WIXLIB

MEDI-CAL EUGlBILIlY MANUAL228- AGENCIES INVOLVED IN THE DISABIUTY NALUATION PROCESSThe roles of various government agencies invoked in the disabilii evaluation process are provided betow.I. SOCIAL SECURITY ADMINfSTRAnON (SSA) AND FEDERAL PROGRAMSDISABUJTY NALUATION DIVISION (FP-DED)-(SSA) contmds with the Disaba Evaluation Division @ED) ofthe state Department of Socid Senrices to periorm m e d i i detemhdons of d i i i t y . . There aretwo components of Dm: Federal Programs (FP)Bmnches determine di7ity for SSA's Tide I!prograrn and T i e XVI, the Supptemental Security lnwme (SSI)prograrn and State Programs (SP)Branches determine d i i for T i e XIX, Medi-Caf, &ng SSA's criteria for disability under SSI.The So& Securrty Ad-onDrsabiI*iEvaluation Analysts in Federal Programs-DED (FP-OED) are respomie for obtainingmedical and vocational doammG&ion, Mdering consuttative examinations. evaluating medicalevidenceand work and/or socia( W r y , and making a diitiity determination along with a Medicalcomdmlt2HEALTH CARE FINANCING ADMINISTRATION (HCFA)HCFA administers the Medicaid prograrn and sets forth the federal regulations for itsimplementation. HCFA has designated the state Department of Health Services (DHS) to overseethe Medicaid prograrn ( M e d i i ) in Cafiimia3.STATE DEPARTMENT OF HEALTH SERVICES (DHS)DHS is responsible for implementing federal regulations,developing policies and procedures, andp M m g guidanceto ensure c o m p l i i w a hregulations. DHS contractswith State Programs-DED(SP-DED)to do disabilii evaluations for those applying fw M e d i i as a b l i or d i e d personDHS works with county we!fare departments (CWDs)to enslne that M e d i i apBications basedon dkabiJity are prooessed tbnely between SP-DED and CWDs4.STATE PROGRAMS-DED (SP-DED)The State Programs-DEDlocated in Los Angeles and Oakland determine d i i for T i e XIXM e d ' i , using SSA's criteria for disability under SSI. SP-DED doesevaluationsfor dientsapplying at CWD for the Aged, BIind and Diiedhnedically Needy (ABD-MN) program. D ' i l i t ycriteria are the same for federal and state DED staff. Upon completion of the d ' i i i i evaluationof a Mind or disabled die* the CWD is advised of the decision so that the M&-Cal claimprocessing may be compieted.SECTION: 50167,50223MANUAL LElTEFl NO.:132#JAY 2 7 199( 22B-1

MEDK AL EUGlBtUTY MANUAL5.COUNTY WUFARE DEPARTMENT (CWD)-Whereas SP-DED is responsible for the medical determination of dia'ty. the CWD is responsiMefor the non-medii portion of determining eligibli for M e d ' i disabilii.The following steps should be followed by CWDs when a M e d i a dient daims to be d - M e d orM i , either verbally or in writing, such as in the Statement of Facts (MC210), Status Report (MC176s). or aDocranentIn case record how d i i was evaluated.Disability, using using methods listed h e 22. Section50167(a)(1); (a) through (c). .U i i to SSA or SP-DED if d i i & is notcoMmedbymethodsWinTitle22,Section50167 (a) (1). (a) thrwgt,(c).MC 223to dedde if a prior dsabCi decision wasmade by SSA tf yes. fesponsibgi for a cutrentevaluation may belong to SSA and d i n t may bereferred back to SSAAn MC Infomalion Notice 13 and a denial noticeof action (NOA), if appIicaWe, must be providedto dient to take to SSASECTION: 50167,50223MANUAL LETTER NO:132CAY 2 7fW 2252

