Kansas Economic and Employment Services Manual

2000 General Eligibility

10-17

2663 Presumptive Medicaid Disability (PMD) - Medical assistance under the Medicaid program is available to persons who meet Social Security disability criteria as determined by the PMDT and DRT (see 2662). Eligibility is determined under existing program rules for the applicable medical coverage group for individuals with a qualifying disability determination. Only the entity making the disability decision differentiates a regular medical assistance case from a Presumptive Medicaid Disability case (note exception for coverage under SI-related Presumptive Medicaid Disability). Social Security does not certify disability for a PMD determination, this is done by the PMDT and DRT. Medical assistance cannot be authorized until the PMDT makes a decision.

Age - A PMD determination is only for individuals under age 65. Because Medicaid based on old age is available at age 65, a PMD is not necessary for persons in this age group. A PMD determination is not necessary for persons eligible under another Medicaid category, such as MA CM. However, a PMD determination may be completed for a current eligible if coverage under the existing group is ending or if other services are sought which would require a disability determination.

PMD is also applicable for children seeking coverage under a disability-related group. Because MediKan eligibility criteria restrict coverage to adults, only Tier 1 determinations will be applicable for children. The PMDT and DRT will use special SSA disability criteria for children when making the determination. A PMD determination will only be necessary when another category of Medicaid or Title 21 is not available. A PMD determination is also appropriate when a child seeks services that are only available to persons with a disability determination.

Example: 16-year old Kim receives Title 21. Her mother has applied for HCBS PD waiver services for Kim. The PD waiver isn’t available with Title 21 and Kim must be determined disabled in order to receive PD services. Because her access to services is limited without a disability determination, Kim is a good candidate for PMD. For both children and adult cases managed at the Clearinghouse, the case will be referred to the local DCF Service Center for PMD information and referral. Referral processing of all PMD-related eligibility is the responsibility of DCF. However, coordination will be necessary to ensure the referral is complete and accurate. These cases should be rare.

 

2663.1 Disability Criteria - In order to qualify under Presumptive Medicaid Disability, the individual must be determined to meet the disability criteria in 2662 and subsections. The processes for making this determination are outlined in these sections. The disability must be expected to last at least 12 months or result in death.

 

2663.2 Eligibility Requirements - Presumptive Medicaid Disability is available under any medical assistance program which requires the individual to be determined disabled. All existing general, financial and non-financial rules for the program involved are applicable: Working Healthy - see 2664, Nursing Facility/Institutional - see 8100, Home and Community Based Services - see 8200, Medically Needy/Spenddown - see 7532, SSI-Related - see 2663.3.

 

2663.3 SSI-Related Coverage - Persons who meet PMD disability criteria and are otherwise eligible for SSI cash assistance are eligible for medical assistance without a spenddown. Except for the establishment of disability, which is done by the PMDT instead of SSA, all general and non-financial criteria of the MS program are applicable.

 

Financial Eligibility - The methodologies, exemption and disregards applicable to the MS program apply. One month base periods are used. Financial eligibility exists if countable resources do not exceed the limit in 5130 and countable income does not exceed the limit in Appendix Item F-8.

 

If the income or resources exceed the maximum levels, eligibility under another medical program may be considered, such as Working Healthy or Medically Needy/spenddown.

 

2663.4 Precedence of the Social Security Disability Determination - A final determination made by Social Security takes precedence over a decision by the PMD (see 2663.6). For new PMD determinations, one of the following two conditions must be met:

 

  1. A final determination of disability or blindness has not been made by Social Security within the past 12 months (also see 2662). Or,
     
  2. A final determination of disability or blindness has been made by Social Security within the past 12 months and the individual reports a change in condition or new disability (also see 2662).
     

Persons who fail to meet the above criteria may receive MediKan coverage (Tier 2 disability). Unless these criteria are met, persons who are determined to meet Tier 1 may not receive Medicaid under PMD but may receive MediKan.

 

2663.5 KAECSES Procedures - Eligibility for PMD is established under the MS program. As stated above, all rules for the applicable program are used for the PMD determination. Therefore, there are no special instructions regarding treatment of income, resources or non-financial factors. All applicable PICK codes must still be used to properly establish eligibility. For a PMD case, the eligibility determination is documented on the PRDD (Presumptive Disability Determination) screen in KAECSES.

