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Staff Tools | GA Program Manual | D. Nonfinancial
Requirements
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DHS home | SPD
Staff Tools | GA Program Manual | D. Nonfinancial
Requirements
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To be eligible for benefits, a person must be a resident of Oregon and not vacationing here. People are residents if they live in Oregon. There is no minimum amount of time a person must live in Oregon to be a resident. However, they must intend to remain in Oregon.
People continue to be residents during temporary periods of absence if they intend to return when the purpose of the absence is completed.
Residency does not require a permanent dwelling or a fixed mailing address.
An applicant or an authorized representative must sign a statement declaring, under penalty of perjury, that the reported citizen/noncitizen status of each person they are requesting benefits for is true.
To be a member of the benefit group a person must meet one of the following:
Link to Worker Guides for more information:
Eligibility Requirement: 461-120-0110
For information on sponsored noncitizen see Family Services Manual, Section 9, Noncitizens.
Individuals in the benefit group must provide their SSN if they have one. If they do not have a SSN, they must make a good faith effort to apply for an SSN and provide it when it is received.
Individuals must actively pursue assets for which they have a legal right or claim. However, people applying for one of the Department’s programs are not required to apply for other programs administered by the Department.
To pursue assets, they must apply for and satisfy all requirements to receive benefits from other programs. They must also pursue legal remedies to obtain assets from any other source if they can secure legal counsel on a contingency fee basis. People do not have to pursue loans.
If they don’t pursue assets, everyone in the filing group is ineligible for GA. This ineligibility ends when they provide evidence that they are willing to cooperate.
By signing the application, clients agree to turn over their rights to reimbursement for health care costs to the Department.
Medical coverage includes the following:
Individual applying for and receiving medical assistance must cooperate in obtaining medical coverage unless they have good cause for not cooperating or are pregnant.
Cooperation includes, but is not limited to, applying for, accepting and maintaining all available medical coverage and identifying and providing information to assist the Department in obtaining benefits. See 461-135-0990 and 461-155-0360 for information about obtaining employer-sponsored cost-effective health insurance. The client is not required to incur a cost for the health insurance.
The Department has the authority to collect reimbursement for medical expenses the Department paid for anyone in the benefit group that should have been paid by another party or resource. The Department does not have the authority to collect reimbursements from Medicare benefits.
People who do not cooperate and do not have good cause, are not eligible for GAM. Ineligibility ends when a person provides evidence that they are willing to cooperate. A person can be penalized only if he or she has the legal right to obtain the health insurance.
Good cause for not cooperating exists when the Department fails to notify the individual of the requirement to enroll in a timely manner. People who claim good cause for refusing to cooperate have 20 days from the date of refusal to provide the statement or evidence.
Medical Cooperation: 461-120-0345,
Medical Assignment: 461-120-0315
Good Cause for Failure to Cooperate: 461-120-0350
The client's age must be:
The client must have filed an application for disability benefits under the Social Security Act and must not meet the non-disability eligiblity requirements under Title II of the Social Security Act. The VERSA screen or a printed copy of the screen is considered verification of this requirement.
A GA client must be one of the following:
Additionally, clients must be ineligible for OSIP(M)) except for clients found eligible under 461-125-0370[1][c]), REF or TANF.
A resident of a public institution or private psychiatric hospital, or a person held for a proceeding in connection with his or her commitment to such an institution, is ineligible.
The client must:
See WG-2 for more information on SSI reimbursements.
A client found by the SSA not to meet SSI disability criteria may continue receiving GA while appealing the SSA finding until a decision is rendered by an Administrative Law Judge (ALJ) for the Social Security Administration's Office of Hearings and Appeals. A client who unsuccessfully appeals to the ALJ is no longer eligible for GA.
A client whose impairment no longer meets the criteria in 461-125-0510 is ineligible for benefits.
The decision by the ALJ is binding on the Department unless the client has a new or significantly worsened impairment.
Specific Program Requirements: 461-135-0700, 461-135-0705
The disability determination is a process that has two basic steps:
Step 1: Does the individual have an impairment (expected to last for 12 continuous months from the date of request) that meets or equals the SSA's listing of impairments or is expected to be terminal within 12 months? If, yes, the individual is determined disabled. If no, go to step 2
Step 2: Individual does not meet or equal a listed impairment but is age 45 or older and meets specific vocational criteria. Individual must have a severe mental or physical impairment (expected to last for 12 continuous months from the date of request) that would prevent them from returning to past relevant work and meet the age and vocational requirements.
An individual must have a physical impairment that can be expected to last for a continuous period of no less than 12 months from the date of request. The medical condition must meet or equal the Listing of Impairments as found in Social Security Regulations contained in 20 CFR Part 404, Subpart P, Appendix 1. For additional information see SSR 82-53 (Basic Disability Guides) or SSR 86-8 (The Sequential Evaluation Process).
Click here to locate 20 CFR.
