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OSIP Program Manual

WG-4 Presumptive Medicaid (OSIPM) Decision Procedures

5/20/13

This Worker Guide contains the following sections:

  1. Background
  2. Referrals from Self Sufficiency
  3. Referrals from OHP Statewide Processing Center
  4. Processing a Presumptive Medicaid Disability Determination Request at the Local SPD/AAA Office
  5. Expedited Process
  6. PMDDT Process
  7. Decisions Binding on the State
  8. Effects of SSA Decisions on Active PM Cases
  9. Hearing Requests
  10. Medical Reviews
  11. Transportation
  12. Forms and Tools

1. Background

Oregon is required to make Medicaid eligibility disability determinations within 90 days on any applicant who meets financial and nonfinancial OSIPM eligibility requirements and alleges a disability that would meet the SSA disability requirements for SSI or SSDI and, in which SSA has not made a disability determination. This is because Oregon elected to become a non-1634 state. This means the State of Oregon elected not to relinquish the responsibility of making Medicaid determinations.

These presumptive Medicaid disability determinations are made for Oregon Supplemental Income Program (including EPD and Home and Community Based Care Services).

2. Referrals from Self Sufficiency

This process is for disabled Medicaid applicants who apply at Self Sufficiency Program offices. This is a guideline to use when developing local referral processes.

Responsible Person
Description of Duties  
Self-Sufficiency Worker
  • Client applies for OHP/FS in branch office.
  • Client indicates that they have a disability on question 2 and 2(a) on page 7 of the DHS 415F.
  • Make eligibility determination on FS and Medicaid.
  • Based on information from the application, screen for OSIP financial and non-financial eligibility criteria using the Referral for Oregon Supplemental Income (OSIPM) Eligibility Decision (DHS 0709).
  • If OSIP criteria are met, ask client if SSA has denied them disability benefits within the last year because their disability didn’t qualify. If denied within last year, determine if there is a new disability being claimed. If denied more than a year ago, determine if their condition has worsened.
  • If client meets OSIP criteria and has not been denied by SSA for their current condition within the last year, a referral is made to Disability Services office according to local process (Fax or Email). Referrals will go directly to the screener or worker-of-the-day in the SPD/AAA branch offices. Use the Referral for Oregon Supplemental Income (OSIPM) Eligibility Decision (DHS 0709).
  • Code CMS with PMP case descriptor.
  • Clients who self-assess they are ineligible will be given opportunity to withdraw using the DHS 457D.
  • Those still wanting referral to SPD/AAA will be referred along with a note that they have been advised they do not appear to qualify.
 
Disability Services Worker
  • Contact client by phone or mail to schedule an interview to obtain information about medical providers, release of information, and to complete forms SDS 0620, SDS 0708 and DHS 2099(s).
  • If client does not respond to, or follow through with the invitation to interview within 90 days of the Date of Request for Medicaid (i.e., date of application for OHP Standard) or within 45 days from the date the Branch Office initiates contact (whichever date is later), deny case and narrate in Oregon ACCESS . Denial notice is sent via the SDS 540. If the client was also denied OHP Standard, include the DHS 462A. Cite 461-125-0370 (for Presumptive Medicaid) and/or OAR 461-125-0510 (for General Assistance). Also cite 461-105-0020 and 410-120-1210. Advise referring Self-Sufficiency branch of denial (so that TRACS can be updated accordingly), and keep a copy of the SDS 540 in the record.
  • If client follows through with the invitation to interview, and a disability determination is needed, make a referral to PMDDT.
 
PMDDT
  • Receives referral from Disability Services Worker.
  • Adds PMP case descriptor to UCMS if needed.
  • Obtains needed information from medical providers to determine disability.
  • Notifies referring worker of decision within 90 days.
  • Narrates decision in TRACS or Oregon ACCESS.
  • If denied, removes PMP case descriptor and replaces with PMD on UCMS.
 
