Medicaid Policy
Medicaid Policy
Individuals who claim to be blind or disabled must complete the Medicaid Disability Application (Form 354). Request medical records and/or doctors’ reports and make a referral to the State Medicaid Disability Office (SMDO), also known as the Medical Review Board (MRB) after receiving the Form 354. Provide assistance if the individual needs help to complete the form.
A. New Disability Determinations
Ask for a new disability determination when individuals say they are blind or disabled in the following situations:
1. The individual has not applied for SSI or SSDI.
2. SSA denied SSI or SSDI for a reason other than blindness or disability, such as too much income, non-citizen status, transfer of assets, or insufficient work history.
3. SSA denied SSI or SSDI because the individual has earned income above the Substantial Gainful Activity level (SGA), and SSA did not review medical evidence.
4. The individual has applied for SSI or SSDI only once in the previous 12 calendar months and SSA has not made a decision.
5. SSA denied SSI or SSDI less than 12 months ago because there was no disability and the individual has a new disabling medical condition that SSA did not consider.
6. SSA denied SSI or SSDI more than 12 months ago because there was no disability and the individual did not appeal.
7. The individual appealed an SSA denial for SSI or SSDI, it has been more than 12 months since the date of the latest SSA appeal decision upholding the denial, and the individual has either exhausted the SSA appeal process or has not filed any further appeals with SSA.
8. The individual has a pending appeal with SSA on a denial for SSI or SSDI, and the individual has a new disabling medical condition that SSA did not consider (only applicable to applicants).
9. The SSI date of disability onset is after the baby left the hospital. See 303-4 if the SSI date of disability is during the baby’s hospital stay.
10. The individual alleges the disability began before the date established by Social Security.
11. The individual is 65 years or more and he requests coverage under the Medicaid Work Incentive program. When a individual 65 years or older requests MWI, the SMDO must determine disability. For someone who was disabled before age 65 and eligible for MWI, complete a disability review within 12 months of when the person turns 65 if he is still working and needs MWI coverage (314).
12. The individual's Medicaid has been closed more than 12 months from the month in which the SMDO review should have occurred.
13. The individual is eligible on a different coverage group and requests a disability coverage group to access disability related services.
Note: Refer to 303-10 to determine whether a disability decision from the SMDO must be requested for a individual leaving a public institution.
B. Periodic Disability Determinations
The State Medicaid Disability Office (SMDO) conducts periodic disability determinations for ongoing cases when the member does not have a disability decision from Social Security.
1. The SMDO disability approval includes a date for redetermination. Begin gathering medical records for the redetermination no earlier than the 1st day of the month the redetermination is due.
2. Do not close the case while the SMDO re-determines disability unless the member is not eligible because of other eligibility factors. Give members a minimum of 30 days to submit SMDO related verification.
3. Consider the member disabled and begin the SMDO review process if a member reapplies or completes the eligibility review process within 12 months of when the SMDO redetermination should have occurred. Open Medicaid during the SMDO process if the member is otherwise eligible.
4. Only the Social Security Administration or the State Medicaid Disability Office can decide a person is no longer disabled.
5. Do not make a referral to the SMDO for a re-determination if:
a. SSA has denied disability and the member is in the SSA appeal process. This applies even if he is receiving continued benefits during the SSA appeal. If the individual is an applicant, refer to A(8)
b. The individual reapplies or completes the eligibility review process before the SMDO redetermination due date. Consider the individual disabled and begin the SMDO redetermination process in the month the redetermination is due.
c. SSA approves disability before the scheduled SMDO re-determination. The member is disabled, and no further SMDO re-determinations are needed while the member is receiving SSI or SSDI.
Note: Refer to 303-10 to determine whether a disability redetermination must be requested for a member leaving a public institution.
C. Incarceration
1. A member with a SMDO disability approval continues to meet disability status while incarcerated and upon release.
· The SMDO may have approved disability before or during the incarceration.
2. Do not attempt to gather documentation for a SMDO redetermination while the member is incarcerated.
3. If the DMD has gathered documentation for the SMDO redetermination before the individual becomes incarcerated, the DMD will forward the documentation to the SMDO, even if incomplete. The DMD must notify the SMDO the member is incarcerated.
· The SMDO will not complete a redetermination unless the existing records clearly show the individual continues to meet or no longer meets disability criteria.
4. Upon the individual’s release, check the due date for the SMDO redetermination. Unless Social Security has made a disability decision since the individual was incarcerated, proceed as follows:.
· If the due date has passed, begin the process of gathering information for the redetermination. Continue Disability Medicaid (if otherwise eligible) during the redetermination.
· If the due date is in the future, set a task to begin the redetermination at the appropriate time.
· If SSA denied disability status, follow policy in Section A above to decide if the SMDO can make a new determination.
5. Develop medical documentation and refer incarcerated applicants for a SMDO determination when the applicant indicates having a disability.
· If the SMDO cannot determine the disability with the medical records provided, or if the SMDO denies disability, determine eligibility for other Medicaid programs.
D. Fair Hearings
If the SMDO decides the individual is not disabled, the individual may request a fair hearing from the DHHS Office of Administrative Hearings (125-1).
1. The individual can ask for a disability reconsideration as part of the hearing request. This may include providing medical records not previously reviewed by the SMDO.
2. If the SMDO has already reconsidered a case, the next level of appeal is the fair hearing. The SMDO cannot conduct a second reconsideration.