----MEDWAL EUGlBILfTY MANUAL22C- COUNTY WELFARE DEPAFKMENT PROCEDURESThissectionliststhevariotsactivities CountyW (CWD)perfomrsmptocessingctaimsfor M e d i a dkbdii. The major CWD activit#s are.fisted m separate sections (22 Gl to G9) whict,provide a more comprehensive disaskm and instnrdionsfor knplementatiMlGI.R m g DisahiRyAppkdhmT o wOr SP-DEDC-2-gSubsbrfrmlG&fdAclivity/ S OC-3. Resun Specifies cirwms&m in which disabiiiiapplications are referred to SSA or accepted byCWD for &hto SP-DED. es andinsbuctionsonprocesStngand engagingmsGActabnswhen-.areworkingD /PDProvidesIcriteria and procedures for determirrirrgf a dm can granted PD. Indudes detaaedcriteria for d i with Human Immunodeficiencyvsus 0 infection.Cb.C O m p J e i h g D f r b n Provides a l i - of forms used in the d i ievalrration process Includes insbucbions on theuseoftheformsGSPmwwngCWD W o r k r r * O wC-&Assemhhg AndPedrstsSmding SP-DWProvidesbad groundonthe dCWDobsenrations and how they can be provided toSP-DED. Includes a form which can be used toprovide obsehatiorrs to s p a .Diswsses ihnaed and MI packet &uathmreaoaca'nreM e d i i mqwstq prior SSI/SSP-recrplerrEs, and Railroad R e l h m n t Boardd i i i ctaimsC-7.-9Wrtt,SP-DED AndDHSAbwt Changes And StsbsProvides instructions for nobJying SP-DED aboutdmp which occur during claim developmentanduseof hbrmbnrqmtsprwidedbys p a . iswssssto commrsnicatewith Ms.Provides brfomration on aIicnrvance, denial and nocjemmmh-onslndudesbrsaucbionsonCWD actions to be taken upon receipt ofSP-DED's decision.C-9.Processing Reexaminations,Re&2wmhzaSbns And Rmiua-Ptavides criteria and instNctions onh0Wreexaminations, redeterminations andreevaluations should be procsssed.SECTION: 950167,50223MANUAL E H E R NO2132MAY 2 7 1994 22G1

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL22 C-11.- REFERRING DISABILITY APPLICATIONS TO SSA OR SP-DEDBACKGROUNDThe 1990 revisions t o CFR 435.541 specify the situations when client must be referred backt o the Social Security Administration (SSAI to apply for disability benefirs, or be allowed to filea Medical application based on disability. Therefore, it is very important that CWDs carefullyreview the MC 223 (Applicant's Supplemental Statement of Facts for Medi-Call to determinewho has jurisdiction over an application for disability benefits.NOTE: A chart at the end of this section identifies situations when a client is referred t o SSAor SP-DED afterlduring SSA's decision on a -disability claim.When a Medi-Cal application based on disability is accepted from client, optional formMC 017 N C 017 (Sp) may be given t o client. This informational form gives client. an overviewof what can be expected when a disability application is filed.2.FEDERAL DISABILITY EVALUATION BY S S AA.Guidelines For Referrino Client To SSASSA refers case t o FP-DEDfor a disability evaluation in the following situations. (Refert o SSAISP-DED chart at the end of this section to determine when to refer client t oSSA.)SSA Has Denied DisabilityStatus W/tf,mThe Revious 60DaysClient must ask SSA t o 'reconsider" a previousdenial action, as client has 60 days t o appealSSA's decision. CWD will deny the Medi-Calapplication.tf ciient has a reconsideration request pendingwith SSA, CWD will deny the Medi-Calapplication.SSl Has Denied DisabilityStatus More Than 60 days ButW i nOne Ywr Of CunentDateSECTION: 50167, 502231.Client must ask SSA t o "reopen" theprevious evaluation. A t its discretion,SSA may or may not 'reopen" theclaim. CWD will deny the Medi-Calapplication. .2.If client's same condition has changedor worsened, CWD must refer clientback t o SSA. CWD will deny theMedi-Cal application.MANUAL LEITER NO,: 142DATE:f EB 0 6 l9%2 -1.1

