, and a new referral to PMDT must be completed in accordance with 2662.5.
Disability determinations are subject to periodic review to determine whether the individual continues to meet disability criteria for purposes of Medicaid eligibility.
Continuing disability reviews may be conducted by the Social Security Administration (SSA), Disability Determination Services (DDS), or the Presumptive Medical Disability Team (PMDT), consistent with the source of the most recent disability determination and applicable review requirements.
A continuing disability review may be initiated based on, but not limited to:
When a continuing disability review is required, the agency must ensure that a current disability determination is available to support ongoing eligibility. Individuals are required to cooperate with a continuing disability review in the same manner as an initial disability determination.
If a continuing disability review results in a determination that the individual no longer meets disability criteria, eligibility under all coverage groups must be determined before taking adverse action in accordance with applicable notice and appeal requirements. (See also 2652, 2662.3, 2662.8, PM2018-10-01, and PM2024-08-01.)
Note: Continuing disability reviews are not applicable to MediKan Tier 2 disability determinations.
An individual who is dissatisfied with a disability determination made by the Presumptive Medical Disability Team (PMDT) may request a reconsideration of that determination. A request for reconsideration must:
The PMDT determination is valid for 12 months, and an individual may receive one reconsideration within that time frame.
A reconsideration request received more than 60 days from the date of the PMDT determination shall be denied. If an individual reports a new or worsening condition after the 60-day reconsideration period has expired, a new application is required, and a new referral to PMDT must be submitted.
The PMDT reconsideration decision will be communicated to eligibility staff for appropriate case action. Eligibility staff shall issue a notice of action advising the individual of the reconsideration outcome in accordance with applicable notice and appeal requirements.
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 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.
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.