D.C. Mun. Regs. tit. 29, r. 29-9513

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-9513 - NON-MAGI ELIGIBILITY GROUP: OPTIONAL AGED, BLIND, AND DISABLED

9513.1

This section shall govern eligibility determinations pursuant to Sections 1902(a)(10)(A)(ii)(X), 1902(m)(1), 1902(a)(10)(A)(ii)(I), and 1905(a)(iv) of the Social Security Act, 42 CFR §§ 435.201(a)(1) - (3) for the optional Aged, Blind, and Disabled (ABD) eligibility group.

9513.2

The Department of Health Care Finance ("Department") may provide Medicaid reimbursement under the optional Aged, Blind, and Disabled (ABD) eligibility group to individuals who:

(a) Are aged sixty-five (65) years or older or who are determined blind or disabled in accordance with the criteria set forth under 42 USC § 1382c, by either the U.S. Social Security Administration (SSA) or by the Department of Human Services, Economic Security Administration (ESA) Medical Review Team (MRT):

(b) Have a household income at or below one hundred percent (100%) of Federal Poverty Level;

(c) Meet the following non-financial eligibility factors in accordance with Section 9506:

(1) Are District residents pursuant to 42 CFR Section 435.403;

(2) Have Social Security Number s (SSNs) or are exempt pursuant to 42 CFR Section 435.910 and Section 9504; and

(3) Are U.S. citizens or nationals, or in satisfactory immigration status; and

(d) Have resources at or below the Supplemental Security Income (SSI) resource levels of four thousand dollars ($4,000) for individuals or six thousand dollars ($6,000) for couples.

9513.3

The Department shall determine whether an applicant meets the eligibility factors for Medicaid reimbursement under the optional ABD eligibility group based upon the submission of:

(a) A complete application for Medicaid in accordance with Section 9501 of this chapter. The date of application shall be the date that a complete application is received by the Department; and

(b) A document containing verification from the Social Security Administration (SSA) if the Department cannot verify an applicant's blindness or disability through electronic data sources, or a completed medical review form in accordance with Subsection 9513.5, if applicable.

9513.4

If an applicant is applying for Medicaid based on age, the Department shall accept self-attestation of aged sixty-five (65) or older unless the attestation is not reasonably compatible with other available information.

9513.5

If an applicant is applying for Medicaid based on blindness or a disability and does not have a blindness or disability determination issued by the SSA, the Department shall immediately provide the applicant (by mail, in person, or other commonly available electronic means) a medical review form that must be completed by a physician to document blindness or disability and be submitted to the Department by the applicant or beneficiary to determine eligibility.

9513.6

All application and renewal materials, including the medical review form, may be submitted to the Department through the following means:

(a) Mail;

(b) In person; or

(c) Other commonly available electronic means.

9513.7

Where the Department determines that an applicant is not at least aged sixty-five (65) or is not blind or disabled based on a review of the submitted medical review form and supporting medical documentation, the applicant shall be ineligible for Medicaid under the optional ABD eligibility group and the Department shall submit a notice to the applicant in accordance with Section 9508 of this chapter.

9513.8

Application timeliness standards for the Department to determine eligibility set forth under Section 9501 of this chapter shall apply.

9513.9

A beneficiary shall immediately notify the Department of any change in circumstances that directly affects the beneficiary's eligibility to receive Medicaid under the optional ABD eligibility group.

9513.10

For continued Medicaid coverage under the optional ABD eligibility group, each beneficiary shall complete and submit (by mail, in person, or through commonly available electronic means) the following renewal documents every twelve (12) months:

(a) Completed and signed pre-populated renewal forms, as described under Section 9501;

(b) If the individual was determined blind or disabled initially by the MRT or no longer has a disability determination from SSA, a new medical review form that is completed by the beneficiary's physician or verification of disability; and

(c) Documents that may be required in order to verify financial and non-financial eligibility factors set forth under Subsection 9513.2.

9513.12

If an individual's benefits have been terminated for failure to submit the prepopulated renewal form and necessary information, then the Department shall determine eligibility without requiring a new application if the individual subsequently submits the pre-populated renewal form and necessary information within thirty (30) days after the date of termination.

D.C. Mun. Regs. tit. 29, r. 29-9513

Reserved by Final Rulemaking published at 62 DCR 11142 (8/14/2015); Final Rulemaking published at 67 DCR 4033 (4/10/2020)