County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Referrals Number Page 050401 1 of 4 Revision Date 04012018 Background The State Program Disability Determination Service Division DDSD is responsible for evaluating medical and employment data to determine if an applicantbeneficiary meets the federal definition of disability This section is being updated to include Affordable Care Act ACA changes issued in SN 1309A Disability is defined as the inability to engage in any substantial gainful activity SGA by reason of a medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than twelve months Refer to MPG 050403 for details on SGA Note DDSD does not determine incapacity for AFDC linkage nor verify pregnancy or social security numbers Purpose This section provides criteria for processing disability referrals Policy Applicantsbeneficiaries who cannot be determined MediCal eligible under Modified Adjusted Gross Income MAGI and claim a disability can continue their MediCal application process by completing a DDSD referral 050401A When to Refer to DDSD The disability referral process to DDSD is used only when The disability cannot be confirmed by the methods detailed in MPG 0503 The applicantbeneficiary application for SSI is denied for excess incomeresource and individual has proof The applicantbeneficiary has been denied SSA within the last 12 months and has reapplied with SSA Applicant was receiving SSISSP and was discontinued for a reason other than termination of disability and does not currently receive Social Security Title II disability benefits SSA refuses to accept a reopening request and individual has proof Applicantbeneficiary was denied benefits for failure to cooperate with DDSD and good cause is established DDSD is only authorized to perform medical needy evaluations on individuals applying for MediCal 10 Day Rule The completed MediCal Supplemental Statement of Facts MC 223 or MC 223C and applicants information must be entered into CalWIN prior to submitting a DDSD referral All referrals must be submitted to DDSD within 10 calendar days from the date The completed MediCal application is received by the county or The beneficiary claims to be disabled whichever is later County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Referrals Number Page 050401 2 of 4 Exceptions to the 10 Day Rule Circumstances beyond the workers control cause a delay in submitting the referral The reasons for the delay must be documented in case comments Do not hold the referral pending evaluation or verifications ie property issues of other nondisability factors If the individual is later found to be ineligible send form MC 222 DDSD Pending Information Update to DDSD The applicantbeneficiary has a pending SSI or Social Security Title II application and 80 days have passed since the MediCal only application date 050401B How to Identify a DDSD Referral Indications of disability for an applicantbeneficiary include the following Answer yes to the disability question on the MediCal application or Makes a written or oral statement to the worker which alleges disability SSISSP is pending on MEDS INQX screen with a H80 payment status Form MC 017 What You Should Know About Your MediCal Disability Application will be given to individuals who wish to pursue a MediCal application based on disability This informational form gives the individual an overview of what can be expected when an application based on disability is filed 050401C Appropriate Referrals The purpose of a disability evaluation is to establish linkage to the NonMAGI program The following applicantsbeneficiaries are referred to DDSD Persons age 18 or older who meet the definition of federally disabled Child who appears or alleges to be disabled Any other person who is potentially disabled or claims to be disabled Disabled person whose condition the worker believes has improved or the person reports an improvement A disabled person who becomes employed in paid unpaid or volunteer work A disabled person who has a break in MediCal benefits for 12 or more months for any reason other than termination of disability Disabled person under age 65 who does not receive Title II disability benefits and has been discontinued from SSISSP for reasons other than termination of disability even though there was no SSA reexamination date Person receiving County Medical Services CMS who requests a disability based MediCal evaluation Ask the applicant if heshe received CMS services in any of the three retroactive months and include those on the DDSD transmittal form MC 221 Person who was denied Title II SSA or Title XVI SSI disability status within 12 months from the SAWS date and o Claims a new medical condition not considered by SSA o More than 60 days from the SAWS 1 date claims the same medical condition has worsened or a new medical condition not considered by SSA Note The applicant must be referred to SSA Applicant who claims to be disabled is working and engaged in SGA County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Referrals Number Page 050401 3 of 4 Note Tactfully discuss a disability referral with an applicantbeneficiary who does not specifically meet the criteria for referral listed above but who could be disabled It is to the individuals benefit to be evaluated for disability because ABD individuals are eligible to larger income deductions 050401D Inappropriate Referrals A disability evaluation referral is inappropriate and the applicantbeneficiary will not be referred for a disability evaluation when the Person within the last 90 days has had a DDSD determination and was found not disabled or no longer disabled unless heshe alleges hisher condition has deteriorated presents new medical evidence or claims a new physicalmental condition exists Applicant was determined disabled under the NonMAGI program within the last 12 months unless the reexamination date has passed or the applicant indicates their condition has improved Person is already classified as aged or disabled unless a blindness evaluation for Pickle eligibility is required Person does not meet other eligibility factors such as California residency or property limits Person who was denied disability status by SSA o Within the previous 60 days and did not request that SSA reconsider their claim o After 60 days but within one year of current date and individual did