MEDI-CAL ELIGIBILITY MANUAL- PROCEDURES SECTION3SSA Denied W m More ThanOne Year Before The CurrentDateIf SSA denied the disability claim afterreopening the previous decision, SSA'sdecision would be controiling overMedi-Cal. CWD will deny the Medi-Calapplication.If ciiem does not allege that the same conditionhas worsenedthat there is a new condition,client will be asked to file a new applicationwith SSA.CWD will deny the Medi-Calappiication.B.S e c i aHandlinalof Federal DecisionsThe following specifies situations when CWD can rescind a prior hkCfiiCal denial, anerfollowing the 1990Regulations which require that a Medi-Cal application be denied andclient referred back t o SSA.SS4 Approves Disability AfterOriginally Denying Cf.aimCWD will RESCIND piior Medical denial andapprove Medi-Cal, if otherwise eligible. Newappiication or referral to SP-DED not needed ifSSA's disablity .onset date coincides withrequest for Medi-Cal coverage.If retro Medi-Cal is needed, send full packet.Include SSA award letter. In item 5 ofMC 221, indicate initial Medi-Cal applicationdate (before diem was referred to SSA) toprotect diem's original fiiing date and specify' d i n t was originally denied and referred toSSA for reopening' in Item 10 (Commentssection) of MC 221.N O l E Request for retro onset must be made-within one year of the montb for whichretroactive coverage is requested.3.STATE DISABILITY EVALUATION BY SP-DED FOR MEDI-CALThe following are guidelines for determining who should and should not be referred to SP-DEDfor a Medi-Cal disabilii evaluation. (Refer t o SSA/ SP-DED Chart a t the end of this section todetermine when t o refer claim to SP-DED afteridwing SSA's decision on a disabili claim.)SECTION: 50167,50223MANUAL LE'ITER NO.: 142DATE:FEB 0 6 1?9p-'*

MEDI-CAL ELIGIBILITY PROCEDURES MANUALA.Who Should NOT Be Referred To SP-DEDincapacity Or PregnancyVerifiation-Rior SP-DED DeaCIsonDisabledRior SP-DED DecisionNot Disdbled-Do not refer clients t o request verification ofincapacity or pregnancyDo not refer client who has had a decisionmade within the past 12 months unless thereexamination date has passed, or there is anindication that the medical condition hasimproved.Do not refer client who has had a claimdenied within the past 90 days. Client shouldbe advised of the appeal process.However, if CWD believes that the SP-DEDdenial is incorrect, the case may be sent backfor a reevaluation within 90 days, asdiscussed in C-9.Other Factors CausingInelig1B17ityDo not refer client who CLEARLY does notmeet other eligibility factors, such a s stateresidence or resource limits, or if there arequestions about other verifications. Otherwise,if DED packet is complete, send it while othereiigibiii factors are being berified.Refusal To Be EvaluatedDo not refer client who refuses to be evaluated,as any client has the right to refuse t o beevaluated for a disability.CWD should discuss the possibiiity of adisabilii referral with clients who appear t o bedisabled but who have not requested adisability evaluation.Exampic: Client 13confined to a wheelchair, orhas difficulty walking, standing or sirring; ?heindividual seems d&oriented, or shows extrememotional distress.Prior SSADiabledDecision-NotDo not refer clients to SP-DED who weredenied disability status by SSA:1.SECTION: 50167,50223MANUAL LE7TER NO.: 142Wnhin 60 days: refer t o S S A for areconsideration.DATE:ffb -0 6 6-13

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL2.W b i n 12 months: client alleges samecondition worsened; does not allege anew condition; did not ask S S A t oreopen claim.3.More than one year ago: client doesnot allege the same condition hasworsened, or that there is a newcondition.4.At any time: when client appealeddenial and decision on appealed claim ispending.Who SHOULD BE Refened To SP-DED8.No Prior SSA EvaluationClient's disability has never been evaluated bySSA.SSA Application Status /sUnknown Or PendingClient's application for RSDl (Tile If) or SSIXVII is pending or client does not knowstatus of claim.-SSA Application DeniedBecause of Excess/ncome/ResourcesClient's application for SSI is denied for excessincome/resources and client has proof of such.and client meets income/resource requirementsfor Medi-CaI.SSA Approved ClaimSSA has set a specific onset date as the stanof disability, and client is requesting retroactiveMedi-Cal coverage prior to that onset dare.SSA h i e d Claim1.SSA denied daim within 12 months,alleges new condition not considered bySSA, has not reapplied with SSA.2.SSA denied claim over 12 months ago,same condition worsened, has notreapplied with SSA.3.SSA denied daim over 12 months ago,has new condition not considered bySSA, has not reapplied with SSA.-SECTION: 50167,50223,MANUAL LETTER NO.: 142DATE:KB 0 6 19522C-1.4

