5101:1-39-03 Medicaid: limiting physical factor.

(A) This rule addresses the eligibility criterion of limiting physical factor. Limiting physical factor is a non-financial medicaid eligibility criterion.

(B) Definitions.

(1) "Administrative agency" is the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS) or other entity that determines eligibility for a medical assistance program.

(2) "CMS packet" consists of all required forms specified in paragraph (C) of this rule and all available current medical information to support the disability claim. The CMS packet is submitted by the administrative agency to the county medical services (CMS) unit for a disability determination.

(3) "Continuing disability review" is the process by which the CMS unit determines whether an individual continues to meet the disability criteria for medicaid eligibility. The CMS unit will conduct a continuing disability review for individuals who are approved for disability or blindness by the CMS unit but who are not yet approved for SSA disability benefits through the social security administration (SSA). The CMS unit shall determine the disability begin date and disability review date.

(4) "Current medical information" is medical information that originated within eighteen months of the date of initial application or continuing disability review.

(5) "Deferral of a disability determination" is the process by which the CMS unit returns the CMS packet to the administrative agency because there is incomplete or insufficient information contained in the CMS packet to approve, deny or continue the disability or blindness claim.

(6) "Disability determination" is the process by which the CMS unit determines whether an individual meets the limiting physical factor eligibility criteria of "blind" or "disabled" for medicaid eligibility. The CMS unit determines blindness and disability in accordance with SSA policy. The SSA sets forth a five-step sequential evaluation process for determining whether or not an individual is disabled.

(7) "Disability begin date" is the date that the CMS unit enters into the electronic eligibility system as the date on which the CMS unit determines an individual meets the limiting physical factor.

(8) "Disability review date" is the date that the CMS unit determines for the continuing disability review and the date that the current CMS approval will expire.

(9) "Individual" is the applicant or recipient of a medical assistance program.

(10) "Limiting physical factor" is a physical or mental characteristic or impairment or combination of characteristics or impairments that may limit an individual's ability to work. For the purposes of medicaid eligibility, limiting physical factor is a non-financial eligibility criterion. There are three ways an individual can meet the eligibility criterion of limiting physical factor:

(a) "Aged" means an individual is age sixty-five years or older. The administrative agency shall determine if the individual meets the limiting physical factor of "aged";

(b) "Blind" as defined in 42 USC 1382c , (12/17/1999) means an individual has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; and

(c) "Disabled", as defined in 42 USC 1382c , (12/17/1999):

(i) An individual age eighteen or over who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.

(ii) An individual under age eighteen who has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.

(11) "Mental deficiency" means mental retardation. The presumptive disability category outlined in paragraph (I) of this rule pertains to individuals who require care and supervision of routine daily activities and are dependent upon others for meeting personal care needs. As a result of mental retardation, the individual's dependence on others grossly exceeds age-appropriate dependence.

(12) "Pending" means the SSA is in the process of making a determination, whether initial or continuing disability review, about whether the individual is disabled and has not yet arrived at a decision.

(13) "Presumptive disability" is a temporary determination of disability. The administrative agency shall determine the limiting physical factor is met when the individual alleges, another person who is applying on behalf of the individual alleges, or the individual appears to have at least one of the specific impairments or conditions listed in paragraph (I) of this rule.

(14) "SSA disability benefits" are disability benefits provided to an individual and authorized by the SSA through Title II and Title XVI of the Social Security Act [ 42 USC 402 (4/7/2000) and 42 USC 416 (8/15/1994)]. "Supplemental Security Income (SSI)" are benefits authorized by the SSA through Title XVI of the Social Security Act.

(C) Administrative agency responsibilities.

(1) The administrative agency shall determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) The administrative agency shall determine the limiting physical factor is met and shall not submit a CMS packet to the CMS unit when:

(a) An individual meets the definition of "aged"; or

(b) An individual has been approved for SSA disability benefits for the individual's own disability or blindness as defined in paragraph (B)(14) of this rule.

(c) An individual has a level of care (LOC) determination in accordance with rule 5101:1-39-04 of the Administrative Code.

(3) The administrative agency shall determine the limiting physical factor is not met and shall submit a CMS packet to the CMS unit for a disability determination when:

(a) An individual has, alleges, 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 being or appears to be blind;

(c) An individual is potentially eligible for alien emergency medical assistance (AEMA) under a category of medicaid that requires a disability determination, in accordance with rule 5101:1-41-20 of the Administrative Code;

(d) An individual has an application for SSA disability benefits pending with the SSA; and

(e) An individual has, alleges 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.

