Rule 5160:1-3-02.9 | Medicaid: disability determination process.
(A) This rule addresses the process of determining blindness or disability for non-citizen emergency medical assistance (NCEMA), medicaid buy-in for workers with disabilities (MBIWD), retroactive coverage for a deceased individual, or the specialized recovery services (SRS) program.
(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 an 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 (SSA'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 October 1, 2023), by the SSA.
(C) Administrative agency responsibilities.
(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 that the limiting physical factor is met and do 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 that the limiting physical factor is not met and submit a disability packet to the DDA for a disability determination when the individual is potentially eligible for one of the following:
(a) NCEMA, except for routine labor and delivery, as described in rule 5160:1-5-06 of the Administrative Code; or
(b) MBIWD, in accordance with rule 5160:1-5-03 of the Administrative Code, when an individual has not 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) SRS, in accordance with rule 5160:1-5-07 of the Administrative Code, when an individual has not been determined disabled by the SSA.
(i) The administrative agency is only required to submit the ODM 03605 "CDJFS Referral to DDU" (rev. 8/2021) as referenced in paragraph (C)(11) of this rule. No other forms or documentation listed in this rule are required to be completed by the administrative agency for an SRS referral to DDA.
(ii) DDA will have access to electronic health records maintained by the recovery manager in order to make an accurate disability determination.
(4) Contact the DDA nurse manager to request an expedited disability decision from the SSA for an individual who has an initial disability application that has been pending for ninety days or longer. The CDJFS shall not submit a disability packet for these individuals.
(5) Presume the limiting physical factor is met and do 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.
(6) Upon request, assist the individual with obtaining medical documentation to support the blindness or disability claim, including, when 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.
(7) Obtain and/or assist the individual with 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 the information along with 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.
(8) 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. 7/2018); and
(b) ODM 07308 "Mental Functional Capacity Assessment" (rev. 7/2018) when the individual has or appears to have a mental impairment; and
(c) JFS 03606 "Medication Dependencies" (rev. 5/2006) when applicable.
(9) Complete the ODM 07004 "Social Summary Report for Disability Determination" (rev. 7/2018).
(10) Obtain signed copies of form ODM 03397 "Authorization for the Release or Use of Protected Health Information (PHI)" (rev. 6/2021) from the individual for all providers who have or may have current medical information.
(11) Complete the ODM 03605 "CDJFS Referral to DDU" (rev. 8/2021).
(12) Submit the disability packet to the DDA for a blindness or disability determination for an individual with potential eligibility as described in paragraph (C)(3) of this rule.
(13) Resubmit the initial disability packet and any additional information to the DDA for a final decision when the DDA has deferred a disability determination and the administrative agency is unable to obtain all of the requested additional medical information.
(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) 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)(13) 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) Discontinuance of an MBIWD DDA-approved individual. When an MBIWD DDA-approved individual is discontinued 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) More than twelve months after 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 (E) of this rule.
(G) 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.
Last updated December 1, 2023 at 9:38 AM
Supplemental Information
Amplifies: 5160.02, 5163.02
Five Year Review Date: 12/1/2028
Prior Effective Dates: 9/3/1977, 1/1/1981, 9/6/1984, 8/1/1985, 7/1/1987 (Emer.), 8/3/1987, 1/1/1988 (Emer.), 3/28/1988, 10/1/1988 (Emer.), 12/20/1988, 4/1/1990, 10/1/1991 (Emer.), 12/1/1991, 12/2/1991, 12/20/1991, 1/1/1992 (Emer.), 3/20/1992, 12/22/1992 (Emer.), 1/1/1993 (Emer.), 2/11/1993, 3/20/1993, 9/1/1993, 8/1/1995 (Emer.), 10/30/1995, 4/1/1999, 10/1/2002, 11/25/2002, 1/1/2005, 2/23/2015, 8/1/2016, 7/1/2018