Listing of Impairments. The adult listing of impairments contains a list of over 300 medical conditions (or impairments) appearing in 14 major body systems. These listed impairments are considered severe enough to prevent a person from doing basic work activity. The listing of impairments is the basis for determining whether an individual may be allowed GA(M) when considering the medical evidence alone. [See 20 CFR 404.1520 (d)]
Most of the listed impairments are permanent or expected to result in death. For all others, the evidence must show that the impairment is expected to last for a continuous period of 12 months from the date of request. Diagnosis of a listed impairment is not enough in making a determination for GA.
The 14 Listings of Impairments Contained in 20 CFR Subpart P Appendix 1:
| 1.00 | Musculoskeleltal System |
| 2.00 | Special Senses and Speech |
| 3.00 | Respiratory System |
| 4.00 | Cardiovascular System |
| 5.00 | Digestive System |
| 6.00 | Genito-Urinary System |
| 7.00 | Hemic and Lymphatic System |
| 8.00 | Skin |
| 9.00 | Endocrine System |
| 10.00 | Multiple Body Systems |
| 11.00 | Neurological |
| 12.00 | Mental |
| 13.00 | Neoplastic Diseases |
| 14.00 |
Immune System |
Meeting a Listed Impairment. If the individual’s medical evidence contains a set of signs, symptoms and laboratory findings which are exactly the same as the criteria included under a listing of impairment category, the individual's impairment meets or equals the level of severity described in the listing and the individual is medically eligible for GA.
Equaling a listing. The medical findings are at least equal in severity and duration to the listed findings. If the client’s impairment is not listed, the Department considers the listed impairment most like the client’s impairment to decide whether the client’s impairment is medically equal to the listed impairment. If the client has more than one impairment, and none of them meets or equals a listed impairment, the Department reviews the symptoms, signs, and laboratory findings about the client’s impairments to determine whether the combination of those impairments is medically equal to a listed impairment.
An individual will be eligible for GA if they do not meet or equal a listed impairment or have a medical condition that is expected to be terminal within 12 months, provided they meet one the following:
If the client is unable to do so, the Department will obtain medical evidence that documents a claim of physical or mental impairment.
Basic work activity means any kind of work activity that averages at least eight hours a day for which income is received, regardless of the adequacy to meet the client’s needs. Work performed against medical advice or at an activity center or sheltered workshop is not basic work activity.
Light work means work that requires lifting no more than 20 pounds at a time with frequent lifting or carrying objects weighing up to 10 pounds and requires occasional stooping. It also requires standing or walking for a total of approximately six hours of an eight-hour workday.
Past relevant work means work that the individual has performed in the last 15 years and that constitutes substantial gainful activity as defined in 20 CFR 404.1574 and 404.1575, in effect November 1, 2003. Also, the past relevant work must have lasted long enough for the individual to learn the techniques, acquire the necessary information, and develop the facilities needed for average performance of the job situation.
Sedentary work means work that requires lifting no more than 10 pounds at a time and occasionally lifting or carrying articles such as docket files, ledgers, and small tools. Although sitting is involved, a certain amount of walking and standing is often necessary in carrying out job duties. Periods of walking and standing should total no more than two hours of an eight-hour workday and sitting should total approximately six hours of an eight-hour workday. Most unskilled sedentary jobs require good use of the hands and fingers for repetitive hand finger actions.
Severe physical impairment means an impairment that significantly limits the individual's physical ability to do basic work activity.
Unskilled work is work that requires little or no judgment to do simple duties that can be learned on the job within 30 days.
Individuals are not eligible if the Department determines that drug addiction or alcoholism is material to their disability. These individuals cannot be considered impaired on that diagnosis of drug addiction or alcoholism alone. On the other hand, a diagnosis of drug addiction or alcoholism should not have an effect on a disability evaluation that is adverse to the individual. Drug addiction and alcoholism are diagnostic terms; they do not denote impairment value or severity. It is necessary to evaluate the severity of the impairment which may be associated with, manifested by, resulting from, or coexisting with these diagnosis'. In making the decision the key issue is whether the individual would continue to meet the definition of disability even if drug or alcohol use were to stop.
Allow the individual to select a qualified medical provider to complete the medical evaluation. Authorize payment for administrative medical examination on the OMAP 729.
The Department will accept evaluations from the following sources:
Additionally, for casework planning and supplemental information, accept evaluations from the following:
Medical documentation must be written and must contain all of the following:
The applicant/recipient must provide or cooperate in obtaining sufficient medical documentation. If the applicant/recipient is unable to do so, the Department must assist the individual in obtaining any medical evidence required to make a disability determination based on the GA impairment criteria.
Department Must Assist: 461-125-0510
Using Admin Exams: 461-125-0810
Medical Documentation: 461-125-0830
GA impairment determinations are made by the local MRT, comprised of staff assigned by the Department providing medical expertise in comparing the individual's medical condition with the medical eligibility requirements. The MRT decides whether a person meets the impairment requirements.
MRT decisions are based on the nature of the impairment, the medical documentation and the social summary.
