Disability 510-05-35-100

(Revised 7/1/2026 Release 26.5 )

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(N.D.A.C. Section 75-02-02.1-14)

The definition of disability in the Social Security Act, Section 1614, for Title II benefits as set forth below, is the definition used in the SSI Program under Title XVI. An individual shall be considered to be disabled for purposes of this title if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months (or, in the case of a child under the age of 18, if he suffers from any medically determinable physical or mental impairment of comparable severity).

SSA and SSI final determinations of disability are binding (42 CFR 435.541) and serve as evidence of the presence or absence of disability. An exception to this provision is if the individual has applied for Workers with Disabilities coverage and Social Security's decision established that the individual is not disabled due to substantial gainful activity. In these situations, the State Review Team may make an independent decision.

Presumptive determinations of disability are not final determinations for Medicaid purposes. Eligibility for Medicaid based on disability cannot be determined until a final determination is made. If a final determination will not be made by Social Security within a reasonable period of time after the date of the Medicaid application, the State Review Team will make a disability determination.

Social Security records show the start date of the individual’s disability. The start date of the disability is the earliest date an individual can be eligible for Medicaid as a disabled person as long as they meet all other Medicaid rules in those months.

For SSI, Social Security does not determine a person’s disability for any month prior to the month they applied for SSI. If the individual has a medical need in the months prior to the start date of their SSI eligibility and they are otherwise eligible for Medicaid in those months, the zone agency must send the information to the State Review Team so they can make a disability determination.

If Social Security determines a person is not disabled or is no longer disabled, the zone agency must determine if the individual is eligible for a different coverage type. Sometimes, individuals in school or job training still get Social Security benefits even if they no longer meet the disability rules. These individuals are not considered disabled and cannot get non-ACA Medicaid.

The State Review Team can make a disability determination when an individual has applied for or is requesting Medicaid based on disability. If they have applied for disability but the SSA has not yet made a determination or will not make a decision, the zone agency will complete and send an SFN 451 to the SRT. Note: If a child is applying for CWD, an SFN 451 and an SFN 228 must both be sent to the SRT. The SRT will make an interim disability determination when: The individual has applied for or is requesting Medicaid, they are otherwise eligible for a disability-based Medicaid coverage, and they have a pending SSA disability application. The applicant is in a high-level facility such as a hospital and it’s necessary to move them to a different facility such as a nursing home, group home, or into the community. In these instances, the SFN 451 can be sent to the State Review Team without verifying they applied for disability or if they are otherwise eligible for Medicaid. However, if the individual has not already applied for disability through SSA, the State Review Team determination may be delayed until verification is received that they applied for disability through the SSA. SSA did not make an SSI disability determination for a month prior to the SSI application month and the applicant requested Medicaid and is otherwise eligible for that month. The applicant may be disabled but SSI did not make a determination because the individual exceeds the SSI income and resource levels. The Medicaid recipient has had a non-pay SSI reason due to income and asset levels for one year. Note: If the individual is non-pay due to income levels AND is 1619(b) eligible, the individual is still disabled and no evaluation by the State Review Team is required. The applicant is not eligible for SSA disability due to not having met the work quarter requirements. This is also known as ‘active uninsured’. The applicant is applying for Workers with Disabilities coverage and is not eligible for SSA disability due to substantial gainful activity. The applicant is within 6 months of reaching full retirement age so SSA may not make a disability determination. The applicant is requesting assistance under the Children with Disabilities coverage and has not been determined disabled by SSA. The applicant has been found disabled by the Veterans’ Administration (VA), Workforce Safety and Insurance (WSI), or the Railroad Retirement Board (RRB), but Social Security has not made a decision. Note: Disability decisions made by VA, WSI, or RRB do not guarantee a disability determination by the State Review Team.

An SFN 451 must be completed and sent to the State Review Team when an individual has applied for or is requesting Medicaid based on a disability and they also have a pending disability application through the SSA. When the SRT receives the completed SFN 451, the SRT will contact the person and request copies of their medical records.

There are times when an individual has to be referred to the SRT for a disability determination but they do not have a pending disability application through the SSA or the SSA will not make a disability determination. If an individual is applying for Incapacity or Emergency Services, they won’t be applying for disability. If they are applying for or requesting disability-based Medicaid, CWD, or WWD, the SSA may not make a disability determination based on one of the reasons listed above in #7. If the individual does not have a pending disability application through the SSA, the SFN 451 and SFN 228 must still be sent to the SRT but the zone agency must contact the individual and request the medical records. The individual can send the medical records directly to the SRT or to the zone agency who will forward the records to the SRT.

The SRT will make a disability determination within the 90 day period that starts on the date the individual applies for or requests Medicaid and a referral to the SRT is required.

The State Review Team cannot make an independent disability determination if the SSA has made a decision. If the SRT makes a determination while the SSA disability application is pending and the SSA later makes a different determination, Medicaid must follow the SSA decision.

Any medical bills incurred by an applicant upon request of the State Review Team to obtain medical information to determine eligibility will be paid through Medicaid. If the applicant is determined to be ineligible for Medicaid, the medical bills will be paid through administrative costs.

If an individual’s Medicaid application is denied or their Medicaid case is closed due to an SSI or SSA denial or termination and they appeal the SSA denial and win the appeal, the denied Medicaid application or case closure can be reversed if the person notifies the zone agency within 6 months of the date on the notice sent to them by the SSA that they won the appeal.