not request that SSA reopen their claim o After 60 days but within one year of current date and individuals condition has changed or worsened and did not reapply with SSA o SSA denied the disability claim after reopening the previous decision o After 60 days from application date and does not claim the same medical condition has worsened or a new medical condition or o Any time they have appealed the SSA denial and the decision is pending 050401E Disability Packet Received from ApplicantBeneficiary All MediCal applicants requiring a disability evaluation must have their SSA status verified to determine if the applicant has had a disability determination adjudicated or has a pending application with SSA SSA evaluates disability claims in the order that will be most beneficial to the applicant 1 Title II SSA disability 2 SSA early retirement applicant over 62 years of age 3 Title XVI SSI Note If SSA denied the disability claim after reopening the previous decision the SSA decision would supersede DDSDs determination Deny the MediCal application if no other linkage is established 050401F Tracking DDSD Referrals Each FRC maintains the pending cases and is responsible for the grantingdenial action once a decision is received from DDSD The state mandates that counties track DDSD referrals Utilize the DDSD Management Report to monitor and track DDSD referrals The report is uploaded to SharePoint weekly County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Referrals Number Page 050401 4 of 4 Procedure Refer to Processing Guide 26 for steps to follow when a completed disability packet is returned to the county Program Impacts Automation Ensure that all CalWIN fields in the Display DisabilityMedical Condition Summary and the Collect Special Indicator Detail windows are completed during each step of the DDSD referral process References ACWDLs 0016 1111 1202 1217 MEM Proc 22C 22C1 22C7 MEDIL 1722 County Policy Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Pending Disability Determination Aid Codes Number Page 050402 1 of 2 Revision Date 04012018 Background When a MediCal beneficiary alleging a disability is not currently considered disabled and other linkage no longer exists the individual alleging the disability may receive MediCal benefits under a Pending Disability Determination aid code until a disability determination is made This does not apply to beneficiaries who are discontinued from aid code 53 This section is being updated to the new format no other changes have been made Purpose This section provides policy for MediCal evaluations when there is a pending disability determination aid code Policy 050402A Pending Beneficiaries Aid Codes If the individual meets the criteria initiate a DDSD referral and place the individual in the appropriate pending disability aid code Aid Code Description 6J Full Scope Zero SOC 6R Full Scope SOC 5J Restricted Scope Zero SOC 5R Restricted Scope SOC Note The above aid codes will not be used when the beneficiary is eligible under another MediCal aid code or reports a disability more than 30 days after the discontinuance for loss of linkage 050402B CalWORKs Recipient Discontinued When a recipient is discontinued from CalWORKs CalWIN will automatically convert to the appropriate MediCal aid code based on previous entries If no MediCal eligibility is found and the individual alleges a disability obtain the individuals written statement of disability and completed DDSD packet Submit the completed DDSD packet within 10 days of receipt as outlined in MPG 050401 and place the recipient in the appropriate pending disability aid code Procedure 050402C Discontinued from Aid Code 53 Beneficiaries discontinued from aid code 53 must be processed as follows If aid code 53 beneficiary is Then alleging a disability appreg a new MediCal application and hold in pending status not alleging a disability no further action is required case remains closed Program Impacts None County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Pending Disability Determination Aid Codes Number Page 050402 2 of 2 References ACWDLs 0240 Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Substantial Gainful Activity SGA Number Page 050403 1 of 3 Revision Date 04012018 Background To be considered disabled an individual must be unable to engage in SGA due to a physical or mental impairment which is expected to result in death or last for a continuous 12month period This section is being updated to the new format no other changes have been made Purpose This section provides guidelines for processing SGA determinations Policy 050403A SGA Determination An SGA determination will be made when an applicantbeneficiary applies for MediCal disability and States on form MC 223 or MC 223C Supplemental Statement of Facts that heshe is working and has gross earnings of more than the current monthly SGA limit Refer to MPG 1101 for SGA limits Meets the criteria for pending disability and has gross earnings of more than the current monthly SGA limit Pending disability will not be approved until an SGA determination is made Note These procedures do not apply to individuals who are blind and return to work after disability has been approved or who meet the eligibility requirements for the 250 Working Disable WD Program Applicants who are denied SSA disability based on the capacity to perform SGA and who are otherwise eligible for the 250 WD Program will be referred to DDSD for a disability evaluation If an SGA evaluation was not performed because the person alleged blindness and DDSD found that the person was disabled but not blind an SGA evaluation must be performed before eligibility as a disabled person can be established When the individual is subsequently found to be engaging in SGA send form MC 222 and a copy of the MC 272 to the State DDSD 050403B Subsidies A subsidy is support an impaired worker receives to include one of the following More pay than the actual value of the service performed Same pay but more supervision Fewersimpler tasks than other nonimpaired workers Results in more pay than the actual work is worth Individuals in sheltered workshops or settings are generally subsidized Subsidies will be verified by obtaining a statement from the employer or evidence from the employer confirming that a subsidy exists and the value of the subsidy The subsidy amount is deducted from gross earnings to determine the net counted earnings for SGA eligibility Subsidies are not considered earned income exemptions when computing budget determinations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Substantial Gainful Activity SGA Number Page 050403 2 of 3 Example Employer states that the value of work is half the actual earnings The individual earns 800 per month Because half the work is subsidized 400 is considered the real value of the work and the individual is not engaging in SGA Note 800 is the nonexempt income use in determining the individuals SOC 050403C Special Work Considerations If a beneficiary is forced to stop working after a short time due to impairment the work is generally considered an Unsuccessful Work Attempt UWA and the earnings from that work will not be used to determine SGA See Desk Aid 85 for UWA examples All of the following must be present for work to be considered UWA There is a break in the individuals employment of 30 days or more Work lasted less than six months Worked stopped due to the individuals impairment Procedure 050403D Determining SGA Follow the steps below when determining SGA Step Action 1 Obtain verification of the individuals monthly gross earnings and Impairment Related Work Expenses IRWE 2 In CalWIN complete the Collect Case Individual Detail Screens Other Information tab Individual choice about 250 WD check yes and Declines to be evaluated for the AD FPL program check yes 3 If Then net countable earnings are greater than current monthly SGA limit evaluate for the 250 WD program applicant is ineligible to the 250 WD program has no other linkage and is engaging in SGA deny the application based on disability net countable earnings are equal to or less than the current monthly SGA limit notate on item 10 on the MC 221 evaluated and is not engaged in SGA complete MC 272 SGA worksheet submit the MC 272 with the completed DDSD packet to DHCS for disability evaluation complete the Display DisabilityMedical Conditions Summary screens in CalWIN image forms in to case file enter case comments County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Substantial Gainful Activity SGA Number Page 050403 3 of 3 Program Impacts None References ACWDLs 0016 0247 1202 MEM Proc 22C2 22C12 Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Limited DDSD Referrals Number Page 050404 1 of 2 Revision Date 04012018 Background A limited DDSD referral packet is required for persons under 65 years of age who were discontinued from SSISSP for reasons other than termination of disability and who are not currently receiving Title II SSA disability benefits Included with the reformatting the DDSD forms listed in this section have been added to MPG 050406 for efficiency Purpose This section provides guidelines for processing limited DDSD referral packets Policy 050404A Limited DDSD Referrals Take all necessary steps to determine the reason the applicant was discontinued from SSISSP using the information obtained from SSA MEDS or IEVS and document the information in case comments SSISSP Record of Disability The SSISSP record of disability is maintained for 12 months After the 12 months have lapsed SSA will show that the beneficiary is not disabled While eligibility may be granted when verification of disability status with SSA is obtained ongoing disability status must be established by DDSD prior to the end of the 12month record retention period Disability Redeterminations All disability redeterminations will require a limited referral packet unless one of the three conditions exist 1 It has been more than 12 months since the applicant was discontinued from MediCal 2 The reexam is due past due or unknown 3 The applicants condition has improved Note A limited referral packet will be used for deceased applicants The MC 223 or MC 223C and documentation of death must be included eg death certificate hospital records etc Disability Reevaluations A limited referral packet may be sent for reexam determinations only when 1 The packet is sent within 30 days of DDSDs decision 2 An earlier onset date on an approved case is needed 3 No new disabling factors are alleged or 4 No new treatment sources are alleged Incomplete or Inaccurate Packet When a packet is returned to the County as an incomplete or inaccurate packet and the packet is resubmitted to DDSD within 30 days of DDSD decision a copy of the DDSD determination must accompany the reevaluation request All other reexams require a complete packet County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Limited DDSD Referrals Number Page 050404 2 of 2 When DDSD is unable to adopt the federal disability determination or SSA has not made a disability determination the limited referral will be returned and a complete referral packet will be requested 050404B Forms needed for a Limited Referral Packet Refer to MPG 050406 for titles and descriptions of forms used to complete a DDSD referral 050404C Submitting a Limited Referral Packet Send the completed limited referral packet to DDSD no later than 10 calendar days from the date the Beneficiary claims to be disabled or Completed MC 223 or MC 223C Supplemental Statement of Facts is received by the County Forward the completed packet via US mail to State of California Health and Human Services Agency Disability Determination Services Division LA State Programs Branch PO Box 992 El Segundo CA 90245 Procedure NA Program Impacts None References ACWDLs 0247 0514 1202 MEPM C223 Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Referrals Number Page 050405 1 of 2 Revision Date 04012018 Background Complete a DDSD referral packet for MediCal applicantsbeneficiaries 21 through 64 years of age who are potentially disabled or allege a disability and request to be evaluated for disability status Included with the reformatting the DDSD forms listed in this section have been added to MPG 050406 for efficiency Purpose This section provides guidelines for processing a DDSD referral packet Policy 050405A DDSD Referrals A DDSD referral packet is submitted to DHCS for 1 MediCal beneficiary 21 through 64 who is potentially disabled 2 MediCal applicantbeneficiary who is eligible under another program and alleges disability and wants to be evaluated for disability status 3 Applicant with a Title II or SSISSP disability determination pending including blindness 4 Person determined presumptively disabled See MPG 0503 5 Person meeting the urgent presumptively disabled criteria See MPG 0503 050405B Forms needed for a DDSD Referral Refer to MPG 050406 for titles and descriptions of forms used to complete a DDSD referral Note DHCS DDSD will accept the original completed DDSD packet or a printed copy form CERMS 050405C Submitting a Complete DDSD Referral Send the completed referral packet to DDSD no later than 10 calendar days from the date the Completed MC 223 or MC 223C Supplemental Statement of Facts is received by the County or Beneficiary claims to be disabled whichever is later Forward the completed packet via US mail to State of California Health and Human Services Agency Disability Determination Services Division LA State Programs Branch PO Box 992 El Segundo CA 90245 050405D DDSD Status Letter A status letter form MC 179 must be sent to each applicant whose referral packet has not been submitted to DDSD by the 80th day from the date of the SAWS date for new applicants Referral packets submitted to DDSD after the 80th day must include a copy of the MC 179 and must indicate on form MC 221 Section 10 that the MC 179 has been submitted County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Referrals Number Page 050405 2 of 2 If a referral packet is received by DDSD on or after the 86th day without a copy of form MC 179 DDSD will send a letter stating that the MC 179 is missing The requirement is to immediately send the client an MC 179 and forward a copy to DDSD Referral packets returned by DDSD for missing or incomplete information and received back by DDSD after the 85th day must also include a copy of the MC 179 and check the box in section 10 of the MC 221 that the MC 179 has been submitted Procedure NA Program Impacts None References ACWDLs 9701 0332 1202 MEM Proc 22C3 8 Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Necessary Forms to Complete DDSD Referral Packets Number Page 050406 1 of 2 Revision Date 04012018 Background Included with the reformatting of this section all DDSD forms and completion instructions have been combined into Desk Aid 86 for efficiency Purpose This section provides guidelines for forms used when processing a DDSD referral packet Policy 050406A Follow the instructions for the completion of each form as specified in Desk Aid 86 050406B DDSD Forms MC 220 Authorization for Release of Information MC 221 LA Disability Determination and Transmittal MC 222 LA DDSD Pending Information Update MC 223 Applicants Supplemental Statement of Facts for MediCal MC 223C Supplemental Statement of Facts for MediCal Child Applicant Only Under Age 18 Note DDSD will not accept forms that have been edited with white out MC 223MC 223C may be completed by one of three methods at applicantapplicants parent request Through the mail During a facetoface interview During a telephone interview with applicantapplicants parent worker completes form MC 223C and mails the form to be signed dated and returned Refer to MediCal Desk Aid 26 MC 223 Essential Entries to ensure that all questions are answered 050406C Other Forms Required for DDSD Referrals 1490 HHSA RRR for Cases Pending Over One Year 1491 HHSA No Determination Contact Form 1492 HHSA No Determination Coversheet 1493 HHSA Transfer of DDSD Decision 1494 HHSA Appeals Rescinding Notice 1495 HHSA Fax DDSD 1496 HHSA DDSD Weekly Activity Log 1497 HHSA DDSD Monthly Activity Log MC Information Notice 013 Important Information Regarding Your Appeal Rights Procedure Refer to Desk Aid 86 located in Eligibility Essentials for instructions on completing these forms County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Necessary Forms to Complete DDSD Referral Packets Number Page 050406 2 of 2 Program Impacts None References ACWDLs 0046 0240 0247 0332 1202 1406 1427 Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operation County of San Diego Health and Human Services Agency HHSA MediCal Program Guide MediCal Eligible Pending DDSD Evaluation Number Page 050407 1 of 2 Revision Date 04012018 Background An applicant with a pending disability evaluation who has linkage to MAGI or NonMAGI MediCal is granted using the appropriate aid code This section is being updated to the new format no other changes have been made Purpose This section provides guidelines for processing an applicant with MediCal eligibility when the DDSD referral packet is pending a disability evaluation and decision Policy 050407A Eligibility Requirements Pending DDSD Evaluation When an applicant is eligible to MediCal and has a pending disability determination the individual is granted MediCal under the appropriate aid code Case comments are completed stating when the DDSD packet was sent When a beneficiary alleging disability is receiving MediCal under a Pending Disability Determination aid code heshe is not eligible to the ABD income deductions The beneficiary must continue to meet all other MediCal eligibility requirements while the DDSD is pending When an applicant does not have linkage to MediCal refer himher to CMS Procedure 050407B Communication with DDSD Notify DDSD of any changes in the applicants status while DDSD is in the process of making a disability determination Send the MC 222 immediately when any of the following occur 1 SSA decision has been made A copy of the SSA document regarding benefits or the SSA denial letter and personalized denial notice will be attached to the MC 222 2 Change in the applicants address 3 Change of applicants name or telephone number including message number If the applicant moves out of state indicate that the disability evaluation is still needed through the month the applicant moved out of state and keep case in pending status 4 Denial or discontinuances of the applicant on the basis of nonmedical information ie excess property etc 5 Withdrawal of the application 6 Cancellation of the Authorization for Release of Information by the applicant 7 The death of the applicant Attach a copy of the death certificate death notes or death County of San Diego Health and Human Services Agency HHSA MediCal Program Guide MediCal Eligible Pending DDSD Evaluation Number Page 050407 2 of 2 summary 8 Receipt of new medical evidence 9 Availability of interpreter provide name and telephone number 10 Receipt of a new authorized representative form or report of change of an AR 11 Applicant becomes incarcerated include date of incarceration name address and telephone number of facility Indicate that the disability evaluation is still needed for the months beginning with any retroactive months through the month of incarceration The case must remain in pending status while the DDSD evaluation is completed 12 Any other information which may affect DDSDs action on the pending case Program Impacts None References ACWDL 0240 MEM Proc 22C3 County Policy Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operation County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Response Number Page 050408 1 of 3 Revision Date 04012018 Background When a DDSD evaluation response is received by the county prompt action is taken on the case to ensure accurate processing of the disability decision This section is being updated to the new format no other changes have been made Purpose This section provides guidelines for processing DDSD evaluation responses Policy 050408A Receipt of DDSD Responses All DDSD responses must be processed within FIVE days of receipt DPC is responsible for o Capture imaging Disability Decisions received from DDSD o Validating the Disability Decision as NFM SP2 DDSD 221R o Forwarding Disability Decision Hardcopies to CMS Recovery at MS W414 within three business days FRC staff is responsible for o Reviewing the Daily DPC Report DDSD tab o Assigning the Disability Decision imaged to appropriate task for processing o Ensuring accurate processing of a disability decision within two business days 050408B Disability Not Approved The DDSD analyst returns the MC 221 with the disability determination attached explaining the basis of their determination when the applicant does not meet the disability criteria based on DDSDs vocational and medical evaluation The DDSD analyst attaches a notice explaining the basis for their determination See DDSD Report Codes Desk Aid 22 If the DDSD rationale notice does not explain the basis for the determination request the information from DDSD 1 Presumptive Disability PD If PD has And Then been granted DDSD subsequently adopts SSAs disability denial and the beneficiary files an appeal with SSA benefits will continue through the appeal process Note DDSD will indicate code Z53 on the MC 221 if SSAs denial is adopted not been granted or the PD individual has not requested SSAs denial NA evaluate eligibility under any other MediCal linkage County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Response Number Page 050408 2 of 3 2 Only MediCal Linkage is Disability If disability is the applicants only linkage to MediCal o Deny or discontinue the case o Attach the DDSD rationale which explains the basis of the determination to the denial or discontinuance NOA and mail it to the applicant Do not send a copy of the form MC 221 to the applicant o Send form 1410 HHSA to notify the hospital of the MediCal denial if the applicant was certified CMS pending the disability evaluation o Enter denial information into case comments o Enter the DDSD determination in Display DisabilityMedical Conditions Summary screens in CalWIN 050408C Disability Approved The DDSD analyst attaches the disability decision to the MC 221 The applicant will be considered disabled under the NonMAGI criteria see Processing Guide 26 for the steps to take when a disability decision is received The onset date provided will take into consideration any request for up to three months retroactive coverage prior to the date of application as long as retro onset is requested on form MC 221 Refer to MPG 0415 for guidelines on annual redetermination for DDSD cases 050408D DDSD Adopts SSA Allowance When the applicant applies for SSA benefits SSA evaluates the applicants disability before evaluating for any other eligibility factors If the SSISSP application is denied because the applicant does not meet the federal disability criteria DDSD will adopt the SSAs determination If SSA has determined the applicant is not disabled the DDSD analyst returns form MC 221 with an attachment indicating the applicant is not disabled per SSA Deny the application following procedures outlined in 050408B above If SSA has determined the applicant is disabled the DDSD analyst returns form MC 221 with an attachment indicating the applicant is disabled per SSA and will give the onset date Approve the application following procedures outlined in 050408C above A disability determination does not mean the applicant is receiving or will receive SSISSP benefits After SSA determines disability SSA reviews for other eligibility factors This review may take several months and the applicant may be determined ineligible to SSISSP If the DDSD decision indicates that DDSD adopted a SSA allowance and the applicant is not currently receiving SSA Disability benefits check MEDS to determine whether the disability continues When MEDS indicates that the applicant is no longer disabled then complete form MC 221 and submit it to DDSD for a reexam Benefits shall not be discontinued unless a DDSD decision is received indicating that the beneficiary ceases to be disabled County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Disability Determination Services Division DDSD Response Number Page 050408 3 of 3 050408E DDSD Disability Cannot be Determined The DDSD analyst may return form MC 221 indicating that she was unable to make a determination The analyst will state the reasons for the no determination on the MC221 and will often request help in locating the applicant or in obtaining the applicants cooperation in attending a consultative exam Note DDSD can medically defer a case referral for up to three months when future evidence is needed to assess duration and severity of impairment Medical deferment is an exception to the rule Common reasons are strokes or heart surgery Unless you receive form MC 221 requesting your help there is no action required Procedures 050408F SSISSP Benefits Granted See Processing Guide 26 for steps when an applicantbeneficiary is granted SSISSP benefits 050408G No Determination Decision Received See Processing Guide 26 for steps when a no Determination Decision is received and DDSD is requesting the countys help Program Impacts None References ACWDL 0046 1123 MEDIL 1722 MEM Proc 22C92 County Policy Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Retroactive Applications Number Page 050409 1 of 2 Revision Date 04012018 Background Retroactive MediCal cannot be granted for disabled or disabled pending applicants until the onset date of disability is determined This section is being updated to the new format no other changes have been made Purpose This section provides guidelines for processing Retroactive DDSD requests Policy 050409A Retroactive Requests Retroactive MediCal can only be granted back to the onset date or 3 three months prior to the application date whichever is less Procedures 050409B Applicant with Acceptable Disability Verifications When an applicant with acceptable verification of disability requests retroactive MediCal and verification of the onset date of disability is not available complete form MC 221 Indicate in section 6 8 and 10 that the applicant is currently disabled and that an earlier onset date of disability is being requested forward the form to DDSD to obtain the date of the onset of disability prior to granting retroactive MediCal 050409C Applicant with Pending Disability Verifications When an application is processed as disability pending retroactive MediCal cannot be granted until the disability evaluation is received back from DDSD DDSD will indicate the onset date of disability on form NFM SP2 DDSD 221R To obtain disability onset dates for SSISSP disabled or blind recipients who request threemonth retroactive MediCal check MEDS INQX to obtain the SSA onset date or submit form 0794 to SSA If the onset date provided by SSA is later then the months of request for retroactive coverage complete a referral to DDSD for the retroactive months 050409D Reapplication by Noncooperative Persons When an applicant has been denied MediCal for noncooperation and later reapplies for retroactive coverage for the denial month retroactive MediCal cannot be granted even if heshe agrees to cooperate with the disability referral process Regulations prohibit retroactive coverage for a month in which the applicant has been denied for noncooperation unless the applicant can show that good cause exists County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Retroactive Applications Number Page 050409 2 of 2 When an applicant withdraws the application and later files a new application then continuing and retroactive eligibility is to be determined based on the information provided on the new SOF as long as that information is reconciled with any information previously provided by the applicant Program Impacts None References ACWDL 0928 MEM 50710 Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Reexaminations Reevaluations and Redeterminations Number Page 050410 1 of 4 Revision Date 04012018 Background Reexaminations reexams are based on the mandatory date when a beneficiarys medical condition is expected to improve The reexam date is given by DDSD with their disability evaluation This section is being modified to include information from MEDIL 1722 issued 11302017 and updated to the new format Purpose This section provides guidelines for processing DDSD cases with a mandatory reexamination date Policy 050410A Reexaminations The beneficiary will continue to be considered disabled until hisher medical condition improves and DDSD has determined the individual is no longer disabled except when the individual refuses to cooperate during the reexam DDSD tracks and provides a disability reexamination case list to the county on a monthly basis Complete a reexamination when one of the following situations occurs DDSD set reexam date is due DDSD notifies the county that a medical reexam is due monthly disability reexamination case list Worker observes or receives information that the beneficiarys medical condition may have improved When DDSD approves the disability determination on an initial case that has HIV involvement DDSD will notate on NFM SP2 DDSD 221R that the case will be exempt from the reexam process until further notice Identify these cases and enter in case comments that no DDSD reexam is required Note A disability packet is not required if a subsequent SSA determination has found the beneficiary to be disabled and has awarded Title II disability benefits The federal disability determination is controlling The beneficiary will continue to receive benefits as a disabled individual as long as the Title II disability benefits are received 050410B CalWIN Case Alert CalWIN will generate a case alert when the reexam date is due Submit a reexamination referral to DDSD See Processing Guide 26 for procedures When the beneficiary does not respond or refuses to cooperate with the reexamination determine whether the individual is eligible for MediCal under a different linkage factor If the beneficiary Then is eligible under a different linkage grant the case using the appropriate aid code and linkage factor County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Reexaminations Reevaluations and Redeterminations Number Page 050410 2 of 4 is not eligible under different linkage Take necessary actions to discontinue the case giving timely notice Complete MC 222 section 9 Client discontinued for failure to cooperate with Disability Reexamination Submit MC 222 to DDSD and image into case record cooperates continue MediCal eligibility until DDSD completes the reevaluation 050410C Request for Reevaluations When there is a disagreement with the decision rendered by DDSD or the evaluation results are believed to be correct a new evaluation of disability may be requested within 90 days of the DDSD decision Request for reevaluation should not be made unless there is reason to believe that one of the following circumstances exists 1 DDSD has performed an independent disability evaluation and denied the claim The applicant states Their condition has deteriorated since the DDSD denial New medical evidence not considered by DDSD is available or A new physical andor mental impairment not previously reported now exists 2 DDSD was unaware of certain medical evidence conditions or recent occurrences which could change the outcome of the decision 3 DDSD adopted a SSA denial and the applicant has a totally new physical or mental condition which is believed would make the SSA decision obsolete 4 DDSD adopted SSAs denial and within 12 months of the denial the applicant Claims a worsening of the same condition which was evaluated by SSA Has obtained new medical evidence