 

Countable income and resources, as well as the number in the assistance plan, are displayed on the PRDD screen. Except for SSI-related determinations, these elements are informational only. The eligibility determination is completed using the same process required by the program for a non-PMD case. Specific medical program eligibility for a PMD case is documented through the Presumptive Disability Type code entered, along with an appropriate Medical Program Subtype must also be used:

 

  1. Working Healthy - The PRDD type code must be WH and the Medical Program Subtype must be WH. Appropriate PICK codes must be in place. The premium amount is entered on MSID.
     
  2. Nursing Facility/Institutional - The PRDD type code must be AC and the Medical Program Subtype must be AC when LTC budgeting is applicable. A patient liability must be determined. Final determination of eligibility must be completed by comparing the patient liability against the Medicaid rate for the facility (see 8172.2). If the patient liability is greater than the Medicaid rate it may be necessary to redetermine eligibility under Medically Needy/Spenddown criteria. The CC override on the SPEN screen must be properly coded and LOTC must be completed to authorize NF payment.
     
  3. Home and Community Based Services (HCBS) - The PRDD type code must be HC and the Medical Program Subtype must be HC when HCBS budgeting is applicable. A client obligation must be determined. Final determination of eligibility must be completed by comparing the client obligation against the monthly plan of care costs (see 8270.2). If the client obligation is greater than the plan of care, eligibility must be redetermined. The CC override on the SPEN screen must be properly coded and LOTC must be completed to authorize HCBS payment.
     
  4. Medically Needy/Spenddown - The PRDD type code must be SD and no medical program subtype is used. The base period and total spenddown amount are determined on the SPEN screen. All other spenddown rules apply.
     
  5. SSI - Related - The PRDD type - SI and medical program subtype is used. Compare ‘Countable Income’ a field against program limits to determine eligibility.
     

2663.6 Final Determination By SSA - A final determination of disability by Social Security is reached when the individual is approved for benefits or is not found to meet disability criteria by Social Security and has no further administrative appeal rights. Thus, if the individual is denied benefits based on disability status and fails to request an administrative appeal within the time frames allowed by Social Security, the Social Security application has ended and the denial is considered a final determination. If the individual is, appeals the decision timely it puts the SSA case back into pending status and a final determination would not have been made.

 

An eligible PMD case must be monitored for a final disability determination from SSA. Coverage under PMD terminates when SSA makes a final determination of eligibility.

 

  1. SSA Decision Favorable - A favorable decision is when the SSA makes a finding of disability and usually results in a benefit award, but not in every situation. Because this is regarded as an ongoing Medicaid case, the determination of final disability is treated as a change subject to change process rules for the applicable program. For example, for Medically Needy, the change is processed the month following the month of change and for Working Healthy the change is processed the following month, but will not impact the monthly premium amount until the 6 month desk review or regular review. However, the PMD eligibility segment must be closed out and a final Medicaid determination must be made.

    If the individual remains eligible under the MS program, a Closure reason must be entered on the PMDD screen in KAECSES. The MS program remains open and the change processed.

    If the individual becomes eligible under a different program, such as SI, the MS program is closed and eligibility is established under the new program. In this case, SI.

    It is not necessary to overlay PMD-eligible months with non-PMD Medicaid eligibility. However, it is necessary to redetermine eligibility for a prior months in the following situations:
     
    1. The individual’s protected filing date with Medicaid is prior to the effective date of PMD eligibility. If a disability onset date is established prior to the date of PMD eligibility, coverage must be determined for the applicable months.
       
    2. The individual receives Tier 2/MediKan coverage. Coverage under Medicaid must be determined for MediKan eligible months.
       
  1. Final SSA Determination Unfavorable - If SSA finds the individual does not meet disability criteria, eligibility under this Medicaid category terminates. Note that no overpayment exists for coverage provided during the presumptive period if eligibility was otherwise determined correctly.
     

 

In the event the individual timely appeals the SSA disability decision and SSA accepts the appeal, the Medicaid case may be reopened. A decision is not considered final until the individual no longer has administrative appeal rights on the decision. Since SSA has accepted the appeal request, a final determination has not been made and the eligibility may continue if all other eligibility factors are met.

Note: When a referral has been made to Disability Determination Services (DDS) because SSA will not make a disability determination as indicated in 2662.2(3), a final decision for purposes of this section is the decision made by DDS. A subsequent application to SSA for a disability determination does not create a Protected Filing Date for the original medical assistance application upon which the DDS determination was made. See also the Note in 2662.10.