MEDI-CAL ELIGIBILITY PROCEDURES MANUALSSA Discontinued ClaimSSA discontinued SSI benefits for reasonsother than disability and client still has themedical condition which was the basis for theSSI decision.SSA Refuses To Reopen ClaimSSA, at its discretion, refuses t o accept areopening request, and client returns t o applyfor Medi-Cal disability.Railroad Retirement(RRBI DisabilityRRB determined Occupational Disability only.BoardMedi-Cal Denied ClaimClient w a s denied Disabled-MN benefits forfailure t o cooperate with SP-DED and goodcause is established.Former SSI Recipient, 65 YearsOr OlderAn evaluation for former blind SSIISSPrecipients may be necessary even if clientreached age 65 or has already been determineddisabled. Under t h e Pickle Amendment t o theSocial Security Act, blind individuals areentitled t o a higher SSIISSP payment level thandisabled or aged persons.Indicate "Pickle Person" on the MC 221 under"Type of Referral" or packet may be rejected a sunnecessary.in-Home Supportive ServicesIiHSSJAn applicanr for IHSS who is NOf receiving SSImust have an independent evaluation ofdisability performed by SP-DED.Omnibus Budget ReconciliationOBRA provides restricted Medi-Cat benefits t ootherwise eligible aliens who are not in asatisfactory immigration status.Act (OBRAISECTION: 50167,50223MANUAL LETTER NO.: 196DATE:22C-1.5A o r i l 2 1 , 1998

SSAfSP-DED CLIENT REFERRAL CHARTkerns 5 to 5 D of t h e MC 223. Applicant's Supple-talStatement of Facts For Medi-Caf. identify whetherclient has applied for Social Security Or SSI disability benefits in the past t w o years. Client's responsesdetermine whether a disabilii a i m is referred to SSA or SP-Dm. The following chart helps to identifywhere the cbim should b e referred.SECTION: 50167,50223MANUAL l lTER NO.: 142

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL22 C-21.-- DETERMINING SUBSTANTIAL GAINFUL ACTIVITY.BACKGROUNDSectlon 435 540 of 42 Code of Federal Regulations (CFR) requlres Medi-Cal to use theSupplemental Securlty lncolne (SSI) definltlon of dlsabillty to decide whether a client is eliglble forhiledl-Cal based on dlsabllity.To be r.onsldered dlsable l.SSI reilulres tliat all II IVI UBIbe."unable lo engage in Substalillal Gainful Acl v ty(SGA). due to a iiedlcallytlelerlii nedphyslcal ormental lr ipalrlnent,which 1s expec.terl l o result In death, or wh cli1s expected to last for aconllnuous perlod of 12 months"A client who perfortiis SGA 1s not disabled. even ifa severe physical or mental llnpairment exlsts2.THE CURRENT SGA AMOUNTSlnce Ihe SGA a n i o u 1 s tnow base11on the fetleral average wage intlex. the dollar alnount maybe aclluslc-d annuallyUslntJ the new formula. the SGA amounl has lncreaseil to 3830 per monlh effectiveJanuary 1. 2005.NOTESlnce the SGA alnounl may change annually, fut lrerevlslons lo the manual regardlngthe : ctual SGA amount wlll only be reflected In lhis section All other leferences to the SGAalnount wlll only stale "Cutrent SGA Alnounl" and no dollar figure will be noled3.WHEN TO USE THESE PROCEDURESTlwscs p ocetlureswill be used when a cl ent.Ides for Medl-Cal tllsab l ly,stales on the MC 223 thal he or she IS worklng, and has grossof more than the current SGA amount por monlh. orearningsnieets the crlterla for Presumpt veD sahil ty(PD) but earns over the currenl SGA amountpcr monlh. PD should not be a proveduntil an SGA determlnallon 1s made (except as licl catetlIn lhc "notos below)NO'TE. Indlvlduals al plylngfor or enroll ?tlin the 250 Percent Worklng Dlsabled (WD) programniust meet tlie SSI fetleral tlelln ttonof cltsablllty except that they may engage in SGA. Whensubrnllllng i l s a l packelsl l y to State Plugrams-Dlsabllity ant1 Adult Programs Divlsion (SPDAPD!, the hlC 22 1 (D sabtlltyTransnltltnl Folln) niust indicate that the case IS a 250 PercentWD case. For ;lddltlonnl informalion reg,xcllntJ tlie 250 Percent WD progrclni. see Seclion 5R ofthis manualNOTEThese j)loceilures do not apply to clients who are blind. or to heneficlarles who return towork aftrr i f s a l hasl tbeenyilpploved If an SGA evaluation was not performed because thecl enta l l g r rI llntlnessland SP- DAPD foulicl that the clienl was dlsabled but no1 bl nd.an SGAe valual onmust l.)e perf@lrnetl l)efole ellglbll tyas a d sabledperson can be establishedSECTION: 50167, 50223MANUAL LETTER NO.: 297DATE: 0711410522C-2.1I.

