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OSIP Program Manual

WG-4 Presumptive Medicaid (OSIPM) Decision Procedures

12/09/14

THIS ENTIRE MANUAL SECTION WAS UPDATED 12-9-14

This Worker Guide contains the following sections:

  1. Background
  2. Processing a Presumptive Medicaid Disability Determination Request at the Local APD/AAA Office
  3. Expedited Process
  4. PMDDT Process
  5. "Binding" SSA Decisions
  6. SSA Decisions on Active PMDDT Cases
  7. Hearing Requests
  8. Medical Reviews
  9. Transportation
  10. Forms and Tools

1. Background

When a client who has been determined ineligible for MAGI alleges a disability that would meet the SSA disability requirements for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) benefits, Oregon is required to make an OSIPM Medicaid eligibility determination within 90 days of the client's Date of Request. If a client has already been determined to be disabled by the Social Security Administration (SSA) see OSIP Program Manual, Section D, part 6

If a non-SSI/non-SSDI applicant meets the financial and nonfinancial eligibility requirements for OSIPM, DHS must make a disability determination using Social Security’s disability criteria. This is because State of Oregon elected to become a non-1634 state. This means Oregon’s Department of Human Services retains responsibility for making Medicaid-related disability determinations.
Presumptive Medicaid disability determinations are made when needed for all Oregon Supplemental Income Programs (including EPD and Home and Community Based Care Services).

 

2. Processing a Presumptive Medicaid Disability Determination Request at the local APD/AAA office

If a person has first been referred to 5503 and is ineligible for MAGI Medicaid and has not had a favorable disability determination by SSA, determine eligibility for OSIPM with the following steps

Responsible Person
Description of Duties  
Disability Services Worker
  • Contact client by phone or mail to schedule an interview to obtain information about medical providers and complete forms SDS 0620 and MSC 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 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. Cite 461-125-0370 (for Presumptive Medicaid). Also cite 461-105-0020 and 410-120-1210. Keep a copy of the SDS 540 in the record.
  • If client follows through with the invitation to interview, using 539A determine financial and non-financial eligibility, other than 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.
  • Determine whether the applicant has made an application for SSDI benefits by asking the client and by checking the Benefit Exchange Information Network (BEIN). If the applicant has not applied for Title II Social Security benefits (including SSDI), remind the client that pursuit of assets is a condition of eligibility for OSIPM benefits. (see 461-120-0330).
  • Process a Presumptive Medicaid Disability Determination request by doing the following:
    • Complete a Request for Presumptive Title XIX Decision. (SDS 0620).
    • Complete an Authorization for Use and Disclosure of Health Information (MSC 2099) for SSA and for each medical/mental health provider seen in the last 2 years (if seen at a hospital or clinic, use the hospital or clinic name). Only one provider per release and the client must initial the 4 lines in Section A of the 2099.
    • Send the above forms and any available medical documentation to PMDDT via one of the following:
      • For referrals containing 50 pages or less:
      • For referrals containing more than 50 pages:
        • Mail to PMDDT at 3420 Cherry Ave NE, Ste. 140, Salem, OR 97303.
    • Code CMS with a PMP case descriptor.
  • If the PMDDT applicant is not already receiving Medicaid, create a P2 Administrative Exam Only case for the client in Oregon ACCESS.
    • Use the current date for the effective date.
    • The Incm code should be NEW.
    • Med Prg/# is not needed.
    • The RVW date should be 90 days after the Date of Request for Medicaid or 65 days after the case is sent to PMDDT, whichever is later.
    • Use the AD or CH in-grant code and the ADM case descriptor.
    • Add the Medical Start Date. The Medical Start Date can be any date on or after the Date of Request.
    • Integrate with the DHS Mainframe.
  • Note: When the Administrative Exams are complete and/or medical records are received, the Administrative Exam Benefit Package case can be closed or converted to an ongoing Medicaid case. When closing an Administrative Exam Benefit Package, use the "OO" close reason code. Do not send the client a closing notice. A decision notice is not required when ending administrative exam.
  • Note:If a client moves to another area of the state, and a presumptive determination has not yet been made, transfer the pending case to the appropriate office.
  • Set a two-week Tickler in Oregon ACCESS to confirm PMDDT received the referral.

     

 
     
PMDDT
  • Receives referral from Disability Services Worker.
  • Adds PMP case descriptor to UCMS and creates Admin P2 Medical case if needed.
  • Obtains needed information from medical providers to determine disability.
  • Notifies referring worker of decision within 90 days.
  • Narrates decision in Oregon ACCESS.
  • If denied, removes PMP case descriptor and replaces with PMD on UCMS.
 
Disability Services Worker
  • If approved by PMDDT:
    • Requests file.
    • Converts from P2 to Program _5, with NCP, PMA and OSP case descriptors and sends appropriate notice.
  • If denied:
 
     
 
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3. Expedited process

This policy applies only to applicants discharging from a hospital, reaching the end of their 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; referrals that can be approved by the local office before sending to PMDDT and referrals that cannot. Referrals that cannot be approved by the local office will be expedited upon receipt at PMDDT.

