210 R.I. Code R. 210-RICR-40-05-1.10

Current through December 3, 2024

Section 210-RICR-40-05-1.10 - State-Administered Community Medicaid Disability Determinations

1.10.1Scope and Purpose

Disability determinations are made by the State's Medicaid Assessment and Review Team (MART) in accordance with the applicable requirements of the SSA based on information supplied by the applicant and by reports obtained from treating physicians and other health care professionals. Anyone who is blind and is seeking IHCC group Community Medicaid who does not qualify for SSI or has never received a determination of disability on that basis by a government agency, is subject to an evaluation by the MART.

1.10.2Disability Standards for Community Medicaid

A. For the purposes of IHCC groups providing Community Medicaid, the standards for determining whether a person has a disability centers on:

1. Duration - The disabling impairment or chronic condition is expected to result in death or has lasted or can be expected to last for at least twelve (12) consecutive months;

2. Substantial Gainful Activity - The impairment or condition adversely affects the person's ability to engage in substantial gainful activity or SGA. For these purposes, SGA is work activity that involves doing significant physical or mental activities. Work may be substantial even if it is done on a part-time basis or if a person does less, gets paid less or has less responsibility than during prior employment. Gainful work activity is the kind of work done for pay or profit whether or not a profit is realized.

3. Application of Standards - The disability determination standards that apply for Community Medicaid vary by age:

a. Persons age eighteen (18) or older. Disability determinations for applicants in this age group are made by the MART using the SSI criteria and standards. The determination is based on an assessment of whether the person seeking coverage is unable to engage in any substantial gainful activity due to any medically determinable physical or mental impairment, or combination of impairments, expected to result in death, or last or could be expected to last for a continuous period of not fewer than twelve (12) months. To meet this definition, there must be a severe impairment, which makes the person unable to do his or her previous work or any other substantial gainful activity existing in the national economy. To determine whether a person is able to do any other work, the MART considers residual functional capacity, age, education, and work experience.

b. Children under age nineteen (19) - MN Only. The MART is not usually responsible for making disability determinations for persons under nineteen (19). In general, these disability determinations are made formally by the SSA in conjunction with SSI eligibility, evaluations conducted by professionals for educational or child welfare services or through a qualified Medicaid provider. The SGA standard does not apply; however. The child must have a physical, mental, or behavioral health impairment, or combination of impairments, resulting in marked and severe functional limitations, expected to result in death or that have lasted or are expected to last for at least twelve (12) consecutive months. The MART may make such disability determinations for MN applicants under age nineteen (19) using the applicable SSI standards.

c. Disability based on Blindness. Applicants seeking eligibility for a disability based on blindness who do not qualify for SSI because their income is too high must meet the duration and SGA standard and have central visual acuity of 20/200 or less, even with glasses, or a limited visual field of twenty degrees (20°) or less in the better eye with the use of a correcting lens.

d. Working Persons with Disabilities - No LTSS. Applicants who have disabilities but who are working are exempt from the SGA step of the sequential evaluation of the disability determination. This exemption applies if the person otherwise meets the requirements set forth for coverage under the Sherlock Plan in the Medicaid Code of Administrative Rules, Sherlock Program, or other related provisions for adults with disabilities.

1.10.3MART Five Step Determination Process

A. This subsection explains the five (5) step sequential review process the MART uses when determining whether an applicant who is age nineteen (19) or older meets the SSI disability criteria. When using the review process, the MART considers all the evidence in an applicant's case record in a series of sequential steps. Upon making a determination of disability at any step in the sequence, the review process stops and the MART does not proceed to the next step. If no determination is made, the MART proceeds from one (1) step to the next in order until a decision is made. The steps are as follows:

1. Step One (1) - At the first (1st) step, the MART must consider the work activity of the person applying, if any. If the applicant is engaging in substantial gainful activity, he or she will be determined ineligible except in instances in which the provisions in Medicaid Code of Administrative Rules, Section 1373: Medicaid for Working People with Disabilities Program, Subchapter 15 Part 1 of this Chapter, or related provisions apply, pertaining to Medicaid eligibility for working persons with disabilities.

2. Step Two (2) - A determination is made whether the individual has a medically determinable impairment that is severe, or a combination of impairments that is severe (20 C.F.R. § 416.920(c) and whether the impairment has lasted or is expected to last for a continuous period of at least twelve (12) months (20 C.F.R. § 416.909). If the durational standard is not met, the Department will find that he or she is not disabled.

a. An impairment or combination of impairments is not severe within the meaning of the Regulations if it does not significantly limit an individual's physical or mental ability to perform basic work activities (20 C.F.R. § 416.921). Examples of basic work activities are listed at 20 C.F.R. § 416.921(b).

b. In determining severity, the Department considers the combined effect of all of an individual's impairments without regard to whether any such impairment, if considered separately, would be sufficient severity (20 C.F.R. § 416.923).

(1) If the Department finds a medically severe combination of impairments, then the combined impact of the impairments will be considered throughout the disability determination process.

(2) If the individual does not have a severe medically determinable impairment or combination of impairments, the Department will find that he or she is not disabled

c. The Department will not consider the individual's age, education, or work experience at Step (2).

d. Step (2) is a de minimis standard. In any case where an impairment (or multiple impairments considered in combination) has more than a minimal effect on the individual's ability to perform one (1) or more basic work activities, adjudication must continue beyond Step (2) in the sequential evaluation process.