(4) The administrative agency shall determine the limiting physical factor is met and shall also submit a CMS packet to the CMS unit for a disability determination when:

(a) An individual is determined to have a presumptive disability in accordance with paragraph (I) of this rule; and

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

(5) As a condition of medicaid eligibility, the administrative agency shall require individuals to apply for any SSA disability benefits to which they are entitled.

(6) Upon request, the administrative agency shall assist the individual in obtaining medical documentation to support the disability or blindness claim. Upon request, the administrative agency shall utilize administrative funds to assist the individual in receiving an eye examination or medical/psychological examination to determine whether an individual is blind or disabled.

(7) The administrative agency shall obtain all available current medical information as well as any other information requested by the CMS unit and submit it in the CMS packet.

(a) The administrative agency shall include in the CMS packet all available current medical information for all alleged impairment(s) or combination of impairments.

(b) The administrative agency shall assist the individual in obtaining existing medical information, tests, services or records from other entities such as the SSA, Ohio rehabilitation services commission, workers' compensation, etc.

(8) The administrative agency shall give the forms listed in this paragraph to the individual, the individual's legal representative, another person applying on behalf of the individual, or the treating physician(s).

(a) JFS 07302, "Basic Medical Form";

(b) JFS 07308, "Mental Functional Capacity Assessment" when the individual has or appears to have a mental impairment; and

(c) JFS 03606, "Physician Certification of Medication Dependency" when applicable.

(9) The administrative agency or SSI case manager shall complete the JFS 07004, "Social Summary Report for Disability Determination".

(10) The administrative agency shall complete the JFS 03605, "ODJFS Referral to CMS" using current medical information.

(11) The administrative agency shall submit the CMS packet to the CMS unit for a disability determination and for a continuing disability review.

(12) When the CMS unit has deferred a disability determination, and the administrative agency is unable to obtain all of the requested additional medical information, the administrative agency shall resubmit the initial CMS packet and any additional information to the CMS unit for a final decision.

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

(14) The administrative agency shall issue proper notice and hearing rights as outlined in division-level designation 5101:6 of the Administrative Code.

(15) The administrative agency shall not terminate medical assistance for a member(s) of an assistance group until a pre-termination review (PTR) of continuing medicaid or medical assistance eligibility has been completed in accordance with rule 5101:1-38-01.1 of the Administrative Code.

(16) The administrative agency shall determine presumptive disability when the individual alleges, another person who is applying on behalf of the individual alleges or the individual appears to have at least one of the specific impairments or conditions listed in paragraph (I) of this rule. The administrative agency shall obtain medical documentation from an appropriate medical professional knowledgeable about the individual's current medical status to support the existence of the specific impairment or condition. The administrative agency shall determine the limiting physical factor is met, approve medicaid eligibility and shall also submit a CMS packet to the CMS unit for a disability determination.

(17) The administrative agency shall submit the following information to the CMS unit for an individual's continuing disability review prior to the disability review date:

(a) A new CMS packet. The CMS packet shall contain all required forms specified in paragraph (C) of this rule and all available current medical information to support the disability claim;

(b) The previously approved CMS packet; and

(c) Any other information requested by the CMS unit.

(D) Responsibilities of the individual.

(1) When the individual alleges a disability or blindness, the individual shall assist the administrative agency in obtaining all available current medical information to include in the CMS packet that supports the disability or blindness claim. The individual shall assist the administrative agency in obtaining any existing medical information, tests, services or records from other entities such as the SSA, Ohio rehabilitation services commission, workers' compensation, etc.

(2) If the SSA makes a decision denying SSA disability benefits the individual has the right to file an appeal with the SSA.

(E) County medical services (CMS) unit responsibilities.

(1) The CMS unit shall approve, deny or defer disability determinations submitted by the administrative agency. The CMS unit shall notify the administrative agency upon approving, denying or deferring a disability determination via the electronic eligibility system and the JFS 03600, "County Medical Services Disability Determination".

(2) When the CMS unit approves a disability, the CMS unit shall determine the disability begin date and the continuing disability review date. The CMS unit shall inform the administrative agency via the electronic eligibility system and the JFS 03600.