Disability Services Worker
  • If approved by PMDDT:
    • Requests file from SSP branch if the household meets ADS client criteria.
    • Converts from P2 to Program _5, with NCP, PMA and OSP case descriptors.
    • Completes the OHP 7204, “Request for Reimbursement of OHP Premiums Paid,” if client is eligible for a refund of OHP Premiums paid.
  • If denied:
    • Issues denial notice (via the SDS 540). If also denied OHP Standard, include the DHS 462A .
    • Narrates denial in Oregon ACCESS.
    • Advises referring Self-Sufficiency branch of decision.
 
Self-Sufficiency Worker
  • If approved by PMDDT, transfers case online.
  • If denied by PMDDT, narrates decision in TRACS.
 
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3. Referrals from OHP Statewide Processing Center

Branch 5503 will determine eligibility for OHP and refer to the local SPD/AAA office contact to review for presumptive Medicaid eligibility based on the matrix in the OHP WG.1.

The client is referred to SPD using the groupwise branch contact process (see AR-11-018) via the OHP Referral Form (DHS 3200). The client will be scheduled for an intake according to local procedures.

    Note: To update branch contacts, please contact the Service Desk

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4. Processing a Presumptive Medicaid Disability Determination Request at the Local SPD/AAA Office

Click here for the PMDDT Referral Flow Chart

If a person makes an application for Medicaid at the field office and has not had a disability determination made by SSA, determine eligibility for OHP standard and proceed with the following steps.

STEP 1: Determine financial and non-financial eligibility, other than the disability, for OSIPM. If the applicant does not meet the financial or non-financial criteria for OSIPM, send appropriate notice of denial. If applicant meets the financial and non-financial criteria for OSIPM proceed to step two.

STEP 2: Determine whether the applicant has made an application for SSI/SSDI by asking the client and by checking the Benefit Exchange Information Network (BEIN) screen. If the applicant has ever received a decision denying their SSI/SSDI based on their alleged disability by SSA, send appropriate notice of denial citing OAR 461-125-0370 (Disability as Basis of Need) and 410-120-1210 (OMAP Medical Assistance Benefit Packages), unless any of the following exceptions apply:

If the applicant alleges either of the above exceptions or SSA has never issued an SSI/SSDI denial, proceed to Step 3 to process a PMDDT disability determination request.

STEP 3: Process a Presumptive Medicaid Disability Determination request by doing the following:

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5. Expedited process

This policy applies only to applicants discharging from a hospital, reaching the end of their 20 days skilled nursing facility benefit or meets one of the conditions listed on the back of the SDS 0620. These referrals are separated into two different classes depending on whether the client has a condition that SSA considers presumptive or not.

Local Office Expedited Decisions:

Applicants with presumptive conditions (as listed on the back of the SDS 0620):
For applicants who meet all other eligibility factors, including service priority level if needed, the local office will have the authority to make an eligibility determination decision with minimal documentation of disability for applicants who have conditions that SSA defines as presumptive. This practice is similar to that of SSA and their field offices. Local office will gather all immediately available medical information before making decision. In most instances this information will be available from the hospital discharge planner or the nursing facility social worker. This information will be reviewed by the MRT team or by a supervisor before final local office decision is made.

Local office will then forward all pertinent documentation to PMDDT. PMDDT will log receipt of referral and will assign to an analyst for final disability determination. Local office will assist PMDDT to locate suitable consultants in the local area for administrative exams if necessary. The local office decision shall be good for 6 months or until PMDDT/DDS gathers medical/psychological and makes final determination.

PMDDT Expedited Decisions

Applicants with other conditions:
Local office will determine whether applicant meets all financial and non-financial criteria before referring to PMDDT. Local office will gather medical/psychological information from facility or hospital along with signed release of information. This information will be faxed or sent to PMDDT. PMDDT will log and assign to the “expedited analyst.” This analyst will be responsible for processing expedited referrals.

