Medical assistance under the Medicaid program is available to individuals who meet Social Security disability criteria as determined by the Presumptive Medical Disability Team (PMDT) and Disability Review Team (DRT) (see 2662). Eligibility is determined under existing program rules for the applicable medical coverage group for individuals with a qualifying disability determination.
A Presumptive Medical Disability case differs from a regular medical assistance case only by the entity making the disability determination. Except for coverage under SSI-related Presumptive Medical Disability, Social Security does not make disability determinations for PMD; disability determinations are made by the PMDT and DRT. Medical assistance cannot be authorized until the PMDT issues a disability determination.
Age - A PMD determination is available only to individuals under age 65. Because Medicaid for the aged is available at age 65, a PMD determination is not necessary for individuals in this age group.
A PMD determination is not required for individuals who are eligible under another Medicaid category , such as Caretaker Medical. However, a PMD determination may be completed for an individual who is currently eligible under another coverage group when that coverage is ending, or when the individual seeks services that require a disability determination.
PMD is also applicable for children seeking coverage under a disability-related group. Because MediKan eligibility is limited to adults, only Tier 1 determinations apply to children. The PMDT and DRT apply SSA childhood disability criteria when making disability determinations for children.
A PMD determination is necessary only when another Medicaid or CHIP coverage group is not available, or when the child seeks services that require a disability determination.
Example: A 16-year-old child receives CHIP (Title 21) coverage. The child’s parent seeks Home and Community-Based Services (HCBS) for Physical Disability (PD) waiver services, which are not available under CHIP and require a disability determination. Because access to services is limited without a disability determination, the child is appropriate for PMD consideration.
To qualify under Presumptive Medical Disability, the individual must meet the disability criteria described in 2662 and its subsections. The disability must be expected to last at least 12 months or result in death. Disability determinations are made by the PMDT and DRT in accordance with these sections.
Presumptive Medical Disability is available under any medical assistance program that requires a disability determination. All applicable general, financial and non-financial eligibility rules for the specific medical assistance program apply, including but not limited to:
Individuals who meet PMD disability criteria and are otherwise eligible for SSI cash assistance are eligible for medical assistance without a spenddown. Except for the disability determination, which is made by the PMDT rather than SSA, all general and non-financial eligibility requirements of the Medically Needy program apply.
Financial Eligibility - The financial methodologies, exemptions, and disregards used for the Medically Needy program apply. One-month base periods are used. Financial eligibility exists when countable resources do not exceed the limit in 5130 and countable income does not exceed the applicable income standard in the F-8, Kansas Medical Assistance Standards.
If income or resources exceed the allowable limits, eligibility under another medical assistance program may be considered, such as Working Healthy or Medically Needy with a spenddown.
A final disability determination made by Social Security takes precedence over a PMD disability determination (see 2663.6). For a new PMD determination, one of the following conditions must be met:
Persons who do not meet these criteria may qualify for MediKan coverage under a Tier 2 disability determination. Individuals who meet Tier 1 criteria but do not meet the conditions above may not receive Medicaid under PMD but may receive MediKan.
Reserved
A final disability determination by Social Security occurs when SSA approves benefits or determines the individual does not meet disability criteria, and no further administrative appeal rights remain. If the individual does not request a timely appeal (per the SSA allowed timeframes), the SSA determination is final. A timely appeal places the SSA determination in pending status and is not considered final.
Coverage under PMD must be monitored for a final SSA disability determination. Coverage ends when SSA makes a final determination.
If the individual becomes eligible under another Medicaid program, eligibility must be established under that group. Ongoing eligibility remains subject to continuing disability reviews as described in 2662.7.
PMD-eligible months do not need to be overlaid with non-PMD Medicaid eligibility. However, eligibility must be reviewed for prior months when:
If the individual timely appeals the SSA decision and SSA accepts the appeal, the determination is not final and eligibility may continue if all other eligibility requirements are met.
NOTE: When SSA will not make a disability determination and a referral is made to Disability Determination Services (DDS) as described in 2662.2(3), the DDS decision is considered the final disability determination for purposes of this section. A subsequent SSA application does not establish a protected filing date for the original medical assistance application associated with the DDS decision. See also the note in 2662.10.