3. Step Three (3) - At the third (3rd) step, the MART must also consider the medical severity of the person's impairment(s). If the person has at least one (1) impairment that meets or equals one (1) of the listings in the SSI rules at 20 C.F.R. Part 404, appendix 1 to subpart P (located at: https://www.ssa.gov/OP_Home/cfr20/404/404-app-p01.htm) and meets the duration requirement, the MART determines the person to be disabled for Medicaid eligibility purposes.

4. Step Four (4) - The fourth (4th) step entails MART consideration of the required assessment of the person's residual functional capacity and past relevant work. If the person continues to perform past relevant work, the MART will the find the person not disabled.

5. Step Five (5) - At the fifth (5th) and last step, the MART considers the assessment of the person's residual functional capacity, age, education, and work experience to determine if the person is able to make an adjustment to other work. If a person is found to be able to make an adjustment to other work, the MART determines the person is not disabled. If the person is not able to make such an adjustment to other work, the MART will find the person to be disabled.

1.10.4Referral to the MART

A. All adults over age nineteen (19) applying for Medicaid are evaluated by the Integrated Eligibility System using the MAGI standard before consideration using the SSI-methodology. The application includes questions about a person's need for care, previous or pending disability determinations and the need for retroactive Medicaid, which provides coverage for certain health expenses incurred in the three (3) months prior to making application.

1. Referral to the MART - Applicants who indicate on the Medicaid application that they have been determined to have a disabling condition by a government agency and/or are seeking retroactive eligibility are referred to the MART for a disability review if they:

a. Are not currently an SSI or RSDI recipient and do not qualify for MAGI-based coverage due to Medicare eligibility or enrollment and/or are seeking retroactive eligibility; or

b. Qualify for such MAGI coverage but would prefer to be evaluated for IHCC through a pathway for Community Medicaid.

2. Limits on Referral - In accordance with Federal Regulations at 20 C.F.R. § 435.541, when a person is seeking Medicaid on the basis of a disability, the following limitations apply:

a. The MART may not make a determination of disability when the only application for benefits has been filed with the SSA.

b. The MART may not make an independent determination of disability if the SSA has made such a determination on the same issues presented in the Medicaid application within the ninety (90) day time limit allowed by Federal Regulations.

c. A determination of disability made by the SSA is binding. Accordingly, the MART, as a unit of the Medicaid Single State Agency, must refer to the SSA all applicants alleging new information or evidence affecting previous determinations of ineligibility based on disability for reconsideration or reopening of the determination except in cases specified in 20 C.F.R. § 435.541(c)(4).

3. These limits on referrals to the MART do not apply if the person is seeking Medicaid as a non-cash recipient with income above the SSI standard through the EAD pathway and the person has not applied for SSI cash benefits; has applied and has been found ineligible for SSI for a reason other than disability; or the SSA has not made a determination on a disability related application within ninety (90) days from the date the application for Medicaid was filed with the SSA.

1.10.5Continuing Eligibility for EAD Adults with Disabilities

A. Continuing eligibility for beneficiaries eligible due to a disability is multifaceted.

1. Medicaid Renewal - Beneficiaries eligible through the EAD pathway on the basis of a disabling impairment are renewed on an annual basis in accordance with the provisions of §00-2.7 of this Chapter, subject to periodic reviews by the MART.

2. MART Periodic Reviews - These reviews must focus on whether there has been any medical improvement in a beneficiary's impairment since the comparison point decision and, if so, whether the improvement is related to the beneficiary's ability to work. For these purposes:

a. Comparison Point Decision (CPD). The most recent favorable decision which is the latest final determination or decision involving a consideration of the medical evidence and whether a person is disabled or continues to be disabled.

b. Medical Improvement. Any decrease in the medical severity of the impairment that was presented at the CPD as measured by changes in symptoms, signs and/or laboratory findings associated with the impairment.

3. The MART must conduct these reviews in accordance with Federal SSI Regulations at 20 C.F.R. § 404.1594 and the schedule for conducting reviews identified at 20 C.F.R. § 416.990. This schedule indicates the reviews must generally be conducted as follows:

a. Impairment expected to improve - six (6) to eighteen (18) months from date of CPD;

b. Impairment not considered permanent, but medical improvement cannot be accurately predicted - once every three (3) years from CPD;

c. Impairment is considered permanent - at least once every seven (7) years, but not more often than once every five (5) years from CDP;

d. Immediately, for the reasons set forth in subsection (b) of the Federal Rule including, but not limited to: the beneficiary returns to work or is reported by government agency or other source to be able to begin working or no longer disabled, electronic data sources indicating earnings increased substantially, or a self-reported recovery from the impairment.

4. Limitations - A periodic review is not required for any beneficiary with a disability determined by the SSA and/or authorized to work under the Sherlock Plan or any other eligibility pathway for adults with disabilities who are working as identified in this Chapter.

5. The eligibility of Medicaid beneficiaries who are sixty-five (65) and older are renewed on an annual basis in accordance with the provisions located in Subchapter 00 Part 2 of this Chapter.

1.10.6Agency and Applicant Responsibilities

The applicant must provide the health care authorizations and information necessary to make a timely and accurate determination of disability. The MART is responsible for assuring that determinations are made in accordance with the Federal Medicaid Regulations at 20 C.F.R. §§ 416.920- 416.985 and may be obtained in hard copy by contacting the Social Security Administration, One Empire Plaza, 6th Floor, Providence, RI 02903 or 1-877-402-0808 (TYY 401-273-6648).

210 R.I. Code R. 210-RICR-40-05-1.10

Amended effective 11/5/2020
Amended effective 6/3/2021
Amended effective 4/9/2023
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/27/2023