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 General Assistance - 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 General Assistance/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 General Assistance/MediKan and Presumptive Medicaid Disability:

 

Tier 1 Disability: The individual is determined to meet the SSA definition of disability or blindness. The 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.

 

Persons must meet Tier 1 disability criteria in order to qualify for Medicaid under Presumptive disability. For General Assistance, the individual must meet either Tier 1 or Tier 2 criteria. The PMDT will initially consider disability under Tier I and, if not met, will then consider disability under Tier 2. Persons cannot receive MediKan coverage unless they receive General Assistance. Therefore, if the individual does not meet all other financial and non-financial criteria for General Assistance, a Tier 2 determination will not be completed.

 

2662.2 Authorization to Determine Disability - A disability determination may only be made by an entity authorized by KHPA. 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 Kansas Health Policy Authority (for months on or after 09-2006 only) - The DRT, along with the PMDT will make disability decisions for Presumptive Medicaid (see 2666) and General Assistance /MediKan (see 2313) 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. EES 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 Miscellaneous Forms section for copies of the forms referenced.
     
    1. Complete sections I and II of the DD-1104, Disability Determination Request, 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 verification of the Social Security denial letter to the referral.
       

    2. Complete section I, II and III of DD-1105, Disability Determination Date/Report, 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. The completed form must be signed and dated by the EES Specialist and the EES Supervisor.
       
    3. Obtain at least two DD-1103 forms, and secure necessary signatures for release of medical information. The client must sign the form unless unable to do so because of the persons 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. Do NOT have the client date the forms at this time. Additional forms may be needed if more doctors are listed on the DD-1105, as an equal number of original DD-1103 forms must be submitted. EES must complete the SRS section of the form.

      An original and 1 copy of Form DD-1104, 1 original DD-1105, and the appropriate number of original DD-1103'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 Form DD-1104, Section III.
       

      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 Form 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 Form DD-1104, and Form 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 local SRS office will:
       

      1. Complete the proper case action indicated; and
         
      2. File the original copy of Form DD-1104 in the Economic/Employment Support file for documentation purposes.
         

      If the decision is favorable, the case must be referred to DDS for review of the condition. The review date reported on the last DD-1104 is to be used. DDS will determine if the client continues to meet disability criteria. Such referral is to include all previous information sent including the returned DD-1104 and 1105 forms. If the decision is negative, the client has the right to request a reconsideration/ appeal of the decision. (See 1614.1 and 1614.3 (9)).

 

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 General Assistance. The eligibility worker is responsible for initiating the PMDT determination. The process outline shall be used for making PMDT referrals. The eligibility worker is responsible for completing the entire referral process through Step 7. The PMDT is responsible for steps 8-13. The eligibility worker then completes Step 14.
 

    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 General Assistance or Medical Assistance.

      A referral may be sent for both General Assistance and Medicaid, for Medicaid only, or for General Assistance only. Individuals who do not meet financial or other criteria for General Assistance may be referred for Medicaid only. For GA/Medicaid referrals, the PMDT will automatically consider disability under both MediKan and Medicaid.
       
    2. The referral must indicate which programs are applicable.

      Example 1:       Application is received for an individual with more than 24 months of prior General Assistance. The client may not receive GA (which means he is prohibited from receiving 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 limit for GA, so the only program considered is Medicaid.
       
    3. The eligibility worker shall use the following guidelines and processes for determining if a referral is sent.
       
      1. 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. The ES-3900, Tell Us If You Have A Disability, is used to gather the additional information. The form is to be used as an application addendum and may be given to the individual to complete or the eligibility worker can contact the client and complete the form by phone. Responses to these questions must be provided prior to sending the referral to the PMDT.

        Note:         Disability is a requirement for both Medicaid and General Assistance. 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 General Assistance and the referral would be for Medicaid only.
         
      2. Duration - Determine from the ES-3900 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 General Assistance. Do not refer if this condition is not met.

        Example:         Client reports on application for cash and medical that he is disabled. The ES-3900 is obtained and client reports his disability, an arm injury, will only last about 6 months. The durational requirements are not met and therefore, no referral is sent.
         
      3. 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 both Medicaid and General Assistance.

        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.
         
      4. 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 General Assistance.

        Example:         Client reports his application for Social Security was denied in 2003 because he wasn't disabled. An old WTPQY confirms the 2003 denial. Because more than 12 months have passed, the case may be referred to the PMDT.
         
      5. 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 General Assistance-MediKan and Medicaid.

        If there is no reported change, refer for General Assistance - MediKan only.

        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 GA due to the reported change.
         
