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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 July 2019 Subchapter Subject Page ending with Page M0310 GENERAL RULES & PROCEDURES M0310.112 24a

2. SSA Denied Disability Within the Past 12 Months

SSA decisions made within the past 12 months are final decisions for Medicaid purposes unless: a) The applicant alleges a condition that is new or in addition to the condition(s) already considered by SSA,

OR

b) The applicant alleges his condition has changed or deteriorated causing a new period of disability AND he requested SSA reopen or reconsider his claim AND SSA has refused to do so or denied it for non-medical reasons. Proof of the decision made by SSA is required.

If the applicant indicates that one of the above exceptions applies, the Medicaid referral should be documented appropriately and sent to the DDS. After reviewing the Medicaid referral and Social Security decision, the DDS may determine that the SSA decision addressed all the conditions reported to Medicaid. In this situation, the DDS will determine that no exception applies and that the SSA decision is still binding. In this situation, the DDS will not make an independent disability determination for Medicaid. Instead, the DDS will document that an exception does not apply and that the SSA determination is still binding until the end of the 12-month period.

If the conditions in a or b above do not exist, the SSA denial of disability is final for Medicaid purposes. DO NOT make a referral to DDS for a disability determination.

3. SSA Denied Disability More Than 12 Months Ago If the applicant alleges a disability and SSA denied the disability more than 12 months ago, follow the procedure in M0310.112 G below to make a referral to DDS. DDS will accept and fully develop the Medicaid referral if more than 12 months have passed since the most recent SSA medical determination, regardless of appeal status with SSA, and for any reason.

F. Decision Pathway for DDS Referrals When determining whether or not a referral to DDS is required, the worker should ask the following questions: