Section 144-332-6-4 - BASIC ELIGIBILITY REQUIREMENTSIndividuals who are aged, blind or disabled and are not receiving SSI or a State Supplement payment may be eligible for Medicaid as SSI - Related if they meet the basic criteria of the SSI Program below.
Section 4.1: AgedThe individual must be 65 years of age in or before the month in which eligibility begins.
Section 4.2: BlindThe individual must have, in terms of ophthalmic measurement, central visual acuity of 20/200 (can see on the eye examination chart at 20 feet what a normal vision can see at 200 feet) or less in the better eye with best correcting glasses or must have a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends at an angular distance of no greater than 20 degrees or must have a visual field efficiency reduced to 20% or less; or if in the opinion of the consulting ophthalmologist the visual field limitation encroach on the central visual axis sufficient to interfere with useful vision. Such a person has what is known as economic blindness which prevents the performance of ordinary activities for which eyesight is essential. For determining the visual field efficiency, the amount of radial contraction in the eight principal meridians shall be determined, and the sum of these eight, divided by 420 (the sum of the eight principal radii of the industrial visual field) multiplied by 100 will give the visual field efficiency of one eye in percentage.
Section 4.3: DisabledCurrent eligibility for Social Security, Railroad Retirement, Medicare or SSI benefits based on disability or blindness is proof of disability.
For individuals whose SSI Benefits are terminated, for reasons other than disability, a contact to the local Social Security Office should be made to determine the next disability review date. For Medicaid purposes this review date will be adopted.
If the individual is not currently receiving benefits from one of the sources above, then an independent disability decision must be made. To determine if a person meets the SSI standard of disability, a referral will be made to the Medical Review Team (MRT). This group consists of a physician and a caseworker who specialize in medical eligibility determinations. This group makes the decision as to whether or not the individual meets the SSI standard of disability and establishes any additional reviews of medical disability.
Section 4.3.1: Making the DecisionI. This decision is based on a medical report which must include a substantive diagnosis based either on existing medical evidence or upon current medical examination. To end coverage based on disability, the Medical Review Team must determine that medical improvement as set forth in 20 CFR 416.994 has occurred in relation to the most recent decision that was favorable to the individual. The medical evidence must be from an acceptable source. Acceptable sources are:
C. licensed or certified psychologists;D. licensed optometrists for the measurement of visual acuity and visual fields. (A report from a physician may be required to determine other aspects of eye diseases);E. a hospital, clinic, sanitarium, medical institution or health care facility; orF. P.E.T. and other school medical records. Reports from chiropractors are not acceptable.
II. The social history must contain sufficient information to make it possible to relate the medical findings to the activities of substantial gainful employment and to determine if the individual is disabled.III. An impairment or combination of impairments is not severe if it does not significantly limit physical or mental ability to do basic work activities. Basic work activities are the abilities and aptitudes necessary to do most jobs. Examples of these include:
A. physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling;B. capacities for seeing, hearing and speaking;C. understanding, carrying out, and remembering simple instruction;E. responding appropriately to supervision, co-workers and usual work situations; and F. dealing with changes in a routine work setting.IV. The following are criteria which the MRT uses to determine if an individual meets the definition of initial disability and any additional reviews for SSI - Related disability coverage: An individual is determined to be disabled only if the physical or mental impairments have lasted or can be expected to last for a continuous period of not less than twelve months, expected to end in death, or are so severe that the individual is not only unable to do previous work, but cannot (considering age, education and work experience) engage in any kind of Substantial Gainful Activity (SGA) which exists in the community regardless of:
A. whether a specific job vacancy exists; orB. whether the individual would be hired if application for work were made. If the individual is not working, disability must be based on activities which still can be performed despite limitations (residual functional capacities). Activities, age, education and work experience will be used when the limitations would not permit the individual to return to prior work in order to determine if the individual can participate in any other type of work.
