701.01 Introduction 2

701.02 Presumptive Disability Process and Procedure 2

701.01 Introduction

(Rev. 05/01/17)

POMS DI 23535.010

Presumptive disability (PD) allows an applicant to be presumed disabled to establish categorical eligibility until a final disability decision is reached. Presumptive disability is appropriate when the applicant has an urgent need for medical services and the available evidence demonstrates a strong likelihood that:

Disability or blindness will be established when complete evidence is obtained, or the evidence establishes a reasonable basis for presuming the individual is currently disabled, and

The disabling impairment has lasted or is likely to last at least 12 months.

Certain disabilities require evaluation after a three or six month period of recovery from the original injury or medical event (major head injuries, strokes, heart attacks, etc.). An individual cannot be determined presumptively disabled during the medical deferral period.

Presumptive disability determinations are not allowed for individuals that are deceased. Process requests for a disability determination for a deceased individuals through the normal disability process.

The following examples are provided to assist in determining the correct date for PD/PB. Do not enter a PD or PB onset earlier than the month in which the claimant filed his or her application.

If the PD finding is made in the month in which the application was filed, enter the application date.

If the current month is the month immediately following the month of filing, use the application date as the onset date.

If the PD finding is made two or more months after the month of filing, enter the month and year prior to the month in which the PD finding is made.

701.02 Presumptive Disability Process and Procedure

(Eff. 03/01/16)

System of Record Prior to processing the application, it must be determined whether the person already has eligibility in Cúram . The following steps apply to most situations. Applications originating in Cúram : Is the applicant Medicaid eligible: Yes: Are they eligible in a full benefit category? Yes: Treat the application like a reported change, apply changes. No: Re-index for the SSI Non-Institutional Queue. If the applicant is found eligible under the ABD category, eligibility in Cúram must be ended before approving the application in MEDS. (See Job Aid Manually Ending Benefits in Healthy Connections Cúram .) No: Re-index application for SSI Non-Institutional Queue.

Definitions Term | Adult | Child (Under Age 18) Disability Report | DHHS Form 3218 ME | DHHS Form 3218-D ME Disability Packet | Disability Cover Letter DHHS Form 3218 ME DHHS Form 921 | Disability Cover Letter DHHS Form 3218-D ME DHHS Form 921

Presumptive Disability Determination Procedure Person | Task Hospital Worker | Complete Medicaid application and Disability Packet. Send Medicaid application and Disability Packet with cover sheet to DHHS via specialty unit email fax line. If the applicant is applying for a BHDD waiver, have the family make a referral via the BHDD Intake Referral number: 800 - 289 - 7012 . Administrative Assistant | If the application is received via the DHHS specialty unit email fax line, separately virtually print the application and disability packet to OnBase under the PD claim type. If a paper application is received, separately scan the application with cover sheet and disability packet with cover sheet into OnBase as a PD claim type. If the application is for waiver services, use the appropriate BHDD site code Eligibility Worker | Access the Medicaid application marked under the PD claim type from OnBase. Check BENDEX (MPPM 102.06.02B), SDX (MPPM 102.06.02C), and SVES (MPPM 102.06.02D) to see if disability is established. If not, check OnBase for an existing MAO99 that has not passed its diary date. If there is no existing MAO99 that has not passed its diary date, process the application minus the disability decision. Verify all other financial and non-financial eligibility criteria. Does the applicant meet all other financial and non-financial criteria? YES – Send the case to the Follow-Up Queue for 90 days or until you receive a MAO99 Return or Presumptive Disability Decision Form. NO – Send the case to the Follow-Up Queue for 90 days to wait for the final disability decision. Do not deny the application at this time. Contact the applicant/AR Disability Determination Services at Vocational Rehabilitation will continue processing the Disability Packet. A Presumptive Disability Decision Form establishes disability until an MAO99 is returned. If applicant meets all eligibility criteria, approve the application in Cúram for the appropriate category. Make a note in the notes section of Cúram and the documentation template stating: “A presumptive disability decision was made, and SCDHHS is waiting for the MAO99 . ” If the MAO99 does not establish disability, assess for Family Planning or other MAGI category in Cúram . DHHS Worker at VR | Access the disability packet marked under the PD claim type from OnBase and complete the Disability Process Checklist to evaluate the Disability Packet for completeness. NOTE: Do not date stamp or make any other marks on the front of the DHHS Form 921 Is the Disability Packet contact information complete and legible and did the applicant sign the Form 921? YES – NOTE: Be sure POA signs their name on behalf of the client, not the client’s name. Include POA document with Disability Packet when submitting to VR. Print the entire application and give to VR. NO – Contact the applicant by phone regarding any incomplete or illegible information in the packet. Refer to Disability Packet Correction Script Make any necessary corrections to the forms and add your initials. Pass to onsite supervisor if unable to reach applicant or additional action needed (such as return of DHHS Form 921 for signature). If supervisor cannot reach applicant by phone, they must communicate the request by mail with use of DHHS Form 1233. Once complete, pass the completed Disability Packet to VR and Scan the Disability Packet into OnBase. NOTE: Be sure POA signs their name on behalf of the client, not the client’s name. Include POA document with Disability Packet when submitting to VR. Once VR returns the MAO99 or Presumptive Disability Decision Form, scan MAO99 or Presumptive Disability Form into OnBase (Document Type: MEDS Categorical Verification; Trailing Document – Yes; Claim Type: PD)

Procedure for Entering Onset Date of Disability MEDS Procedure: If an Eligibility Worker can determine that the disability criteria is met without forwarding the case for a disability determination (SSA disability or current VR decision), the onset date of disability must be entered on HH Member Detail (HMS06). The onset date of disability entered would be a verified date based on BENDEX or SDX and can be found on one of the following sources: Award Letter if dated within the last 12 months MA099 if the diary date has not passed BENDEX SDX DISABILITY ONSET SVES SSA DIB ONSET SVES SSI DIB ONSET When a date is entered in HMS06, the system will set the standard of promptness as 45 days rather than 90 days. MEDS will then establish 45 days as the appropriate standard of promptness when the application is locked If the onset date has not been established, leave the Disability Onset (DO) date blank and MEDS will establish 90 days as the appropriate standard of promptness