(3) The CMS unit shall approve, deny or defer continuing disability reviews submitted by the administrative agency. The CMS unit shall notify the administrative agency upon approving, denying or deferring a continuing disability review via the electronic eligibility system and the JFS 03600.

(4) In accordance with paragraph (C)(12) of this rule, when the administrative agency is unable to obtain all of the requested additional medical information in a deferred case, the administrative agency shall resubmit the initial CMS packet to the CMS unit. The CMS unit shall make a final decision on the case. The CMS unit shall notify the administrative agency of the decision via the electronic eligibility system and the JFS 03600.

(F) Medicaid eligibility during initial eligibility determination.

(1) In order for an individual to be eligible for medicaid, the individual must meet all medicaid eligibility criteria.

(2) As a condition of medicaid eligibility, the administrative agency shall require individuals to apply for any SSA disability benefits to which they are entitled.

(3) If the individual meets limiting physical factor in addition to all medicaid eligibility criteria in accordance with paragraphs (C)(1) to (C)(2) of this rule, the administrative agency shall approve medicaid eligibility.

(4) If the individual meets limiting physical factor in addition to all medicaid eligibility criteria in accordance with paragraphs (C)(1) and (C)(4) of this rule, the administrative agency shall approve medicaid eligibility and shall also submit a CMS packet to the CMS unit for a disability determination.

(5) If the individual does not meet limiting physical factor in accordance with paragraph (C)(3) of this rule, the administrative agency shall not approve medicaid eligibility and shall also submit a CMS packet to the CMS unit for a disability determination.

(6) If the SSA denies the individual SSA disability benefits or does not complete a disability determination for a non-disability reason, the administrative agency shall submit a CMS packet to the CMS unit for a disability determination, in accordance with paragraph (C) of this rule.

(a) If the CMS unit approves the disability, the limiting physical factor is met and the administrative agency shall approve medicaid eligibility.

(b) If the CMS unit denies the disability, the limiting physical factor is not met and the administrative agency shall not approve medicaid eligibility.

(7) When the individual's SSA application is pending, the administrative agency shall submit a CMS packet to the CMS unit for a disability determination, in accordance with paragraph (C) of this rule.

(a) If the CMS unit approves the disability, the limiting physical factor is met and the administrative agency shall approve medicaid eligibility until the SSA makes a decision on the SSA application.

(b) If the CMS unit denies the disability, the limiting physical factor is not met and the administrative agency shall not approve medicaid eligibility until the SSA makes a decision on the SSA application:

(i) If the SSA makes a decision approving SSA disability benefits, the limiting physical factor is met and the administrative agency shall determine medicaid eligibility based upon the initial medicaid application and continue medicaid eligibility until a medicaid redetermination is required.

(ii) If the SSA makes a decision denying SSA disability benefits, the limiting physical factor is not met and the administrative agency shall not approve medicaid eligibility.

(8) When the SSA makes a decision denying SSA disability benefits, the individual has a right to appeal the SSA decision.

(9) The SSA appeal consists of several levels of administrative review that shall be requested within certain time periods and at the proper level. The levels of administrative review are reconsideration, administrative law judge (ALJ) hearing, and appeals council review. The appeals council review ends the administrative review process. If an individual is still dissatisfied, he/she may request judicial review which is done by filing an action in federal court.

(a) If the individual appeals the SSA decision, the administrative agency shall continue medicaid eligibility through the SSA appeals council review process. The SSA gives an individual sixty-five days to request an appeal after receiving notice of denial. Eligibility for medicaid shall continue through the sixty-fifth day from the date on the adverse SSA disability decision.

(b) If an individual requests an appeal of the SSA decision before medicaid is terminated, medicaid shall be continued until a decision is made after the SSA appeals council review. The SSA appeals council review is the final administrative decision.

(c) If the individual fails to appeal the SSA decision within the sixty-five day period, but is later permitted by the SSA to appeal for good cause shown, the administrative agency shall restore medicaid eligibility back to the date of the medicaid termination.

(d) If the individual fails to appeal the SSA decision in accordance with paragraph (F) of this rule, the limiting physical factor is no longer met.

(G) Medicaid eligibility during continuing disability review.

(1) In order for an individual to be eligible for medicaid, the individual must meet all medicaid eligibility criteria. If the individual meets all medicaid eligibility criteria, the administrative agency shall continue medicaid eligibility while the CMS unit is conducting a continuing disability review.

