New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 106 - STATE FUNDED ASSISTANCE PROGRAMS
Part 420 - RECIPIENT POLICIES - REQUIREMENTS FOR DETERMINING DISABILITY
Section 8.106.420.8 - DISABILITY DETERMINATION PROCESS

Universal Citation: 8 NM Admin Code 8.106.420.8

Current through Register Vol. 35, No. 18, September 24, 2024

A. Disability determination: The department must find:

(1) medical evidence of physical or mental impairment(s), and

(2) medical and non-medical evidence to support that the severity of the impairment(s) is sufficient to significantly restrict the applicant's capacity to perform basic work-related activities or prevent engagement in gainful employment; or

(3) that, absent the above findings, an unsubstantiated statement of impairment or inability to work shall not be adequate to establish disability.

B. Case development process:

(1) all eligibility factors must be met prior to determining disability;

(2) complete a medical/social summary describing the applicant's health history; appearance, work and personal situation;

(3) assist, if appropriate, the applicant with obtaining documentary evidence;

(4) schedule, if appropriate, appointments for the applicant; and

(5) determine the need for additional documents for evidence.

C. The department may use the following alternative methodology to determine disability for set and variable term general assistance.

(1) Documentation requirements:
(a) The medical information must be documented on the department's standardized and approved medical release/physician's statement or may be documented on a physician's statement that includes all the information required to make a disability determination.

(b) The medical information used to substantiate impairment and finding of disability must include, but shall not be limited to:
(i) a record or narrative report resulting from examinations or diagnostic procedures;

(ii) a statement of the impairment;

(iii) a projected time period of the length of the disability; and

(iv) certification that the impairment precludes employment within the individual's capacity.

(2) Duration of an impairment: The duration of the impairment shall be evaluated by the department based on medical documentation.
(a) An impairment substantiated by medical documentation that precludes the individual's capacity to engage in gainful employment that is expected to last at least thirty days from the date of disability and for less than eight months shall be eligible for a set term certification.

(b) An impairment substantiated by medical documentation that precludes the individual's capacity to engage in gainful employment that is expected to last at least thirty days from the date of disability and for an indefinite period exceeding 6 months shall be eligible for a period of no more than six months without substantiating medical evidence consistent with Subsection D of 8.106.420.8 below.

(3) The alternative methodology shall be used no more that once in any 12 month period.

D. Development of evidence: The applicant is responsible to obtain and provide evidence of the nature and severity of the impairment(s) as well as the capacity to work. Non-medical evidence will not be considered in the absence of medical evidence.

(1) Medical evidence: Medical evidence must be submitted and considered to verify the existence of physical, mental impairment(s) or both.
(a) Source: Medical evidence must be obtained from approved source(s), limited to: medical doctors, physician assistants, doctors of osteopathy or podiatry, ophthalmologists, psychiatrists or psychologists, state-licensed providers, and individuals that meet the minimum mental health professional qualifications set by their community mental health services employer.

(b) Timeliness of report: Medical evidence over six months old from the date of application may be useful to support a pattern of recurring impairment, but should be accompanied by current medical evidence.

(c) Department assistance:
(i) Requests for reports: When necessary the department shall assist in obtaining medical evidence by making no more than two written requests per medical provider, for copies of relevant existing medical reports.

(ii) Examinations: The department shall schedule and, based on available funding, pay for a medical examination or other appropriate procedure(s) for purposes of obtaining current medical evidence. The applicant shall first be referred to the individual's own physician or provider.

(2) Non-medical evidence: Non-medical evidence may be submitted and considered from public and private agencies, schools, parents and caregivers, social workers and employers, and other sources to assist in the determination of whether the impairment(s) are of sufficient severity to restrict the applicant's capacity to perform basic work-related activities or prevent engagement in gainful employment.

E. Case disposition: Once an impairment is established, all the medical and non-medical evidence is considered in assessing impairment severity to determine disability. Case disposition shall include:

(1) a thorough review of documentary evidence;

(2) a determination as to whether disability is supported;

(3) the anticipated duration of the impairment;

(4) specific contingency requirements; and

(5) the certification review period for disability review.

F. Certification period: The certification period is primarily based on the prognosis and anticipated duration of the impairment(s), as established by medical evidence.

(1) Set term: A set term is assigned where medical evidence supports that a significant improvement in the impairment(s) is anticipated or probable in the six months following application. A set term certification shall not exceed eight months in total duration. A new application may be submitted for consideration of a new term.

(2) Variable term: A variable term is assigned where medical evidence supports that a significant change in the impairment(s) is not anticipated or probable in the six months following application.

G. Contingencies: Eligibility for benefits may be made contingent upon satisfactory completion of written condition(s) that may include, but are not limited to:

(1) follow treatment plans as prescribed by a physician or mental health provider;

(2) seek and utilize available community based resources;

(3) accept treatment as recommended by a physician or mental health provider;

(4) pursue a referral for DVR, or other available, services.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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