Revision 16-4; Effective December 1, 2016

 

 

D-2100 When a Medical Determination Is Not Required

Revision 12-4; Effective December 1, 2012

 

Receipt of Medicare is an indication that the person is either:

  • age 65 or older; or
  • has been determined blind or disabled based on the Social Security Administration (SSA) criteria for RSDI Title II or SSI Title XVI disability.

A medical determination is not required to establish blindness or disability if the person has Medicare. The receipt of the Medicare is satisfactory verification that the person has been determined to meet the SSA's criteria for aged, blind or disabled. This includes a person determined blind or disabled by SSA in the 24-month period before receiving Medicare. Upon verification of the receipt of a disability benefit, a medical determination is not required to establish blindness or disability if a person is currently receiving disability benefits from:

  • SSI;
  • RSDI; or
  • Railroad Retirement.

For an eligibility determination during the retroactive coverage months, a medical determination is not required to establish blindness or disability during that retroactive coverage period if a person:

  • has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
  • has a date of onset for RSDI Title II blindness or disability based on SSA query records; and
  • the date of onset for the RSDI Title II blindness or disability covers the retroactive coverage months prior to the application.

Note: Do not use the Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for:

  • retroactive coverage;
  • current coverage; or
  • future coverage.

A medical determination is not required to establish blindness or disability if a person:

  • applies with HHSC for SSI-related medical assistance only (MAO);
  • is under age 65; and
  • lost SSI for reasons other than a decision that the disability or blindness has stopped.

 

D-2200 When a Medical Determination Is Required

Revision 16-4; Effective December 1, 2016

 

When an individual does not have Medicare or is not receiving a disability benefit from SSIRSDI, or Railroad Retirement (See E-4200, Railroad Retirement Benefits), a medical determination, including date of onset, of either disability or blindness is required. The date of onset can affect the start date of Medicaid.

The following must not be used to establish disability for MEPD programs:

  • a Civil Service disability  determination;
  • a medical certification an individual submits to an Achieving a Better Life Experience (ABLE) program or to the Internal Revenue Service as proof of meeting ABLE program requirements.

An individuals under age 65 who lives in an institutional setting and who would, except for income, be eligible for SSI if they lived outside the facility, must meet the SSA's definition of disability or blindness. These individuals may or may not have applied for SSI cash benefits.

If a medical decision for determining blindness or disability is required, request a decision from the Disability Determination Unit (DDU). See Section D-2300, Requesting a Decision from the Disability Determination Unit (DDU).

Do not request a decision from the DDU in the following circumstances

 

If an individual … then …

resides in a state supported living center or the Rio Grande State Center,

the staff at these facilities, and not HHSC staff, is responsible for ensuring the completion of the forms for a disability determination.

requests an eligibility determination during a retroactive period and the individual:

  • has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
  • has a date of onset for RSDI Title II blindness or disability based on SSA query records; and
  • the date of onset for the RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application,

the DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability because federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset.

A medical determination of disability or blindness is required when RSDI Title II blindness or disability is not established and an individual is:

  • under age 65;
  • either under or over age 65 and applying for the Medicaid Buy-In (MBI) program; or
  • either under or over age 65 and presumed to be a child with a disability to meet exception to transfer penalty.

To determine whether  RSDI Title II blindness or disability is established, query the SSA records available.

Do not use the SSI Title XVI "Dsblty Onset Date" as the basis to establish blindness or disability.

 

D-2300 Requesting a Decision from the Disability Determination Unit (DDU)

Revision 14-4; Effective December 1, 2014

 

When a medical decision for determining blindness or disability is necessary, a decision must be requested from DDU. Complete and submit these forms for imaging, along with the medical records, to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:

  • Form H3034, Disability Determination Socio-Economic Report
  • Form H3035, Medical Information Release/Disability Determination

In addition to these forms, submit the following when available:

  • Minimum Data Set information (physician's signature page)
  • Medical treatment records for a waiver applicant
  • Medical records for an applicant for primary home care services through Community Attendant Services (CAS)

DDU may request more complete medical documentation.

On receipt of Form H3034, Form H3035 or other medical records, DDU uses this information to determine whether the person meets SSA's definition of disability or blindness and makes the final decision about disability or blindness.

DDU will consider the date of onset for the retroactive period, if needed. Specify the retroactive months needed on Form H3034. DDU's date of onset, however, cannot precede the RSDI Title II disability onset date indicated on the SSA query.

 

D-2400 Disability Determination Unit (DDU) Request Required

Revision 11-4; Effective December 1, 2011

 

When the application is for a person who is younger than age 65 and has never had a disability determination, an override for the application due date default of 45 days is needed. The application due date will be 90 days from the file date. Follow the steps in the system procedure instructions for this override.

