Current through Register 1531, September 27, 2024
(A) An EAEDC
applicant or client younger than 65 years old is disabled if he or she has an
impairment or combination of impairments that is expected to last 60 days or
more and that substantially reduces or eliminates the applicant's or client's
ability to support himself or herself.
An applicant or client shall be considered as having such an
impairment or combination of impairments if he or she:
(1) has an impairment or combination of
impairments verified by a competent medical authority as defined in
106 CMR
701.600:
Definition of
Terms, on a medical report prescribed by the Department, which meets
the requirements of 106 CMR 703.191(D). The competent medical authority and the
agency or organization under contract/agreement with the Department to provide
disability evaluation services (hereafter referred to as the Department's
agent), when required, determines that the impairment:
(a) meets a standard as specified in
106 CMR
703.192;
(b) is included in the SSI Listing of
Impairments as specified in 20 CFR, Part 404 , Subpart P, Appendix 1;
or
(c) substantially reduces or
eliminates the applicant's or client's ability to support himself or herself
when consideration is given to the vocational factors as specified in
106 CMR
703.193; or
(2) has written notification from SSA or an
administrative law judge that he or she is considered disabled for purposes of
SSI or SSDI and/or that he or she is eligible for SSI or SSDI. However, this
provision does not apply to those who are not currently receiving SSI or SSDI
payments due to the recoupment of an overpayment by SSA. Such person is not
eligible for EAEDC.
(B)
An EAEDC applicant or client must apply for SSI and cooperate in the SSI
application and/or appeal process when required by the Department or the
Department's agent.
(C) An EAEDC
client must submit verifications at times determined by the Department and/or
the Department's agent of his or her:
(1)
disability as defined in 106 CMR 703.191(A)(1) from a competent medical
authority as defined in
106 CMR
701.600: Definition of
Terms; or
(2) being
determined disabled for purposes of SSI or SSDI as specified in 106 CMR
703.191(A)(2).
(D) The
medical report required by 106 CMR 703.191(A)(1) must be completed within 30
days of providing it to the Department and must be based on an examination
conducted within the preceding 30 days from completion unless:
(1) the medical report is for an applicant;
and
(2) the impairments listed are
chronic and no improvement could be expected.
(E) The Department's agent shall make the
determination of disability for EAEDC eligibility except when:
(1) a competent medical authority as defined
in
106 CMR
701.600:
Definition of Terms
verifies that the applicant or client has an impairment or combination
of impairments that:
(a) is expected to last
at least 60 days but not more than 90 days; and
(b) meets or is equivalent to a medical
standard defined in
106 CMR
703.192 or impairment included in the SSI
Listing of Impairments.
(2) the applicant's or client's medical
report is not completed by a competent medical authority, is not completed
within 30 days of filing with the Department, or is not based on an examination
conducted within 30 days from completion as required by 106 CMR
703.191(D);
(3) a competent medical
authority verifies that the EAEDC applicant or client does not have an
impairment that affects his or her ability to work and/or that the applicant's
or client's impairment or combination of impairments is not expected to last
for 60 days or more; or
(4) the
applicant or client verifies that he or she is eligible for SSI or SSDI or
considered disabled for purposes of SSI or SSDI (see106 CMR
703.191(A)(2)) .
(F) If a
disability determination by the Department's agent is:
(1) required and the competent medical
authority states that the applicant or client meets a medical standard, SSI
Listing of Impairments, or has an impairment affecting his or her ability to
work, and if otherwise eligible, the applicant or client shall receive EAEDC
benefits pending a review by the Department's agent; or
(2) not required because of 106 CMR
703.191(E), the EAEDC applicant or client shall be considered disabled upon
giving the Department the necessary medical report or verifications and shall
receive EAEDC benefits if otherwise eligible.
(G) When the Department's agent is required
to make a disability determination (see106 CMR 703.191(E)) ,
it shall determine in the order listed whether the applicant or client has an
impairment or combination of impairments that:
(1) meets the MassHealth disability
standards;
(2) meets or is
equivalent to a medical standard specified in
106 CMR
703.192;
(3) does not meet a medical standard
specified in
106 CMR
703.192, but meets or is equivalent to an
impairment included in the SSI Listing of Impairments; or
(4) neither meets nor is equivalent to a
medical standard specified in
106 CMR
703.192 or an impairment included in the SSI
Listing of Impairments, but the impairment, or combination of impairments,
substantially reduces or eliminates the applicant's or client's ability to
support himself or herself when consideration is given to the vocational
factors specified in
106 CMR
703.193.
In making the determination in 106 CMR 703.191(G)(4), the
impairment, or combination of impairments, shall not be compared to the medical
standards specified in
106 CMR
703.192 or the SSI Listing of Impairments.
The determination shall be based on the applicant's or client's functional
capacity and his or her ability to do work in light of the vocational factors
as specified in
106 CMR
703.193.
(H) The Department's agent shall make a
determination that an applicant or client is not disabled only if:
(1) the agent has considered all evidence
submitted by the applicant or client and/or obtained by the Department
(see
106
CMR 702.315(B)(2)) . The
Department shall consider a test completed and diagnosis made more than 30 days
prior to the completion of the applicant's or client's medical report if it is
still relevant to his or her current impairments;
(2) the clinical information available
establishes that one or more of the findings required to meet or equal the
applicable medical standard or the SSI listed impairment, is not satisfied and
additional clinical information would not enable the applicant or client to
meet or equal the applicable medical standard or the SSI listed impairment;
and
(3) a vocational determination
of not disabled is made pursuant to
106 CMR
703.193. In making this determination, the
Department's agent shall rely on the functional capacity assessment made by the
competent medical authority who completed the applicant's or client's medical
report unless:
(a) the assessment is
inconsistent with the clinical findings or the clinical findings are not
sufficient to make this determination; or
(b) the assessment is inconsistent with the
statements made by the applicant or client. In either of these situations, the
Department's agent shall obtain whatever additional information is needed to
determine the applicant's or client's functional capacity.
(I) When an applicant, who has
previously been denied by the Department's agent, makes another claim of
disability, an eligibility determination shall be completed:
(1) when the Department's agent makes a
decision on this new disability claim; or
(2) if such a determination is not made in
time to allow initial benefits to be provided within 30 days of the date of
application, a presumptive finding of eligibility based on the disability shall
be made pending the decision from the Department's agent.
(J) When a client who has been previously
denied by the Department's agent, makes another claim of disability within a
continuous 60-month period, the eligibility determination shall be based on the
applicant or client not being disabled, pending a decision by the Department's
agent.
(K) The decision of the
Department's agent as to whether an applicant or client is disabled shall be
the decision of the Department. A Department hearings referee may affirm,
modify or reverse the finding of the agency or organization providing the
disability evaluation services.