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL4.PROCEDURESASGA DETERMINATIONSThe EW shall cteter iiinewhether a client is performing SGA when a cl enthas earnedincome over the current SGA amount per month. The EW shall,1Clicnt's gross monthly ealnlngs (if irregular, earnings shouldbe averaged). Earn ngsderived from ln-Home SupportiveSewices are lreatetl as earned income2Delerniine Whether there are impairment-related work expenses(IRWEs) or subsiclies that can ieduce earnings below theSGA amount (IRWEs and Subsicl esare discussed furtherIn 1111sseclion)3.Denv4.m.A lull disabilily packet lo SP-DAPD, including an MC 220.Mcdi-Cal disabilily application 11 "net countable earnings"arc over llie current SGA amounlMC 221.and MC 223, only if "net countable earn1ngs"do not exceed the current SGAarnour t5&J Is sent lo SP-DAPD via a DAPD Pending Information Update Form (MC 222)when a disab l typacket was sent to SP-DAPD and the cllenl is subsequenlly foundto be engaging in SGA SP-DAPD will stop case development and return case tocounty of orbginWork Acliv tyReport Forrn (MC 273. Exhibit 2) should be provided to cl enlwhoseealnings are over the current SGA amount to help in making SGA cleterni nations.B.IMPAIRMENT-RELATEDWORK EXPENSESImpairinenl-related work expenses (IRWEs) are celtain expenses thal are incurred and pa dby an impaired client lo enable himlher to work1.SGA DelerminationIRWEs can be declucteil hoin gloss earnings lo arrive at "net countable ea nings"If "net counlable earnings" are over lhe current SGA ainou it,deny lhe applicat on.For self-employment. lRWEs can be deducted from net incollie. 11hot alreadycteduclett Iron1 gross income as a business expense.Exaniple The current SGA arnolrnt IS 830 The clieril earns S 1. looper niorilh andlias 5200 worlh of IRWEs for special trarisporlatron costs to go to work arid forrriedrcalror s ieecledlo coritrol n seizlrre clisorder In this exaniple t11e"netcorrritablecarnrngs"are 900 per n o n l(Sl 1 100-200) As "riel co rnlableearnrngs"( 900) arerriore iliarr the ctrrreril SGA aniounl. the clrerif is perfornirng SGA and the applicalroriIS rlenreclDo NOT apply ABD-MN or AFDC MNIMI ea nedincomc cleductions wlier clelerminiiig SGA.SECTION. 50167. 50223MANUAL LETTER NO.: 297DATE: 07/14/0522C-2.2

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL2.Allowable IRWE DeductionsDeductions are allowed when the following conditions exist:a.Disabled client needs the itemlse icein order to work. Theneed must be verified by the prescribing source (e.g., doctor,Vocational Rehabilitation [VR]). The cost must also beverified.b.Cost is paid by disabled client and not reimbursed by anothersource (e.g., Medicare, VR). The cost must be paid in cash,including checks or money orders, and not in kind.c.Expense is "reasonable". It represents comparable chargesfor the itemlse icein the community. Sources such as amedical supplier or VR may be contacted.Example: Client states he/she needs an attendant to assist inactivities to prepare for work. Client has a family memberperform theservices and is charged 15 per hour. If Personal Care Servicesprovided through In-Home Supportive Setvices allows a payment of 4.25 per hour, only 4.25 per hour should be allowed as adeduction.Budqetinq of IRWEPayment must be made after client became disabled in order for costto be deducted. Payment is computed in the following ways:a.b.Recurring and Non-Recurring IRWEsI.Recurring costs, such as monthly payments for awheelchair: the amount paid monthly is deductible.2.Non-recurring down payments, or full purchase pricepaid for an item: a lump sum payment may be proratedover 12 months.Cost Incurred Before or After Work1.Befo

medi-cal eligibility procedures manual 12. dhs 7035afdhs 7035c - medical report on adultichild allegation of hiv 'p 13. dhs 7045 - worker observations isa ability 22 c-5 - providing cwd worker observations 1. use of mc 221 or dhs 7045 2. use of worker observations by sp-dapd