PMDDT analyst will review information and will make a determination within 5 business days. If further supporting documentation is necessary the analyst will notify the assigned worker of the need for additional information. The analyst will indicate what information is needed and that the decision may be delayed pending receipt of the needed information. Local staff will work with the analyst to arrange for administrative exams or to obtain the information from additional providers.

Medical Record Information Required to Expedite Decisions:

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6. PMDDT Process

All medical and vocational documentation will be evaluated by the PMDDT for a presumptive Medicaid disability determination. If the client is found, based on the medical evidence submitted or gathered by PMDDT to meet the SSA disability requirements for SSI/SSDI, they meet the disability requirements for Medicaid (OSIPM).

The PMDDT will forward documentation of the disability decision, along with all medical evidence back to the field person who originated the request.

Upon Notification of Approval from PMDDT

Staff will need to open the case as a program 5 with NCP, OSP and PMA (remove PMP) case descriptors. Code a medical review date as indicated by PMDDT (Date medical improvement expected or NFM if no improvement expected). If the case is approved at OHP Statewide Processing Center, the case will be opened and transferred to the appropriate field office.

If PMDDT has approved disability within 90 days but SSA denied the disability after the 90th day Medicaid eligibility can continue until the SSA Appeals Council renders their final decision (the client must follow through with all appeals). See section 8 of this WG for more information.

Premium Refund Process. Clients who were originally opened under the OHP standard package, will need to be reimbursed for any premiums they made during any period they have been found eligible for the OHP Plus benefit package. A Request for Reimbursement of Premiums form (OHP 7204) will need to be completed and sent to the client by staff if the client paid any premiums while they were waiting for their OHP Plus benefits to be approved. The client will need to complete this form and request to be reimbursed for any premiums paid and return it to the address listed on the form.

Through the OHP Premium Billing Office, OMAP will reimburse, if appropriate, any premium payments the client paid while they would have been otherwise eligible for the OHP Plus benefit package. If the premiums are outstanding, adjust the premiums by doing the following (DHS 7204 not needed for these premiums):

Upon Notification of Denial from PMDDT

Staff will need to send a denial notice to the applicant advising them they are not eligible for OSIPM based on their disability. OAR 461-125-0370 (Disability as Basis of Need) and 410-120-1210 (OMAP Medical Assistance Benefit Packages) will be cited in the notice to the client. Code CMS with a PMD case descriptor (remove PMP).

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7. Decisions Binding on the State

All favorable SSA decisions are binding on the State. In most cases, unfavorable SSA disability decisions (denials) are binding on the State. An exception occurs, and PMDDT decisions supersede SSA denials, in the following situations:

The following situations clarify when SSA disability decisions are binding on the State.

Situation 1: Client has an SSA denial at the time of Medicaid application

If the client has an SSA disability denial at the time that the client requests Medicaid, the SSA decision is usually binding. This is because an SSA decision is meant to be effective for a period of at least 12 months. The decision is effective for even longer than 12 months for clients who do not develop a new or different condition or experience a significant worsening of their existing condition. The following is a more detailed explanation of new, different or worsened conditions and their affect on Presumptive Medicaid eligibility.

Situation 2: Client is denied by SSA while their Medicaid application is pending

The SSA denial is binding on PMDDT unless one of the following is true:

Situation 3: Presumptive Medicaid is approved and SSA denies the case at a later date

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8. Effects of SSA Decisions on Active PM Cases

As outlined above, Social Security disability decisions are binding on the State. When a client has been found eligible for Presumptive Medicaid (OSIPM) (5/NCP)) based on a presumptive disability decision, appropriate action is required when SSA makes a disability decision on the same case.

