1614.6 Procedures For Requests Related to a Disability Determination

A request for a fair hearing on a decision based on a disability determination made by the agency, or contractors, according to 2662 is initially reviewed by the entity responsible for the disability decision.

DDS Disability Determinations – When the agency receives a fair hearing request based on a DDS disability determination, eligibility staff shall take the following actions: The hearing request shall be sent to the Office of Administrative Hearings with an indication that this is an appeal of a DDS disability determination. A DDS reconsideration of the disability determination shall be initiated by completing the following: The agency shall complete a new DD-1104 and forward to DDS, clearly indicating that this is a request for Reconsideration. In addition, the original DD-1104 and DD-1105 , as well as a new signed and dated DD-1103 should be attached. The appellant shall be instructed to complete and sign the DD-1103 release form and return to the agency within 12 days. If timely returned to the agency, the forms, along with a new DD-1104, Disability Determination Request - Medical Assistance Case form completed by the agency with the reconsideration box clearly marked shall be forwarded to DDS for review. The agency shall also include the original disability determination file compiled by DDS. If the appellant fails to timely return the requested forms, no further action on the reconsideration is required. The agency shall complete an Appeal Summary and forward to the Office of Administrative Hearings as indicated above. The Appeal Summary shall be clearly identified as a DDS disability determination appeal. A copy of the DDS disability determination file shall be included. In most instances, the reconsideration process will not be completed by DDS at this point. Staff should report on the Appeal Summary that a disability reconsideration by DDS is in progress. If the reconsideration is completed by DDS before the scheduled hearing date, the decision will determine the next step. If the decision is favorable, eligibility shall be redetermined and approved for coverage if otherwise eligible. The agency shall submit a motion to dismiss the appeal to the Office of Administrative Hearings since the issue is now moot. If the decision is unfavorable, the agency shall submit the reconsideration packet received from DDS as newly received evidence. If the reconsideration is not completed by DDS before the scheduled hearing date, the agency shall request a continuation of the hearing clearly stating the reason for the request. If the request is denied, the agency shall proceed to hearing without the reconsideration decision or documentation. However, the reconsideration process shall continue: The agency may request that the hearing record remain open after the scheduled hearing has occurred to submit the reconsideration decision and documentation once completed. If the request is granted, the agency shall submit the documentation once received. If the request is denied, the reconsideration process will continue, but the ultimate decision and documentation will not be included in the hearing decision. The agency shall still act upon the reconsideration decision, even when reported after the hearing decision is issued. If the DDS decision is unfavorable, no further action is required. The applicant continues to fail to meet disability criteria. If the decision is favorable, the applicant is now determined to be disabled. Eligibility shall be redetermined and approved for coverage if otherwise eligible.

Presumptive Medical Disability Team (PMDT) Determinations – A fair hearing request may involve MediKan or Medicaid. Any request for a fair hearing regarding the disability determination must be sent to the Office of Administrative Hearings. The PMDT shall immediately be notified of the request. For cases where there is sufficient medical evidence, the PMDT will process a reconsideration of the disability determination. All cases approved for Tier 2 but denied Tier 1 will have sufficient evidence and be reconsidered. Any additional information available to the eligibility worker must be noted on the referral (e.g., medical services, social information hospitalizations, etc.). Copies of the fair hearing request and any related materials should be included with the referral. The PMDT may request additional information from the eligibility worker to develop the reconsideration. If the reconsideration establishes that the appellant meets disability criteria, or that a higher level of disability does exist, the case will be referred back to the eligibility worker for redetermination based on the new disability determination. However, if the reconsideration upholds the original disability decision, the case will be prepared for a fair hearing. The PMDT will take the lead in preparing the appeal summary and representing the agency at the hearing, with the support of the eligibility worker.