Lawriter - OAC - 5160:1-3-02.9 Medicaid: disability determination process.

5160:1-3-02.9 Medicaid: disability determination process.

(A) This rule addresses the process of determining blindness or disability for medical assistance eligibility purposes.

(B) Definitions.

(1) "Administrative agency," for the purpose of this rule, means the county department of job and family services (CDJFS).

(2) "Current medical information" means medical records that originated within eighteen months of the date of initial application.

(3) "Deferred" means the delay in the determination for a disability packet due to incomplete or a insufficient amount of current medical information for the disability determination area (DDA) to approve, deny or continue the blindness or disability claim.

(4) "Disability begin date" means the date the individual is otherwise eligible for medical assistance and meets the limiting physical factor.

(5) "Disability determination" is the process by which the DDA determines whether the individual meets the social security administration's definition of "blind" or "disabled" for medical assistance eligibility. The DDA determines blindness and disability in accordance with SSA policy.

(6) "Disability packet" consists of all required forms specified in paragraph (C) of this rule and all available current medical information to support the individual's blindness or disability claim. The disability packet is submitted by the administrative agency to the DDA for a disability determination.

(7) "Disability review date" means the date, determined by the DDA, that the individual's current blindness or disability approval will expire.

(8) "Limiting physical factor" is a non-financial eligibility criterion consisting of a physical or mental characteristic or impairment, or a combination of physical or mental characteristics or impairments, that may limit the individual's ability to work. An individual meets the limiting physical factor by meeting the criteria of age, blindness or disability as set forth in rule 5160:1-3-02 of the Administrative Code.

(9) "SSA disability" means a determination of blindness or disability, as set forth in section 1902 of the Social Security Act (as in effect on October 1, 2017), by the social security administration (SSA).

(C) Administrative agency responsibilities. The administrative agency shall:

(1) Determine eligibility for medical assistance in accordance with the eligibility rules contained in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(2) Determine the limiting physical factor is met and shall not submit a disability packet to the DDA when the individual:

(a) Is sixty-five years of age or older; or

(b) Has been approved for SSA disability for the individual's own blindness or disability.

(3) Determine the limiting physical factor is not met and shall submit a disability packet to the DDA for a disability determination when the individual is potentially eligible for one of the following:

(a) Alien emergency medical assistance (AEMA) in accordance with rule 5160:1-5-06 of the Administrative Code; or

(b) Medicaid buy-in for workers with disabilities (MBIWD) in accordance with rule 5160:1-5-03 of the Administrative Code when an individual has not yet been determined disabled by the SSA; or

(c) Medical assistance for an individual who has died and retroactive eligibility is requested in accordance with rule 5160:1-2-01 of the Administrative Code; or

(d) An individual has an initial application for SSA disability pending with the SSA for ninety days or more.

(4) Presume the limiting physical factor is met and shall not submit a disability packet to the DDA for a disability determination when the individual is determined to have a presumptive disability by the SSA and has an application for SSA disability pending.

(5) Upon request, assist the individual with obtaining medical documentation to support the blindness or disability claim, including, if necessary, using administrative funds to assist the individual with receiving a medical, psychological or eye examination to determine whether the individual is blind or disabled.

(6) Obtain and/or assist the individual in obtaining all available current medical information that pertains to the individual's alleged impairment(s) or combination of impairments, as well as any other information requested by the DDA, and submit it in the disability packet. This includes existing medical information, tests, services or records from other entities such as the SSA, opportunities for Ohioans with disabilities, workers' compensation, etc.

(7) Provide 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) ODM 07302 "Basic Medical" (rev. 5/2018 ); and

(b) ODM 07308 "Mental Functional Capacity Assessment" (rev. 5/2018 ) when the individual has or appears to have a mental impairment; and

(c) JFS 03606 "Medication Dependencies" (rev. 5/2006 ) when applicable.

(8) Complete the ODM 07004 "Social Summary Report for Disability Determination" (rev. 5/2018 ).

