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West Virginia Income Maintenance Manual Chapter 13

West Virginia Income Maintenance Manual Page 12 Chapter 13 Determining Disability, Incapacity, and Blindness

PRESUMPTIVE MEDICAL APPROVAL 13.6.1 INTRODUCTION The process of making a disability, incapacity or blindness decision at the local level is referred to as the presumptive medical eligibility process. In some situations, the decision may be made prior to obtaining any medical reports. However, in all other situations, the presumptive medical decision is made only when medical information and the social summary are available. The presumptive decision is always one of presumptive approval, not presumptive medical denial. When the case is referred to the Medical Review Team (MRT) for a final decision, the presumptive medical eligibility decision is made by the Worker, with approval of his Supervisor. The guidelines for presumptive medical decisions based on medical and social information are found below. The definitions of incapacity, blindness, and disability follow. In making a presumptive medical decision of incapacity or disability, the Worker uses the guidelines appropriate for the coverage group to determine if the medical/psychological impairment of the applicant is likely to last the required length of time. He then uses the social summary information to determine if the impairment: • Prevents the incapacitated parent, age 18 and over, from working; or, • Prevents the applicant under age 18 from functioning independently and effectively in an age-appropriate manner; or, • Prevents the incapacitated parent from caring for himself or performing household duties and, therefore, requires the presence of the spouse in the home. 13.6.2 WHEN THE APPLICANT HAS RECEIVED SSI BASED ON DISABILITY OR BLINDNESS When an individual whose SSI payment has terminated applies for Medicaid, and it is necessary to establish incapacity, disability, or blindness, the procedure is as follows: