Section 120.314 Disabled

Section 120

Section 120.314  Disabled

MANG(D)

a)         To be eligible for medical assistance as a disabled person an

individual must be determined disabled as currently defined by the Social

Security Administration.  (See 20 CFR 416, Subpart I, April 1, 1984.)

b)         If an individual is receiving Supplemental Security Income

(SSI) or primary Social Security (OASDI) benefits, the Department shall accept

the Social Security Administration determination of disability.  The Department

will make the determination when the client has been denied SSI on the basis of

too much income or when the client is applying for medical assistance only and

not receiving SSI or OASDI.  The Department uses the same criteria for

disability as is used under SSI.  (See 20 CFR 416, Subpart I, April 1, 1984).

c)         If a child was terminated from SSI due to the August 22, 1996,

change in disability standards (Public Law 104-193), and the child was eligible

for both Medicaid and SSI on August 22, 1996, the child is considered disabled

unless:

1)         the child becomes 18, or

2)         the child has not received Medicaid for 12 months, or

3)         the child no longer meets the pre-August 22, 1996, definition

of disability.

d)         Appeals

1)         If an individual applying for or receiving medical assistance

is determined currently "not disabled" by SSA under the SSI or

primary OASDI programs, the Department shall accept SSA's determination of

disability and deny or cancel the case, no matter which agency made the

original determination of eligibility.

2)         If the individual appeals the SSA determination of disability

to SSA, medical assistance shall be continued for recipients through the level

of a determination by an Administrative Law Judge (ALJ) subject to the time

limits of subsection (d)(3) of this Section

rmination of

disability and deny or cancel the case, no matter which agency made the

original determination of eligibility.

2)         If the individual appeals the SSA determination of disability

to SSA, medical assistance shall be continued for recipients through the level

of a determination by an Administrative Law Judge (ALJ) subject to the time

limits of subsection (d)(3) of this Section.  If medical assistance has been

canceled, but the client later appeals to SSA, the case shall be reinstated

through the ALJ level subject to the time limits of subsection (d)(3) of this

Section.

3)         If the client notifies the Department of his or her appeal to

SSA within ten days after the date of the Department notice, medical assistance

will be continued with no break.  If the client notifies the Department of his

or her appeal to SSA within 11 through 65 days after the date of the Department

notice, medical assistance will be reinstated back to the original date of

cancellation.  If the client notifies the Department of his or her appeal to

SSA more than 65 days after the date of the Department notice, medical

assistance will be provided prospectively only, unless the client actually

appealed to SSA within 65 days after the date of the Department notice, in

which case medical assistance will be reinstated back to the original date of

cancellation.

4)         Medical assistance shall not be provided to applicants for

medical assistance through the SSA appeals process.

5)         If an Administrative Law Judge finds the individual "not

disabled", the Department shall accept that finding as final.  The

individual shall not have the right to appeal the determination of disability

to the Department at any time during this process.

e)         Redetermination of disability is a condition of continuing

eligibility for individuals who are not applying for or receiving SSI or OASDI

benefits.

f)         When appropriate, the Department shall pay for a medical

examination to determine disability.