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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 January 2014 Subchapter Subject Page ending with Page M0310 GENERAL RULES & PROCEDURES M0310.112 21

M0310.112 DISABLED

A. Introduction For individuals who meet no other full-benefit covered group and claim to have a disabling condition, Medicaid eligibility uses the same definition of “being disabled” that the Social Security Administration (SSA) uses. 1. Definition of a Disabled Individual

For an individual 18 or older, the SSA defines “being disabled” as an individual’s inability to do any substantial gainful activity (SGA) or work because of a severe, medically determinable physical or mental impairment or combination of impairments. This impairment(s) has lasted or is expected to last for a continuous period of not less than 12 months, or the impairment is expected to result in death. For a child under 18, the SSA defines “being disabled” as having a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations. These limitations must have lasted or be expected to last for a period of not less than 12 continuous months, or the impairment is expected to result in death. However, a child cannot be found disabled if, at application, the child is performing SGA and is not currently entitled to Supplemental Security Income (SSI) benefits. 2. Disability Determination Services Disability Determination Services (DDS) is a division of the Virginia Department for Aging and Rehabilitative Services (DARS) DDS is charged with making disability determinations for individuals who allege they are disabled for the purpose of qualifying for Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI) disability or blindness benefits, and/or Medicaid. An individual must file separate applications for SSDI/SSI benefits with SSA and for Medicaid with LDSS. The Department of Medical Assistance Services (DMAS) contracts with DARS to have DDS process disability and blindness claims and make determinations of “disabled” or “not disabled” based upon federal regulations. DDS uses the same definitions of disability and blindness and the same evaluation criteria for all three programs. See M0310.106 for the definition of blindness. 3. Factors Involved in a Disability Decision The LDSS does not determine whether or not an individual meets the disability requirements. DDS determines whether or not an individual is disabled as defined by the SSA by evaluating a series of factors in sequential order. The following information is intended to provide a general overview for the LDSS worker of this sequential process and does not provide a complete explanation of the disability determination process: a. Engaged in Substantial Gainful Activity (SGA)?

Is the individual currently engaged in substantial gainful activity (SGA)? SGA means work that: (1) involves doing significant and productive physical or mental duties and (2) is done (or intended) for pay or profit and (3) earnings are above a certain amount. If an individual is working and earning SGA, a finding must be made that the person is not disabled, and no medical evaluation is done. If the individual is not earning SGA, DDS proceeds to the next step.