Sometimes an application cannot be certified within 90 days because a disability determination is pending past the initial 90 days. In these cases, send Form H1247, Notice of Delay in Certification, to the applicant and the facility administrator, if applicable.

Applications for which delay-in-certification procedures have been followed are excluded from the delinquent count in timeliness reports. These applications are excluded for 180 days (90 days + 90-day extension); however, if the application is still pending on the 181st day, it will be counted as delinquent. Applications that cannot be certified within the normal 90-day limit, plus the 90-day extension, must be denied. A new application will be necessary to reconsider eligibility.

 

D-2500 Supplemental Security Income (SSI) Applicants and Retroactive Coverage

Revision 14-4; Effective December 1, 2014

 

An applicant for Social Security disability benefits is evaluated for both SSI Title XVI and RSDI Title II disability eligibility. HHSC determines Medicaid eligibility for retroactive coverage for up to:

  • three months before the date of SSI application for a person who has been denied SSI; or
  • two months before the month in which an SSI recipient's Medicaid coverage automatically begins.

In these cases, the medical records; Form H3034, Disability Determination Socio-Economic Report; and Form H3035, Medical Information Release/Disability Determination, should be imaged in the Texas Integrated Eligibility Redesign System (TIERS). DDU uses this information to make the final decision (disability or blindness) for the retroactive coverage months. DDU enters the disability determination in case comments and in the Disability Determination — DDU page in TIERS, which indicates the decision, including the date of onset of the disability or blindness.

Federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset, and DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability. As a result, deny an application based on the person not meeting blind (Not Blind) or disabled (Not Disabled) criteria when a person applies for Medicaid and the person:

  • has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
  • has a date of onset for RSDI Title II blindness or disability based on Social Security Administration (SSA) query records; and
  • the date of onset for RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application.

Note: Do not use the SSI Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for retroactive coverage.

Federal regulations prohibit a state from making a disability decision that conflicts with an SSA decision. DDU cannot make an independent decision until all appeals to SSA regarding the date of disability onset for both RSDI Title II and SSI Title XVI are settled.

Request medical records covering the period for which eligibility is being tested when:

  • there is no date of onset for RSDI Title II disability; or
  • 90 days have elapsed since the SSI/RSDI file date and SSA has not completed a disability determination.

Submit the following items for imaging to the Texas Health and Human Services Commission, P.O. Box 149027, Austin, TX 78714-9971:

  • Medical records
  • Form H3034
  • Form H3035

Occasionally, Form 4116, State of Texas Purchase Voucher, is required to provide payment to medical providers for submitting medical records. If Form 4116 is required, submit this form for imaging with the medical records, Form H3034 and Form H3035.

 

D-2600 Disability Determination Unit (DDU) Decision

Revision 13-2; Effective June 1, 2013

 

DDU will enter the disability determination in TIERS case comments and in the Disability Determination – DDU page. This determination will include notification about the decision, including the date of onset of the disability or blindness and if the individual is permanently excused from any further medical review.

  • Do not make a final eligibility decision until DDU has completed the Disability Determination – DDU page in TIERS and documented the decision in case comments.
  • Medicaid cannot begin and the medical effective date cannot precede or be earlier than the first day of the month in which the onset of the disability or blindness occurred.
  • Medicaid begin and end date for ME – A&D Emergency is date-specific. Medicaid does not occur in full month increments for this program.
  • Before certifying a person under age 65 for Medicaid, the eligibility specialist must review case comments and the Disability Determination – DDU page to see if the individual has had a previous disability determination and/or is permanently excused. If documentation does not indicate that the individual is permanently excused, the eligibility specialist may contact DDU. The specialist must document in case comments concerning any previous disability determination decision.

 

D-2700 Use of Decision on the Disability Determination – DDU Page in TIERS

Revision 13-2; Effective June 1, 2013

 

Some applicants for Medicaid in an institutional setting are former recipients of Medicaid.

If a person was certified for Medicaid in an institutional setting based on the medical decision for either disability or blindness reflected in TIERS case comments and documented on the Disability Determination – DDU page, continue to use the existing record to reinstate the Medicaid in an institutional setting, unless case comments indicates a review of the disability or blindness is needed.

In addition, if TIERS case comments and the Disability Determination – DDU page indicates the applicant is permanently excused from further medical review, staff can continue to use this decision for future ME-A and D-Emergency requests or applications.

Do not use the existing Disability Determination – DDU page to process an application in any other situations, except those mentioned above.

 

D-2800 Disability Determination at Time of Review

Revision 09-4; Effective December 1, 2009

 

At each periodic review, determine whether the decision about disability or blindness is current. Unless Form H3035, Medical Information Release/Disability Determination, indicates that the applicant is permanently excused from further medical review, complete a new Form H3034, Disability Determination Socio-Economic Report, and Form H3035 before the date of review indicated on Form H3035.