5101:1-5-20 Disability financial assistance: the determination of a disability.

(A) What is the definition of disability and how is it determined?

(1) "Disability" for purposes of the disability financial assistance (DFA) program is defined in section 5115.01 of the Revised Code. "Disability" applies to an individual who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than nine months.

(2) The determination of disability is made by the disability determination area, and is based on supplemental security income (SSI) disability criteria except for the twelve-month period for SSI disability requirement.

(3) The county agency cannot make its own determination of a disability.

(4) The determination of disability by the disability determination area for medicaid may be used to meet the disability determination requirement for the DFA program.

(B) What is the responsibility of the county agency in the disability determination process?

(1) The county agency shall develop the medical information necessary for submission to the disability determination area for a determination of disability in the following situations:

(a) An individual has, alleges to have, or appears to have a physical or mental impairment, or combination of impairments that may limit his or her ability to work;

(b) An individual is, alleges to be, or appears to be blind;

(c) An individual has, alleges to have, or appears to have a physical or mental impairment, blindness, or combination of impairments, but is eligible for medicaid under a category other than disability or blindness;

(d) An individual has a pending application for social security administration (SSA) disability benefits under Title II of the Social Security Act, and/or SSI benefits under Title XVI of the Social Security Act [ 42 U.S.C. 402 (12/8/2014) and 42 U.S.C. 1382 (12/26/2013) respectively]; or

(e) An individual is determined to have presumptive disability by the SSA, and the individual has an application for SSA disability benefits pending.

(2) The county agency shall give the following forms to the individual, the individual's legal representative, the authorized representative, or the treating physician(s):

(a) The ODM 07302 "Basic Medical" (rev. 7/2014 ) which must be signed by a licensed physician;

(b) The ODM 07308 "Mental Functional Capacity Assessment" (rev. 1/2015). This form is provided when the individual has or appears to have a mental impairment. This form must be signed by a licensed physician/psychiatrist or licensed psychologist ; and

(c) The ODM 03606 "Medication Dependencies" (rev. 7/2014) when applicable.

(3) When the individual alleges a disability or blindness, the individual must provide documentation from an appropriate medical professional knowledgeable about the individual's current medical status to support the existence of the impairment or condition.

(4) Upon request, the county agency shall assist the individual in obtaining medical documentation to support the disability or blindness claim. Upon request, the county agency shall use administrative funds to assist the individual in receiving an eye examination or medical/psychological examination to determine whether an individual is blind or disabled. The county agency shall assist the individual in obtaining existing medical information, tests, services or records from other entities, such as the SSA, opportunities for Ohioans with disabilities, Ohio rehabilitation services commission, workers compensation, etc.

(5) Upon receipt of the medical documentation the county agency shall submit the following documentation to the disability determination area for a disability determination:

(a) The JFS 03605 "CDJFS Referral to DDU" (rev. 06/2006);

(b) The ODM 07004 "Social Summary Report for Disability Determination" (rev. 7/2014);

(c) The ODM 07302;

(d) All available current medical information for all alleged impairment(s) or combination of impairments;

(e) The ODM 07308 when applicable.

(6) When the disability determination area determines that an individual meets the disability requirement for DFA, the county agency shall approve DFA for the individual, provided that the following conditions are met:

(a) The individual meets all DFA eligibility requirements contained in this rule;

(b) The individual is not eligible for an interim or advance payment from SSI; and

(c) The individual complies with the requirements of DFA interim assistance as described in rule 5101:1-5-70 of the Administrative Code.

(7) The county agency shall maintain case records in accordance with rule 5101:9-9-21 of the Administrative Code.

(8) The county agency shall issue proper notice and hearing rights as described in division 5101:6 of the Administrative Code.

(9) All individuals who appear to meet the aged, blind or disabled criteria as described in rule 5160:1-3-02 of the Administrative Code, shall be referred to the SSA to apply for SSA disability benefits under Title II of the Social Security Act and/or SSI benefits under Title XVI of the Social Security Act. Additionally, all individuals applying for or in receipt of DFA who appear to meet the blind or disabled criteria described in rule 5160:1-3-02 of the Administrative Code shall be referred to the SSI case management program.

(C) What is the disability determination area's responsibility in the disability determination process?

(1) The disability determination area will review all medical documentation and notify the county agency of the approval, denial or deferral of a determination.

(2) The disability determination area shall enter this information into the statewide automated eligibility system .

(3) When the disability determination area approves a disability, a disability begin date and disability review date are provided by the disability determination area. The disability review date is the date on which the current approval will expire.

(4) If the disability determination area defers a disability determination, it will request additional medical documentation from the county agency. If the county agency is unable to obtain all of the requested additional medical information, the county agency shall re-submit the initial disability and any additional information to the disability determination area. The disability determination area must make a final decision on the case.

(5) Any decision made by the disability determination area is subject to all hearing and appeal rights as described in division 5101:6 of the Administrative Code.

(D) What requirements does the individual have?

(1) Each applicant for or recipient of DFA who, in the judgment of the Ohio department of job and family services (ODJFS) or the county agency might be eligible for SSI, shall as a condition of eligibility for DFA, apply for SSI when directed by the ODJFS or the county agency.

(2) The applicant or recipient, as a condition of eligibility for DFA, must pursue reconsiderations and appeals of the SSA decisions that deny the individual SSI benefits.

(E) How is a disability determination re-review handled?

(1) The county agency shall submit the following information to the disability determination area prior to the disability review date:

(a) All required forms specified in this rule and all available current medical information to support the disability claim ;

(b) The previously approved disability paperwork ; and

(c) Any other information requested by the disability determination area.

(2) The county agency shall not terminate DFA based solely on the expiration of the current disability approval without a new determination of disability.

(3) If the individual continues to meet all other DFA eligibility requirements as described in Chapter 5101:1-5 of the Administrative Code, the county agency shall continue DFA eligibility for the individual while the disability determination area is conducting the disability review.

(F) How is the disability determination affected when DFA benefits are terminated, and the individual reapplies for DFA?

(1) If the individual reapplies within twelve months after the disability begin date, the disability criterion is met. The county agency shall not submit new disability paperwork to the disability determination area. The county agency shall apply the existing disability review date, in accordance with paragraph (C)(3) of this rule.

(2) If the individual reapplies beyond twelve months of the disability begin date, the disability criterion is not met. The county agency shall submit a new disability packet to the disability determination area for a disability determination, in accordance with paragraph (B) of this rule.

Effective: 1/1/2016
Five Year Review (FYR) Dates: 09/17/2015 and 01/01/2021
Promulgated Under: 111.15
Statutory Authority: 5115.03
Rule Amplifies: 5115.01, 5115.03
Prior Effective Dates: 9/3/77, 1/1/81, 6/1/84, 9/6/84, 8/1/85, 7/1/87 (Emer.), 8/3/87, 1/1/88, 3/28/88, 4/1/89 (Emer.), 4/24/89, 4/1/90, 10/1/90, 10/1/91 (Emer.), 12/20/91, 4/1/92 (Emer.), 6/30/92, 12/22/92 (Emer.), 3/20/93, 10/30/95, 7/1/98, 7/1/03, 1/1/05, 4/1/10