V. A child is considered disabled if there is any medically determinable physical or mental impairment of comparable severity.VI. The physical or mental impairment must be one that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. The individual must follow any prescribed treatment plan.VII. Coverage may be granted or continued if the individual has good reason for not following a prescribed treatment plan. These reasons include: A. the specific medical treatment is contrary to the established teaching and tenets of the individual's religion.B. the prescribed treatment is cataract surgery for one eye but there is an impairment of the other eye resulting in a severe loss of vision which is not subject to improvement through treatment.C. surgery was previously performed with unsuccessful results and the same surgery is again being recommended for the same impairment.D. the treatment is very risky, unusual, or of a great magnitude such as open heart surgery or organ transplants.E. the treatment involves amputation of an extremity or a major part of an extremity.VIII. A person who otherwise qualifies for medical benefits, by reason of disability, cannot be an eligible individual for any month if determined to be a drug addict or an alcoholic unless undergoing treatment that may be appropriate and available for that condition. If the individual is in an institution it must be approved for this purpose and treatment must be available.IX. An applicant may receive Medicaid coverage if the Medical Review Team (MRT) determines that s/he is presumptively disabled or blind and meets all other financial and non-financial requirements for Medicaid. A final determination must be made within six months of the presumptive decision.A. Presumptive eligibility entitles the individual to full Medicaid benefits. If subsequently found not medically or otherwise eligible, adequate and timely notice must be given before coverage stops.B. The start date for presumptive decisions is the first day of the month in which the decision is made. If the final decision is that the individual is not eligible, the closing will take place even if a hearing is requested. A reconsideration cannot be done.C. If an individual's prior application has been denied base on medical factors, a presumptive decision can be made only when there is sufficient evidence of an worsening of his/her physical or mental condition (or the existence of a new impairment) which could demonstrate a strong likelihood that the subsequent presumptive decision should be allowed.D. A presumptive decision can be made when the alleged impairment falls within the following categories: 1. amputation of two limbs or a leg at the hip;2. total deafness or blindness;3. a stroke more than three months ago with continued marked difficulty in walking or using a hand or arm;4. cerebral palsy, muscular dystrophy or muscle atrophy;5. diabetes with amputation of a foot;9. a child age 6 months or younger showing low weight at gestational age (age at birth based on date of conception);10. a physician or knowledgeable source confirms an individual is receiving hospice services due to terminal cancer; or 11. spinal cord injury producing the inability to ambulate without the use of a walker or bilateral hand-held assistive device.Section 4.3.2: Referral to Vocational RehabilitationPersons under age 65 who are blind or disabled, are to be referred to Vocational Rehabilitation for review of the individual's need to use their services.
Section 4.3.3: Reconsiderations (Appeals)An individual may request a reconsideration (appeal) within thirty days of notification of the disability decision. A reconsideration is done when additional information regarding the original impairment is available. If requested within ten days of the date of the denial notice, the original application date is used and temporary coverage may be granted on the 46th day.
For individuals being closed because it has been determined that they are no longer disabled, coverage will continue if a reconsideration is requested within ten days of the closing notice.
Any request for reconsideration made more than thirty days from the date of the notice of the disability decision requires a new application.
Section 4.3.4: Determination of Continued Eligibility when the Disabled Individual Begins to WorkWhen earnings are reported the Medical Review Team (MRT) will be alerted when:
I. a medical review has not been done nor has one been scheduled in the past or coming six months. These are usually situations of longer term disability such as asthma. The MRT will reschedule a review within the next six to twelve months. This gives the individual an opportunity to try the job, on an ongoing basis, to see if work is possible on this basis.II. the MRT has identified the situation as one in which recovery is expected even if a review has been done or is expected to be done in the past or coming six months. In this instance the MRT may do a complete review regardless of the scheduled review date and request current medical information if recovery is expected within six months. Usually these are situations with a short term disability such as recovery from an accident. If the individual is not scheduled for further medical review, the MRT does not need to be alerted when earnings are reported, but any earnings must be budgeted. These are usually situations of terminal illness or severe disability with no chance of recovery.
10- 144 C.M.R. ch. 332, § 6-4