(2) If the SSA had previously denied the individual SSA disability benefits or did not complete a disability determination for a non-disability reason and the CMS unit approved the disability, the administrative agency shall submit a CMS packet to the CMS unit for a disability determination, in accordance with paragraph (C) of this rule.

(a) If the CMS unit approves the disability, the limiting physical factor is met and the administrative agency shall continue medicaid eligibility.

(b) If the CMS unit denies the disability, the limiting physical factor is not met and the administrative agency shall not continue medicaid eligibility.

(3) When the individual's SSA application is pending at the time of the continuing disability review, the administrative agency shall submit a CMS packet to the CMS unit in accordance with paragraph (C) of this rule.

(a) If the CMS unit approves the disability, the limiting physical factor is met and the administrative agency shall continue medicaid eligibility until the SSA makes a decision on the SSA application.

(b) If the CMS unit denies the disability, the limiting physical factor is not met and the administrative agency shall not continue medicaid eligibility.

(4) If the individual's SSA application is in an appeal at the time of the continuing disability review, the administrative agency shall continue medicaid eligibility through the SSA appeals council review process, in accordance with paragraph (F)(6) of this rule.

(H) Reapplication for medicaid. When an individual is terminated from medicaid and reapplies:

(1) Within twelve months after the disability begin date, the limiting physical factor is met. The administrative agency shall not submit a new CMS packet to the CMS unit. The administrative agency shall apply the existing disability review date, in accordance with paragraph (G) of this rule.

(2) Beyond twelve months of the disability begin date, the limiting physical factor is not met. The administrative agency shall submit a new CMS packet to the CMS unit for a disability determination, in accordance with paragraphs (C) to (F) of this rule.

(I) Presumptive disability conditions or impairments:

(1) Amputation of a leg at the hip;

(2) Total deafness;

(3) Total blindness;

(4) Bed confinement or immobility without a wheelchair, walker, or crutches, due to a longstanding condition, excluding recent accident and recent surgery;

(5) A stroke (cerebral vascular accident) more than three months in the past and continued marked difficulty in walking or using a hand or arm;

(6) Cerebral palsy, muscular dystrophy or muscle atrophy and marked difficulty in walking (e.g., use of braces), speaking or coordination of the hands or arms;

(7) Down's syndrome;

(8) An allegation of severe mental deficiency made by a person applying on behalf of an individual who is at least seven years of age, in accordance with the definition of "mental deficiency" in paragraph (B) of this rule;

(9) A child who has not attained his or her first birthday and the birth certificate or other evidence (e.g., the hospital admission summary) shows a weight below twelve hundred grams (two pounds, ten ounces) at birth;

(10) A child who has not attained his or her first birthday and the birth certificate or other evidence (e.g., the hospital admission summary) shows a gestational age at birth on the table below with the corresponding birth-weight indicated:

Gestational age and birth weight

Gestational age (in weeks) Weight at birth

37-40 Less than 2000 grams (4 pounds, 6 ounces)

36 1875 grams or less (4 pounds, 2 ounces)

35 1700 grams or less (3 pounds, 12 ounces)

34 1500 grams or less (3 pounds, 5 ounces)

33 1200 grams to 1325 grams (2 pounds, 10 ounces to 2 pounds, 15 ounces)

(11) Diseases and/or illnesses that are a result of human immunodeficiency virus (HIV) infection, and the diseases and/or illnesses have progressed to the point where the individual is unable to work for a minimum of twelve consecutive months, as confirmed by a licensed physician;

(12) An individual who is receiving hospice services because of terminal illness;

(13) A spinal cord injury producing inability to ambulate without the use of a walker or bilateral hand held assistive devices for more than two weeks;

(14) End stage renal disease with ongoing dialysis; or

(15) Amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease).

Eff 9-3-77; 1-1-81; 9-6-84; 8-1-85; 7-1-87 (Emer.); 8-3-87; 1-1-88 (Emer.); 3-28-88; 10-1-88 (Emer.); 12-20-88; 10-1-91 (Emer.); 12-2-91; 10-1-02; 11-25-02; Rescinded and renacted eff. 1-1-05
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.01 , 5111.011
Rule Amplifies: 5111.01 , 5111.011 , 5111.012
Replaces: 5101:1-39-03, 5101:1-39- 03.1, 5101:1-39- 03.2, 5101:1-39- 03.3
R.C. 119.032 review dates: 01/01/2010