2662.4 Presumptive Medical Disability Team (PMDT)

A disability determination by the Presumptive Medical Disability Team (PMDT) is required for individuals seeking Presumptive Medicaid (Tier 1) or MediKan (Tier 2). The agency determines whether an individual meets the criteria for a referral to the PMDT and initiates the referral when appropriate. Disability determinations (and redeterminations) are made by the PMDT and certified by the Disability Review Team (DRT), unless otherwise specified by policy.

A referral to the PMDT may be made for both Medicaid (Tier 1) and MediKan (Tier 2), or for Medicaid only (Tier 1 only). A referral for MediKan only is not appropriate. Individuals who do not meet the financial or non-financial criteria for MediKan may be referred for Medicaid only. When a referral is made for both Medicaid and MediKan, the PMDT considers disability under both programs. Persons who have reached the MediKan lifetime limit may be referred for Medicaid only.

The referral to the PMDT must indicate which program(s) are applicable. Examples: An application is received for an individual who has already received 12 months of MediKan coverage. The applicant may not receive MediKan, so the only program considered is Medicaid. An application is received for an individual whose countable monthly income is $500.00. This is over the income limit for MediKan, so the only program considered is Medicaid.

Declaration of Disability A referral to the PMDT requires a declaration of disability by the individual. The declaration may be made on the application for medical assistance or through direct contact with the agency. The declaration must include sufficient information to indicate that the disability may meet minimum program requirements. Disability is a requirement for both Medicaid disability-based coverage and MediKan. If the individual does not claim a disability or does not respond to the disability-related questions, a referral to the PMDT is not appropriate. For couples, when only one spouse declares a disability, MediKan eligibility does not exist and any referral to the PMDT would be for Medicaid only.

Duration Requirement The agency must determine whether the individual alleges a disability expected to last at least 12 months or result in death. This durational requirement applies to both Medicaid and MediKan. If the durational requirement is not met, a referral to the PMDT is not appropriate. Example: An individual reports a temporary injury expected to last six (6) months on the application for medical assistance. Because the durational requirement is not met, no referral to the PMDT is made.

Status of SSA Disability Application The agency must determine whether the Social Security Administration (SSA) has made a final disability determination. A determination is not considered final if the SSA application is still pending or under appeal. If SSA has not made a final determination, a referral to the PMDT may be made for Medicaid and, when applicable, MediKan. Example: An individual was denied SSA disability benefits and timely appealed the decision and is currently awaiting a hearing. Because the SSA determination is not final, a referral to the PMDT is appropriate.

SSA Determination Older Than 12 Months When an individual reports that a final SSA disability determination occurred more than 12 months prior, the case may be referred to the PMDT. Verification of the date of the SSA determination should be attempted but must not delay the PMDT referral. Example: The applicant reports that Social Security denied their application 18 months prior because of not meeting disability criteria. The EATSS interface confirms the denial. Because more than 12 months have passed since the final SSA determination, a new referral to PMDT is appropriate. The individual must also be referred to reapply for disability benefits with the SSA.

SSA Determination Within Past 12 Month When SSA has made a final disability determination within the past 12 months , a referral to the PMDT is only appropriate if the individual reports a change in condition or a new disability. The individual’s statement regarding the change is sufficient for referral purposes. Example: The applicant was denied by Social Security 6 months ago as their medical condition did not meet SSA disability standards. However, they report on their Medicaid application that the medical condition has worsened. Because a new or worsening condition has been reported, a referral to the PMDT is appropriate. The individual must also be referred to reapply for disability benefits with the SSA.

Application for SSA Benefits Unless verification of a pending SSA disability application verified, the individual must be advised to apply for SSA disability benefits. Verification of a pending SSA application is required prior to MediKan approval. However, medical assistance under Medicaid may not be denied solely because the individual has not applied (or provided verification of applying) for SSA benefits, in accordance with 2124 .

Disability Questionnaires and Medical Information The agency collects medical information necessary for a PMDT disability determination using the following forms: ES-3903 Presumptive Medical Disability Determination Questionnaire ES-3904 HIPAA Compliant Authorization to Disclose Information to KDHE Completion of the required questionnaire and receipt of the original, validly signed release of information are program requirements. These forms allow the PMDT to obtain medical records and complete the disability determination. Failure to provide requested information may delay the disability determination or result in an unfavorable determination. Individuals needing assistance should be directed to friends, family, and other community resources for assistance. In addition, the form includes language directing the applicant to contact the PMDT at their toll-free number (1-888-547-2763) if they have questions about the form. Questionnaires or release forms received, even if only partially complete, should still be forwarded to the PMDT as part of the referral process. Upon receipt of the questionnaire and HIPAA release, the PMDT will review the form and determine if additional information is needed and contact the applicant if necessary.

Disability Determination Process The PMDT develops the disability case and evaluates medical evidence. All disability determinations must be certified by the Disability Review Team (DRT), which consists of qualified medical and disability professionals. The DRT evaluates medical, vocational, and other relevant evidence and makes the final disability determination. Disability determination services may be provided through a contractual arrangement with Disability Determination Services (DDS). The PMDT records and maintains disability determination outcomes and reviews disability statuses when deemed appropriate by the agency. Eligibility staff uses the disability determination to complete the Medicaid eligibility determination and issue required notices in accordance with 1430 .