  1. When SSA makes a favorable decision on an active Presumptive Medicaid case :
    1. Convert the case to another appropriate OHP Plus Medicaid program, if eligible. For example, OSIP Program 4 for those found eligible for SSI or those found eligible for SSDI whose income does not exceed OSIPM standards; or
    2. If the client is only eligible for OHP Standard, send a timely reduction notice (i.e., an individual found eligible for SSDI, with SSDI over the OSIPM income limit but under OHP standard and the individual is not receiving Medicare); or
    3. If no Medicaid eligibility exists, send a timely closing notice.
  2. When SSA makes an unfavorable decision on an active Presumptive Medicaid case:
    1. Advise the client that in order to remain eligible for OSIP(M) based on presumptive disability, they must request a reconsideration of the SSA decision within 60 days.
    2. If the client fails to pursue reconsideration within 60 days:
      1. Convert the case to another appropriate Medicaid program, if eligible.
      2. Send a timely notice of closure or reduction if not eligible for another Medicaid program or if reducing to OHP Standard. Presumptive Medicaid (Program 5/NCP) cannot be continued in this situation. If a hearing is requested, the hearing issue will be based on the binding decision made by SSA. Only SSA can reverse this decision so hearings on the disability issue itself must be pursued through SSA’s appeal process.
    3. If the SSA decision is reversed and the decision is favorable at reconsideration:
      1. Convert the case to another appropriate Medicaid program, if eligible. For example, OSIP Program 4 for those found eligible for SSI or those found eligible for SSDI whose income does not exceed OSIPM standards.
      2. If the individual is awarded SSDI and income is over OSIPM income limit, send a timely notice of reduction if the case is converting to OHP Standard.
      3. Send a timely closing notice if no Medicaid eligibility exists.
    4. If the SSA decision remains unfavorable at reconsideration, advise the client that in order to remain eligible for OSIP(M) based on presumptive disability, they must request a hearing of the SSA decision within 60 days in order to remain eligible for OSIP(M).
    5. If the client fails to pursue hearing within 60 days:
      1. Convert the case to another appropriate Medicaid program, if eligible.
      2. Send a timely notice of closure or reduction if not eligible for another Medicaid program or if reducing to OHP Standard. Presumptive Medicaid (5/NCP) cannot be continued in this situation. If a hearing is requested the hearing issue will be based on the binding decision made by SSA. Only SSA can reverse this decision, so hearings on the disability issue itself must be pursued through SSA’s appeal process.
    6. If the SSA decision is reversed and the decision is favorable at the hearing level:
      1. Convert the case to another appropriate Medicaid program, if eligible. For example, OSIP Program 4 for those found eligible for SSI or those found eligible for SSDI whose income does not exceed OSIPM standards.
      2. Send a timely notice of reduction if the case is converting to OHP Standard (i.e., an individual found eligible for SSDI, with SSDI over the OSIPM income limit but under OHP standard and the individual is not receiving Medicare).
      3. Send a timely closing notice if no Medicaid eligibility exists.
    7. If the SSA decision remains unfavorable at hearing, advise the client in order to remain eligible for OSIP(M) based on presumptive disability, they must request an appeal of the SSA decision within 60 days in order to remain eligible for OSIP(M).
    8. If the client fails to pursue appeal within 60 days:
      1. Convert the case to another appropriate Medicaid program, if eligible.
      2. Send a timely notice of closure or reduction if not eligible for another Medicaid program or if reducing to OHP Standard. Presumptive Medicaid (5/NCP) cannot be continued in this situation. If a hearing is requested the hearing issue will be based on the binding decision made by SSA. Only SSA can reverse this decision so hearings on the disability issue itself must be pursued through SSA’s appeal process.
    9. If the SSA decision is reversed and the decision is favorable at appeal level:
      1. Convert the case to another appropriate Medicaid program, if eligible. For example, OSIP Program 4 for those found eligible for SSI or those found eligible for SSDI whose income does not exceed OSIPM standards.
      2. Send a timely notice of reduction if the case is converting to OHP Standard (i.e., an individual found eligible for SSDI, with SSDI over the OSIPM income limit but under OHP standard and the individual is not receiving Medicare).
      3. Send a timely closing notice if no Medicaid eligibility exists.
    10. If the SSA decision remains unfavorable at the Appeals Council level, Presumptive Medicaid must be closed.
      1. Convert the case to another appropriate Medicaid program, if eligible.
      2. Send a timely notice of closure or reduction if not eligible for another Medicaid program or if reducing to OHP Standard. Presumptive Medicaid (5/NCP) cannot be continued in this situation. If a hearing is requested the hearing issue will be based on the binding decision made by SSA. Only SSA can reverse this decision, so hearings on the disability issue itself must be pursued through SSA’s appeal process.

