Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.00-004 - Medical Services Policy MSP 3323.7: Substantial Gainful Activity - the guidelines for determining when earnings demonstrate the ability to engage in substantial gainful activity (SGA) have been revised from $500 to $700
Current through Register Vol. 49, No. 9, September, 2024
The pay status code series beginning with "N"s are the denial codes on WTPY. A brief description of the .denial code is included on the query response.
3322.5 Dual Applications
When an individual applies for both Medicaid and Social Security Disability or SSI, and the application with SSA is still pending, the county should initiate an MRT determination of disability if the individual appears to meet all other eligibility requirements. The Agency will have 90 days from the date of Medicaid application to make this determination. While an MRT decision is pending, the county office worker should check the Social Security Disability or SSI status of the applicant 30 days after the Medicaid application has been made, and again at certification, if found eligible by MRT. If MRT finds that the individual meets the disability requirements and SSA has not yet made a decision, the county may certify the case for Medicaid. To verify that no SSA decision has been made, the WASM screen will be checked, if appropriate, and the individual or authorized representative will be contacted by mail or telephone prior to certification.
Additional case action is indicated as follows:
If application for Social Security Disability is approved first:
Notify MRT
Approve Medicaid application (if all other requirements have been met)
If application for SSI is approved first:
Notify MRT
Deny Medicaid application, except for LTC, which may be approved for. facility payment on WNHU (if all other requirements have been met)
If SSA determines the applicant is NOT disabled:
Notify MRT
Deny Medicaid application
If the county certifies a case based on an MRT disability decision and later learns the individual has been denied by SSA, the Medicaid case will be closed after appropriate notice, unless the recipient appeals the closure. If the appeal is made within the 10-day time frame, the Medicaid case will remain open pending the outcome of the DHS appeals process. In no case, will the Medicaid case remain open pending the outcome of the SSA appeals process if the recipient has appealed the SSA decision. If an approved Medicaid recipient is approved for SSI, the system will automatically convert the Medicaid case to an SSI category and no further action will be required of the county, except to notify MRT that no future reexamination is required, if appropriate.
3323 Procedure for Verification by Medical Review Team
The following procedures will be followed for verification of blindness or disability through the Medical Review Team.
If the individual is found to be engaged in SGA, deny the application, using action reason 070, denied due to employment. Do not send the application to MRT.
The county office worker will complete Part 1 of Form DCO-107, when the form is needed. The applicant must sign and date the form in Part 2. The form will then be given to the applicant to take to the medical practitioner of his or her choice. A stamped envelope addressed to the county office will be provided with the DCO-107. The medical practitioner will complete Part 3 of the form and return the form to the county office.
If an applicant states he or she does not have the funds for payment of a physician's examination, the applicant should be informed that MRT can arrange and pay for an examination. If the applicant wishes MRT to do this, the county office worker should report this on the DCO-108 Social Report.
The Medical Review Team (MRT) will report the decision regarding physical or mental incapacity to the county office on Form DCO-109.
If MRT finds that the medical information is not adequate to make a decision, further medical/psychiatric/psychological examinations may be recommended by MRT at the expense of the Agency.
Arrangements for such evaluations will-be made by MRT only. When medical and social evidence has been resubmitted on questioned cases, the Medical Review Team will make a decision as to disability and notify the county office on Form DCO-109. This decision of. MRT will be final, subject to the regular, appeal process, unless a later decision by SSA finds the individual not disabled.
If a reapplication is filed and the case has been closed within the past five years for reasons other than disability and the last Form DCO-109 stated, "Reexamination not. necessary" or the date for reexamination has not yet been reached, new medical and social information will not be submitted to MRT. If the case has been closed for more than five years, new medical and social information must be submitted. In all cases of reapplication, a DCO-106 wi 11 be completed to determi ne the appli cant's SSA disability status.
When medical and social information indicates that an individual may recover in a year or more and/or be rehabilitated to the point where he/she could meet substantial gainful employment, MRT will require reexamination. Whether or not required by MRT, reexamination may be requested by the county office at any time for the aforementioned reasons.
In either case, it is the responsibility of the county office to initiate the reexam by submitting current medical and social information (DCO-106, DC0-108A, and DCO-107 and/or DHS-81) to MRT.
When indicated on the DCO-109, the county office will key the appropriate date to WALR for future action. The county office will contact the individual in a timely manner that will allow all necessary medical and social information to reach MRT by the first of the month of reexamination. When the reexamination decision is not received in the county office by the end of month in which the reexamination was required, the case will remain open pending receipt of the MRT decision.
Substantial gainful activity (SGA) is defined as the performance of significant physical and/or mental work activities for pay or profit, or work activities generally performed for pay or profit.
Countable monthly earnings are obtained by deducting any employer subsidy and any impairment related work expense (not payroll deductions) from the gross income (gross income includes payment in-kind for the performance of work in lieu of cash). Then, if earnings are irregular, they will be averaged over the period of months being considered to obtain countable monthly earnings.
Employer subsidy is the payment of wages that is more than the value of the actual services performed.
If the work is sheltered or if there is marked discrepancy between the amount of pay and the value of services, there exists the strong possibility of a subsidy that requires development of specific evidence.
Sheltered Employment is work performed by disabled individuals in a protected environment under an institutional program; nonsheltered employment is any work performed by individuals in an unprotected environment.
Impairment Related Work Expenses are items or services needed in order to maintain employment, such as attendant services, prostheses, or other devices. Drugs and medical services are not deductible unless it can be shown they are necessary to control the disability to enable the individual to work. Deductible expenses must be paid for by-the individual, and cannot bereimbursable from any source. Legitimate expenses may include installation, repair, or maintenance. The payments may be deducted in one month or prorated over 12 months.
The expenses must be considered "reasonable," i.e., not more than Medicare would allow or than would ordinarily be charged in the individual's community.
The following SGA Earnings Guidelines provide the basis for evaluating whether an individual is engaged in SGA:
When "a." or "b." occurs in a nonsheltered employment situation (or if gross earnings include a subsidy), current medical and social information will be submitted to MRT.
When average countable monthly earnings from sheltered employment fall within the $300 to $700 per month range, the work is not ordinarily SGA. However, if earnings include a subsidy, current medical and social information will be submitted to MRT.
When there is no subsidy involved in gross pay and when there is no marked discrepancy between the amount of pay and the value of the services, an assumption will be made that pay from employment is fully earned. Action will be taken to deny the application or close the case as the individual does not meet the criteria for disability (Re. 3310). Advance notice for closure will be given on the DC0-700.
NOTE: If an applicant reports earnings of more than $700 per month, the county office worker may deny the application due to employment without making a referral to MRT.