regarding the same condition that SSA did not consider in its previous evaluation If Then the applicant within the previous 60 days of SSAs denial will be instructed to file an appeal with SSA more than 60 days must file a new application with SSA If either situation occurs or the applicant has not reapplied a new DDSD packet will be required 050410D Redetermination of Disability Status A redetermination of a persons disability status will be requested for an applicant who meets the following criteria A limited DDSD referral packet will be sent when the applicant 1 Was previously determined disabled by DDSD 2 Was discontinued for a reason other than the disability 3 Reapplies for MediCal alleging that the same disability continues to exist County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Reexaminations Reevaluations and Redeterminations Number Page 050410 3 of 4 A Complete DDSD referral packet will be sent when 1 Reapplication date is more than 12 months since the person was discontinued from MediCal 2 No reexam date was set on the previous MC 221 3 Reexam date is unknown due or past due 4 An improvement in the persons condition is noticed Note A copy of the prior MC 221 must be included with both the limited and the complete DDSD packets Check the redetermination box on the MC 221 and provide an explanation in the comments section Unless other linkage exists the case will be placed in pending status and MediCal benefits will not be granted until DDSD returns the redetermination DDSD will check with SSA to determine if there has been a subsequent federal determination within the past 12 months If there has been a federal denialcessation of benefits DDSD will adopt the SSA decision and the person will be referred back to SSA The MediCal application will be denied 050410E Disability is Determined by SSA When DDSD initially determined the individual disabled a subsequent SSA Title II disability claim is allowed and a reexam is due DDSD will adopt the federal reexam date as long as it is set at a future date or it is not pending DDSD will advise that the federal case takes precedence and SSAs determination will be used to establish disability linkage If DDSD initially determined the individual disabled a subsequent SSA Title II disability claim is pending and a reexam is due DDSD will adopt the results of the federal reexam and advise the county to verify disability status with SSA in 60 to 90 days Submit form MC 194 to SSA 60 days after the reexamination date to request reverification of disability MediCal benefits will continue while the federal reexam is pending Procedures 050410F Federal Appeal Rights Exhausted When the beneficiary has exhausted all federal appeal rights twelve or more months prior to the DDSD reexam date and the final federal disability decision determined the beneficiary is not disabled evaluate for any other linkage If Then no other linkage exist discontinue the case and dont refer to DDSD federal decision was for nondisability reason refer the case to DDSD 050410G SSA Timely Appeal Filed When the beneficiary was receiving MediCal based upon disability and is later determined by SSA not to be disabled follow procedures outlined below If the beneficiary Then is not MediCal eligible under any other linkage factors request verification that the individual filed an appeal with SSA County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Reexaminations Reevaluations and Redeterminations Number Page 050410 4 of 4 filed a timely appeal continue benefits until a final determination is made did not file a timely appeal evaluate for other linkage grant if eligible under appropriate aid code discontinue benefits with timely notice do not refer to DDSD When the beneficiary filed a timely appeal of the federal decision and the SSA appeal is still pending DDSD will not complete a reexam on these cases DDSD will reset the reexam date according to the level at which the SSA appeal is pending which may vary from ninety days to two years DDSD will advise An appeal is pending on a federal Title IISSI denialcessation The case remains under SSA jurisdiction A revised reexam date has been set for At that time DDSD will determine whether a medical reexam is necessary Program Impacts None References ACWDLs 0935 0622 1202 MEM Proc 22C9 22C92A Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Director Eligibility Operation County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Special Situations Number Page 050411 1 of 3 Revision Date 04012018 Background State regulations require that disability for MediCal purposes be determined using Title II disability or SSISSP criteria This section is being updated to the new format no other changes have been made Purpose This section provides policy on processing MediCal DDSD when there are special situations Policy 050411A Death DDSD will automatically grant disability status for a person for the month of death Although disability status is automatic only for the month of death the State will consider requests for a retroactive onset If a retroactive onset appears appropriate ie the applicant was hospitalized in the month prior to death the retro onset box must be checked When the request for coverage is for the month of death only note on MC 221 box 10 No earlier onset needed If an applicant dies after a DDSD referral has been initiated notify DDSD of the applicants death by telephone and follow up with MC 222 This information will help expedite the determination A death certificate expedites processing the worker will forward a copy when available If not available DDSD will either contact the family or will obtain the certificate through government records if one is not provided Note Although death is considered a disability status do not grant MediCal presumptively The purpose of granting MediCal presumptively is to expedite issuance of a MediCal card so that a patient who meets presumptive criteria can receive medical treatment right away A deceased person does not fit that situation 050411B Disabled Children If the applicant indicates that there is a disabled or potentially disabled child in the home the applicant will complete form MC 223C and indicate hisher relationship to the child on the form The DDSD packet will be processed following procedures outline in MPG 050406 050411C Railroad Retirement Board RRB