Local Office Expedited Decisions:

For applicants with conditions listed on the back of the SDS 0620):


PMDDT Expedited Decisions

Applicants with conditions NOT listed on the back of the SDS 0620:

Examples of information required to expedite decisions:

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4. PMDDT Process

All medical and vocational documentation will be evaluated by the Presumptive Medicaid Disability Determination Team (PMDDT) for an SSA criteria based disability determination. If the client is found to meet the SSA disability requirements for SSI/SSDI, the client meets the disability requirements for Medicaid (OSIPM).

Once a determination is made, PMDDT will archive the client's PMDDT case. Archive information and tracking numbers will be narrated in Oregon ACCESS.

Upon Notification of Approval from PMDDT

Staff will need to open the case as a Program 5 with NCP, OSP and PMA case descriptors (remove PMP coding). Code a medical review date as indicated by PMDDT (This is the date by which medical improvement is reasonably expected or NFM (no further medical) is used if no improvement is reasonably expected).

If PMDDT has approved disability within 90 days of the client's DOR, but SSA denied the disability after the 90th day, OSIPM eligibility can continue until the SSA Appeals Council renders their final decision. The client must follow through with all SSA appeals, or the SSA decision may become 'binding' on the State and the individuals application for Medicaid based on disability. See section 7 of this WG for more information.

 

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 (MAP Medical Assistance Benefit Packages) will be cited in the notice to the client. Code CMS with a PMD case descriptor and remove PMP.

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5. "Binding" SSA Decisions

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:

PMDDT will evaluate the impact of SSA decisions on PMDDT applicant cases while the case is pending. Once a PMDDT case is approved, the local APD/AAA office should ensure the client understands that he or she must appeal any future SSA denials in order to retain their OSIPM Medicaid benefit.


Unfavorable SSA Decisions:

If SSA issues an unfavorable disability determination after PMDDT approves a case, the OSIPM Medicaid case continues as long as the client files a timely reconsideration request of the SSA decision.

APD/AAA staff should advise clients who receive SSA denials to appeal SSA's decision. Appeals must be filed within 60 days using SSA forms available online or at the local SSA office.


Favorable SSA Decisions:
As discussed above, favorable Social Security disability decisions are always binding on the State. When SSA makes a favorable decision for a PMDDT client, appropriate action is required.


Monitoring of SSA Decisions on Approved PMDDT 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 review ongoing cases for SSA decisions using the BEIN screens at the client's yearly recertification

If the client has an SSA denial that they have not timely appealed and/or a denial from the Appeals Council, forward the case to PMDDT for review using the instructions in paragraph 10 below for medical reviews.

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6. Hearing Requests

All hearing requests initiated from a local field office or PMDDT decision will be handled by the local field office and their hearings represenative. The Office of Administrative Hearings is impartial and not affiliated with the Oregon Health Authority or the Department of Human Services. Hearings usually are held by phone, rarely in person, unless requested by the client. Local policy and procedure as to how to handle a hearing request will be followed. PMDDT Disability Analysts and/or Medical Consultants can be called as expert witnesses or subject matter experts in hearings related to a PMDDT decision.

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7. 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 the nature and severity of a client’s physical and/or mental impairments, 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).

For client's who have a medical review due on their presumptive case, a MAGI 'Due Process' 7210 should be sent prior to processing the PMDDT Medical review. Follow the normal Due Process procedure for a client who would be losing OSIPM. The procedures can be found in the New Procedure Document, purple section titled 'Due Process-Existing APD/AAA clients losing eligibility for current APD program.

If the MAGI determination is favorable, coordinate with 5503 to open a MAGI case and close OSIPM. If the MAGI determination is NOT favorable, follow the procedures listed below to process a medical review.

File Preparation for medical review:

Prior to the Medical Review Date, prepare the PMDDT file. Include the following:

 

REMEMBER: Regardless of the Medical Review Date, all PMDDT cases must be monitored for SSA decisions as noted in Section 7 above.

When forms are complete, refer the case to PMDDT via the process in section 2. 

 

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8. 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.
 

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9.Disability Liaison Program (DBL)

Commencing January 2015, PMDDT offers a new Disability Liaison Program (DBL) pursuant to OAR  461-125-0370 (7) Clients of a branch office (SEE OAR 461-001-000) who have been determined to have a disability by PMDDT, may receive free assistance from the PMDDT DBL’s with applications and administrative appeals for Social Security Insurance Benefits. This applies to clients who have now switched over to MAGI as long as they were found disabled by PMDDT and are a client of a branch office. PMDDT staff will reach out and contact prospective DBL clients by phone and mail

 

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10.Forms and tools

Forms

 

 

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