    4. Schedule a Telephone Consultation - As part of the initial interview, the eligibility worker is responsible for contacting the PMDT and scheduling the Telephone Consultation (TC). The purpose of the TC is to gather information pertinent to the disability determination, including medical history, activities of daily living and vocational information. The TC will be conducted by the PMDT. If the applicant does not have a phone, the agency shall make a phone available for the TC.

      If an interview is not completed, the worker is encouraged to contact the applicant by phone to discuss the process and scheduling. If this is not successful, the eligibility worker shall make an appointment time for the applicant at least 1 week in the future and notify the applicant of the time and purpose of the TC.

      The eligibility worker records the date and time of the Telephone Consultation on the Telephone Consultation Guide (ES -3903). The guide is a tool the applicant can complete prior to the TC in preparation of the TC. The guide is then given, or mailed, to the applicant. Completing the Telephone Consultation Guide is not required, but is greatly encouraged.
       
    5. Obtain Three Copies of the ES-3904, HIPAA Compliant Authorization to Disclose information to Kansas Health Policy Authority - These releases are necessary in order to obtain medical records. The releases must be signed. The eligibility worker shall obtain the releases as part of the interview process. If a face-to-face interview is not completed, mail the forms to the individual. Instruct the individual to return the forms to the PMDT. A pre-addressed envelope shall be included. The PMDT must receive the original forms, as medical providers may not accept copies. If the eligibility worker obtains the forms from the client, they are faxed to the PMDT. The original copies are sent to the PMDT. Providing signed releases is a program requirement and negative action may be taken if the individual doesn't provide them.
       
    6. Obtain the ES-3908, Disability Consultation/ Representation Referral to Kansas Legal Services for persons applying for General Assistance - If the individual already has representation, a KLS referral is not necessary. Information on the representative is noted on the initial referral form (see 1724).
       
    7. 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.
       
    8. Provide the individual with Presumptive Medicaid Disability Determination Brochure (ES-3902).
       
    9. Complete the Presumptive Medicaid Disability Team Referral (ES-3901) - The referral is to be sent to the PMDT within 1 day of the completed interview. If there is no interview scheduled, the referral must be sent within 2 days of receiving the application. All fields must be completed in Section 1 in order for the referral to be accepted by the PMDT. Fields in Section 2 are to be completed if the information is available. But, do not hold the referral while waiting for the information.
       
    10. 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 KHPA staff. All policies and procedures used by the PMDT to determine disability are located in the PMST Procedures Manual.
       
    11. Assign to Case Development Specialist - Upon receipt of the ES-3901, the case will be assigned to a CDS. The Specialist will be responsible for completing the telephone consultation, requesting medical evidence, scheduling any consultive examinations and preparing the disability file for the Disability Examiner.
       
    12. 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.
       
    13. 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 made a determination of the individual's status. KHPA currently contracts with Disability Determination Services for services provided by the Disability Review Team. The PMDT's DE may also serve as the DE for the DRT.
       
    14. Notification to PMDT - The DRT will notify the PMDT of the outcome of the disability determination. The information will be recorded by the PMDT.
       
    15. Notification to the Eligibility Worker - The PMDT will send final notification regarding the disability determination to the case worker on the PMDD Notification of Changes and Final Decision Form (ES-3906). The form will be sent electronically to the case worker with a copy to the Regional PMDD mailbox. The PMDT will retain the disability file.
       
    16. 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 General Assistance or 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.
     

    1. The Telephone Consultation - A Telephone Consultation must be completed as part of the PMDT's disability determination. One appointment will be scheduled by the eligibility worker. If the applicant/recipient fails to keep the appointment, it shall be considered non-cooperation. A second appointment will NOT be automatically rescheduled.
       
    2. 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 45 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 (communicate on the ES-3106 - e.g., failure to provide information, excess resources).

     

    A special form to report changes between the entities has been developed. The ES-3906, The Presumptive Medical Disability Determination Notification of Changes and Final Decision, shall be used as the tool to report these changes. The form may be faxed or sent electronically.

     

    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 an/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, 1104, and 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 Protected Filing Dates - The date an application for medical assistance or General Assistance is made is considered the Protected Filing Date if a determination of medical assistance cannot be made because a final Social Security disability determination has not been issued. The initial application date is active as long as the individual cooperates with the medical assistance determination and the SSA application is pending an initial determination or is in appeal status. Verification of a timely appeal is required. Failure to cooperate with General Assistance criteria does not impact the medical protected filing date. Final action must be taken on the application once SSA makes a final determination.

     

    If SSA finds the individual is disabled, 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 General Assistance - MediKan recipients. Persons who are receiving Presumptive Medicaid Disability coverage are converted to another type of Medicaid.

     

    If SSA finds the individual is not disabled, Medicaid 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.

     

    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.