Disability RRB is the federal agency responsible for administering the retirement system for railroad employees RRB evaluates total and permanent disability using Title II SSISSP disability criteria Retired railroad employees who meet the Total and Permanent Disability Criteria Meet the disability criteria for MediCal Occupational Disability Criteria Cannot perform hisher last railroad job County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Special Situations Number Page 050411 2 of 3 Was not evaluated for capability to perform other past work including previous railroad jobs Does not establish disability for MediCal purposes 050411D RRB Verifications Request that the applicant submit verifications to identify the type of benefit awarded Award notification or a written statement from RRB or Send a written request to the RRB district office If the individual Then fails or refuses to provide verification without good cause deny the application for failure to cooperate states that the award is based on occupational disability but the condition has worsened submit a DDSD complete referral See MPG 0504 Note When a beneficiarys request for reclassification as a disabled person is denied for failure to cooperate only the reclassification is affected Do not discontinue MediCal benefits unless all other linkage ceases or another reason for discontinuance exists 050411E RRB Total and Permanent Disability If RRB benefits were issued on the basis of total and permanent disability the applicant is disabled for MediCal and will be evaluated for other MediCal eligibility criteria Document in the case comments 1 Disability onset date or date benefits began prior to MediCal effective date 2 Type of RRB disability award 3 Date of the RRB notice 050411F Federal Decisions Rescind a prior MediCal denial when SSA approves disability after originally denying the claim Complete a DDSD referral when the SSA disability onset date does not coincide with the request for MediCal or a retro MediCal is requested A complete referral packet will be sent to DDSD including a copy of the SSA award letter Notate in item 5 of the MC 221 the MediCal application date to protect applicants original filing date and specify originally denied and referred to SSA for reopening in Item 10 of the MC 221 Note Request for retro onset must be made within one year of the month for which retroactive coverage is requested County of San Diego Health and Human Services Agency HHSA MediCal Program Guide DDSD Special Situations Number Page 050411 3 of 3 050411G DRU vs Kizer Lawsuit When DDSD has determined that an applicant is disabled and the applicant becomes a MediCal beneficiary and a subsequent SSA disability denial determination becomes available do not discontinue MediCal benefits at that time due to the Disabled Rights Union DRU lawsuit A restraining order was issued in the case of DRU vs Kizer preventing the termination of MediCal for individuals subsequently denied SSA disability benefits This court order is still in effect When the county becomes aware that the beneficiary was denied disability on hisher SSA claim enter the information into case comments Do not rerefer the case back to DDSD for a reexam or reexamination Procedures NA Program Impacts None References ACWDL 8754 1202 MEM Proc 22C Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Receiving and Requesting DDSD Status Information Number Page 050412 1 of 2 Revision Date 04012018 Background The DDSD Quarterly Case Status Reports are used to track and monitor DDSD case actions Included with the reformatting of this section the procedures used to process these reports have been removed and placed in Processing Guide 27 Purpose This section describes each report and provides instructions for processing Policy 050412A DDSD Quarterly Reports The DDSD Quarterly Reports are available in SharePoint The reports filter the following information and are described in the following sections Subject Description State Pending Number of disability applications pending with DDSD State Closed Number of disability applications closed with DDSD CalWIN Pending Number of DDSD cases pending in CalWIN that are not pending with DDSD CalWIN Closed Number of disability applications pending with DDSD that are closed in CalWIN Decisions Imaged Number of disability decisions imaged in CERMS Action Taken Number of applications with disability decisions received from DDSD and MC Program is approveddenied in CalWIN Action Pending Number of applications with disability decisions received from DDSD and MC Program is NOT approveddenied in CalWIN No Match Number of applications pending or closed with DDSD that have no MC application in CalWIN to match the application date 050412B Distribution of DDSD Reports The DDSD Quarterly Case Status Reports are posted in SharePoint on the following months January April July October 050412C State Pending and CalWIN Pending Cases identified in the State Pending list are cases that DDSD has registered as received in their system and continue pending a decision This section should match the number of cases pending in CalWIN The CalWIN Pending section lists all cases pending in CalWIN that are not pending with DDSD County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Receiving and Requesting DDSD Status Information Number Page 050412 2 of 2 050412D State Closed and Decisions Imaged Cases identified in the State Closed list are cases that State DDSD has registered as completed A decision for these cases should be imaged in the case record This section should match the number of decisions imaged to CERMS 050412E CalWIN Closed List Cases identified in the CalWIN Closed list are cases that are closed in CalWIN yet they continue pending with DDSD 050412F Actions Pending Report The Action Pending Report identifies cases pending in CalWIN that have a disability decision capture imaged in CERMS 050412G No Match Cases identified in the No Match list are cases that are listed in the State Pending or Closed list that have no MediCal application in CalWIN Procedures Refer to Processing Guide 27 located in the Eligibility Essentials website for the procedures used to process these reports Program Impacts None References ACWDL 8754 MEM Proc 22C Sunset Date This policy will be reviewed for continuance by 04302021 Approval for Release Rick Wanne Eligibility Operations