Current through Register Vol. 48, No. 38, September 20, 2024
MANG(D)
a) To be
eligible for medical assistance as a disabled person an individual must be
determined disabled as currently defined by the Social Security Administration.
(See 20 CFR 416, Subpart I, April 1, 1984.)
b) If an individual is receiving Supplemental
Security Income (SSI) or primary Social Security (OASDI) benefits, the
Department shall accept the Social Security Administration determination of
disability. The Department will make the determination when the client has been
denied SSI on the basis of too much income or when the client is applying for
medical assistance only and not receiving SSI or OASDI. The Department uses the
same criteria for disability as is used under SSI. (See 20 CFR 416, Subpart I,
April 1, 1984).
c) If a child was
terminated from SSI due to the August 22, 1996, change in disability standards
( Public Law
104-193), and the child was eligible for both
Medicaid and SSI on August 22, 1996, the child is considered disabled unless:
1) the child becomes 18, or
2) the child has not received Medicaid for 12
months, or
3) the child no longer
meets the pre-August 22, 1996, definition of disability.
d) Appeals
1) If an individual applying for or receiving
medical assistance is determined currently "not disabled" by SSA under the SSI
or primary OASDI programs, the Department shall accept SSA's determination of
disability and deny or cancel the case, no matter which agency made the
original determination of eligibility.
2) If the individual appeals the SSA
determination of disability to SSA, medical assistance shall be continued for
recipients through the level of a determination by an Administrative Law Judge
(ALJ) subject to the time limits of subsection (d)(3) of this Section. If
medical assistance has been canceled, but the client later appeals to SSA, the
case shall be reinstated through the ALJ level subject to the time limits of
subsection (d)(3) of this Section.
3) If the client notifies the Department of
his or her appeal to SSA within ten days after the date of the Department
notice, medical assistance will be continued with no break. If the client
notifies the Department of his or her appeal to SSA within 11 through 65 days
after the date of the Department notice, medical assistance will be reinstated
back to the original date of cancellation. If the client notifies the
Department of his or her appeal to SSA more than 65 days after the date of the
Department notice, medical assistance will be provided prospectively only,
unless the client actually appealed to SSA within 65 days after the date of the
Department notice, in which case medical assistance will be reinstated back to
the original date of cancellation.
4) Medical assistance shall not be provided
to applicants for medical assistance through the SSA appeals process.
5) If an Administrative Law Judge finds the
individual "not disabled", the Department shall accept that finding as final.
The individual shall not have the right to appeal the determination of
disability to the Department at any time during this process.
e) Redetermination of disability
is a condition of continuing eligibility for individuals who are not applying
for or receiving SSI or OASDI benefits.
f) When appropriate, the Department shall pay
for a medical examination to determine disability.