Options – Local Office Monitoring of SSA Decisions on Presumptive Disability Cases

This is an important part of these procedures and will help to ensure the integrity of the Presumptive Medicaid process. Please be sure to do the following:

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9. Hearing Requests

Process all hearings requested by the applicant on the disability denial in the normal manner. PMDDT staff will be available to testify as a witness at the hearing representatives request.

OHP-Statewide Processing Center (SPC)

All hearing requests initiated from an OHP-SPC decision will be handled by the OHP Central hearing representatives. If the hearing request is received through the local office on an OHP-SPC decision, it should be forwarded to OHP-SPC for appropriate action.

Local Field Office

All hearing requests initiated from a local field office or PMDDT decision will be handled by the local field office and their hearings representative. Local policy and procedure as to how to handle a hearing request will be followed. PMDDT central staff and contract physicians can be called as expert witnesses in hearings related to a PMDDT decision.

10. Medical Reviews

PMDDT assigns a Medical Review Date to all Presumptive Medicaid cases.  Medical Review Dates vary between one and seven years.  Medical Review Dates are dependent upon a client’s physical or mental condition, age, education level and work experience.

In certain cases, when medical improvement is not expected, no Medical Review will be needed.  If no Medical Review is needed, the case will be marked “NFM” (No Further Medical).

A list of upcoming Medical Reviews due is available on View Direct Report WCM0390R-A or WCM0390R-C. For instructions on accessing this report, see the Support Staff Assistance Manual, Section (F)(2).

File Preparation:

Prior to the Medical Review Date, prepare the PMDDT file. Include all medical records used to make the previous PMDDT decision. In addition, update the following forms and include copies of these forms with your referral to PMDDT:

REMEMBER: Regardless of the Medical Review Date, all PMDDT cases must be monitored for SSA decisions as noted in Section 7 above (Situation 3). If SSA denies the client’s disability claim after PMDDT approves the case, the Medicaid case continues as long as the client files timely appeals with SSA. If the client does not file timely appeals, or if the disability claim is denied at the appeals council level, the SSA decision becomes binding.  If an SSA denial has become binding, the case should not be referred to PMDDT.  The local office should issue a timely continuing benefit notice, citing 461-125-0370(2) as the basis for reduction or closure.

When forms are complete, refer the case to PMDDT. 

11. Transportation

When the PMDDT schedules an applicant for administrative examinations to determine if an applicant is eligible for Medicaid based on disability, branch staff must do the following:

  • Complete a transportation screening interview to determine if the applicant has transportation available to go to the administrative examination(s).
    • When arranging a ride, workers must consider all options, including volunteer services.
    • In all instances, the branch is responsible for authorizing the least expensive mode of transportation that is suitable for the client’s needs.
  • If the applicant has no other means of transportation, the local branch office will contact PMDDT.
    • PMDDT will fax a completed DMAP 729 (Administrative Medical Examination/ Report Authorization) form to the person’s transportation brokerage.
    • The brokerage will then arrange the ride.
  • If the applicant has transportation available, the branch can reimburse the person for the ride.
    • The branch will contact PMDDT to request a completed DMAP 729 form.
    • PMDDT will fax the completed DMAP 729 form to the branch.
    • The branch will issue payment via the DHS 437 (Authorization for Cash Payment), using Code 35.
 

12.Forms and tools

Forms

Tools

 

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