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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 25

Has the individual applied for SSDI or SSI? If no, refer to DDS.

If yes and a decision has not been made, refer to DDS.

If yes and a decision has been made, was the disability allowed or denied? If allowed, refer to M0310.112 B, because another determination of disability may not be necessary. If denied, look at the date of the last determination.

If the last SSA denial determination was made more than 12 months in the past, refer to DDS regardless of whether or not the decision is in an appeal with SSA. If the last SSA denial determination was made less than 12 months in the past, and there is a new condition that has not been evaluated by SSA, refer to DDS.

If the last SSA denial determination was made less than 12 months in the past, and there has not been a worsening of a condition already evaluated by SSA, do not refer to DDS.

If the last SSA denial determination was made less than 12 months in the past, but there is a worsening of a condition already evaluated by SSA, ask if the individual has filed for a reconsideration or reopening of his case with SSA. If yes and the case is currently under reconsideration, do not refer to DDS. The SSA decision remains binding unless SSA reverses the decision. If yes and the SSA refused to reconsider his case because he does not meet the SSI eligibility requirements, refer to DDS.

If no, do NOT refer to DDS. The individual must initiate an appeal of his denial with SSA. Unless SSA refuses the appeal request or turns it down for non-disability related reasons, the disability determination remains binding for 12 months. G. LDSS Procedures When a Disability Determination is Required There are two types of DDS referrals for the purposes of Medicaid eligibility: non-expedited and expedited. Most referrals are non-expedited. Expedited referrals are limited to individuals who are hospitalized and require a Medicaid disability determination so they can be transitioned directly from the hospital to a rehabilitation facility For both types of referrals, the eligibility worker must request the necessary verifications needed to determine eligibility so that the application can be processed when the disability determination is received.