(9) Obtain signed copies of form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 2/2016 ) from the individual for all providers who have or may have current medical information.

(10) Complete the JFS 03605 "CDJFS Referral to DDU" (rev. 6/2006 ) using current medical information.

(11) Submit the disability packet to the DDA for a blindness or disability determination.

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

(D) Individual responsibilities.

(1) When the individual alleges a blindness or disability, the individual shall assist the administrative agency with obtaining all available current medical information that supports the blindness or disability claim.

(2) As a condition of eligibility for medical assistance, the individual is required to apply for any disability benefits to which the individual may be entitled in accordance with rule 5160:1-2-10 of the Administrative Code.

(E) Disability determination area (DDA) responsibilities.

(1) The DDA shall approve, deny or defer disability determinations, and shall notify the administrative agency via the electronic eligibility system.

(2) The DDA shall determine the disability begin date and end date, as appropriate, for approved blindness or disability claims, and shall inform the administrative agency via the electronic eligibility system.

(3) In accordance with paragraph (C)(12) of this rule, when the initial disability packet is resubmitted to the DDA because the administrative agency was unable to obtain the requested additional medical information, the DDA shall make a final decision on the case based upon the information available in the initial disability packet, and shall notify the administrative agency of the decision via the electronic eligibility system.

(F) Eligibility for medical assistance during initial disability determination.

(1) If the individual meets all other medical assistance eligibility criteria and also meets the limiting physical factor in accordance with paragraph (C)(2) of this rule, the administrative agency shall approve eligibility for medical assistance, and shall not submit a disability packet to the DDA.

(2) If the individual meets all other medical assistance eligibility criteria, but has not yet been determined to meet the limiting physical factor, the administrative agency shall not approve eligibility for medical assistance and shall submit a disability packet to the DDA for a disability determination in accordance with paragraph (C)(3) of this rule.

(3) When the individual's SSA disability application is pending for ninety days or more, the administrative agency shall submit a disability packet to the DDA for a disability determination.

(a) If the DDA approves the blindness or disability, the limiting physical factor is met, and the individual meets all other medical assistance eligibility criteria, the administrative agency shall approve eligibility for medical assistance until the date the SSA makes a decision on the SSA application.

(b) If the DDA denies the blindness or disability, the limiting physical factor is not met and the administrative agency shall deny eligibility for medical assistance until the SSA makes a decision on the SSA application.

(i) If the SSA approves SSA disability, the limiting physical factor is met and the administrative agency shall determine eligibility for medical assistance based upon the initial application for medical assistance and continue eligibility for medical assistance until a renewal is required.

(ii) If the SSA denies SSA disability, the limiting physical factor is not met and the administrative agency shall deny eligibility for medical assistance programs where blindness or disability is an eligibility requirement.

(G) Renewal for medical assistance. When an individual is terminated from medical assistance and reapplies:

(1) Within twelve months after the disability begin date, the individual meets the limiting physical factor for the remainder of the twelve months. The administrative agency shall not submit a new disability packet to the DDA. The administrative agency shall apply the existing disability review date.

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

(H) Eligibility for medical assistance when SSA denials are appealed.

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

(2) An individual shall not be eligible for medical assistance programs, where blindness or disability is an eligibility requirement, during the SSA appeals process.

Effective: 7/1/2018
Five Year Review (FYR) Dates: 8/1/2021
Promulgated Under: 111.15
Statutory Authority: 5163.02, 5160.02
Rule Amplifies: 5160.02 , 5163.02
Prior Effective Dates: 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, 4/1/90, 10/1/91 (Emer.), 12/1/91, 12/2/91, 12/20/91, 1/1/92 (Emer.), 3/20/92, 12/22/92 (Emer.), 1/1/93 (Emer.), 2/11/93, 3/20/93, 9/1/93, 8/1/95 (Emer.), 10/30/95, 4/1/99, 10/1/02, 11/25/02, 1/1/05, 2/23/15, 8/1/16