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Medicaid Decision Procedures
OSIP Program Manual
WG-4 Presumptive Medicaid (OSIPM) Decision Procedures
THIS ENTIRE MANUAL SECTION WAS UPDATED 12-9-14
This Worker Guide contains the following sections:
- Processing a Presumptive Medicaid Disability Determination
Request at the Local APD/AAA Office
- Expedited Process
- PMDDT Process
- "Binding" SSA Decisions
- SSA Decisions on Active PMDDT Cases
- Hearing Requests
- Medical Reviews
- Forms and Tools
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
|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
- 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.
- 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:
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
- If an applicant with a condition on the back of the SDS 0620 meets all other eligibility factors, including service priority level when applicable, the local office has the authority to make an eligibility determination with minimal documentation of disability. This practice is similar to that of SSA and their field offices. The local office will gather all immediately available medical documentation before making the 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 supervisor before the local office decision is made.
- The local office will then forward all pertinent documentation to PMDDT, (including the SDS 0620 and MSC 2099's for SSA and all medical/mental health providers seen in the last 2 years). PMDDT will log receipt of the referral and assign the case to an analyst for a final disability determination. If needed, the local office will assist PMDDT with gathering additional medical records. The local office decision is effective for 6 months or until PMDDT makes a final determination.
PMDDT Expedited Decisions
Applicants with conditions NOT listed on the back of the SDS 0620:
- The local office will determine whether applicant meets all financial and non-financial
criteria BEFORE referring the case to PMDDT. Local office will gather medical/psychological
information from the most recent facility or hospital along with the SDS 0620 and MSC 2099's for SSA and all medical/mental health providers seen in the last 2 years. This information will be emailed, faxed or sent to PMDDT. PMDDT will log receipt of the referral and assign the case to a Disability Analyst for a final disability determination.
- The PMDDT Disability Analyst will review information and will make a determination within
5 business days unless additional documentation is required to make a favorable decision. If further supporting documentation is necessary the analyst
will notify the assigned APD/AAA worker. Depending on the nature of the disability and adequacy of the documentation, the case may require additional processing time. The
Disability Analyst will indicate what information is needed and that the decision may be
delayed pending receipt of the needed information. Local staff may be asked to work with
PMDDT to arrange for administrative exams or to obtain the information
from additional providers.
Examples of information required to expedite decisions:
- Medical/Mental Health records/Information (may include the following):
- Admission Assessment
- Consultive Reports
- Progress Notes
- Therapy Assessments/progress records (PT, OT, ST)
- History and Physical assessments
- Hospice orders and records
- Discharge Summary (if discharged from hospital)
- Lab tests and test results
- CAT/PET scans
- Biopsy results
- Nursing Home Records/Information (may include the
- Admission Assessment
- Physician Progress Notes/Assessments
- Therapy Assessments and Progress notes (PT, OT, ST)
- Nursing Notes
- Hospice orders/Records
- Oregon State Hospital Records/Information (may include the following):
- Admission Assessments
- Current updated assessments
- Treatment records
- Forensic assessments
- Results of psychological testing
- Authorization for Use
and Disclosure of Health Information form - MSC
- One provider per form
- Physician's, Hospital's or Clinic's full name, address, city and state
- Expiration or event date filled in with an actual date
- Initials of client or representative in the highlighted
box on the second page
- Legal signature, Mark of the individual or legal representative with current date and the appropriate authorizing document(s) such as Power of Attorney, Authorized Healthcare Proxy, Guardianship etc.
- Completion of SDS 0620
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).
- Note: PMDDT will narrate receipt of referral,
assignment to Disability Analyst, disability determinations and other important case actions in Oregon ACCESS.
- Note: Unlike the field APD/AAA offices, PMDDT does NOT receive case 'ticklers' or alerts from Oregon ACCESS.
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
- Note: If case has been referred by 5503,
request a case transfer.
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.
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 makes a disability decision before SSA.
- SSA denies the case for technical reasons.
- SSA denies the case more than 90 days after the Date of Request for Medicaid.
- The client alleges a new or different condition, not evaluated by SSA.
- The client alleges that their condition has worsened more than 12 months after their most recent SSA denial.
- Note: A worsenging of condition more than 12 months after their latest SSA denial does NOT relieve the client of the burden to continue their SSA appeal to the next level(s).
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.
- If the client does not file a timely appeal request on the SSA decision, the SSA decision may be binding on the Department. In certain cases, APD/AAA staff may contact PMDDT to discuss the case. PMDDT, through a Memorandum of Understanding with SSA, has access to privileged information that is NOT available to the APD/AAA field offices.
- For clients who file a timely appeal request with SSA, continue the OSIPM eligibility as long as the client is in the SSA administrative appeals process. This includes the Reconsideration, the Hearing and the Appeals Council levels. The Appeals Council level is the final administrative decision of SSA. Claims that proceed to federal district court, appellate and/or supreme courts are NOT binding on the State. OSIPM benefits must be closed with the appropriate due process notice after the client receives a denial from the SSA Appeals Council. APD/AAA staff may consult with PMDDT regarding continuing benefits in these situations.
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.
- Evaluate eligibilty for all other APD Medicaid programs and covert the case if appropriate.
- If the client is ineligible for all APD Medicaid programs, you must look at eligibility for all other Medical programs prior to closing the presumptive case. Follow the "Due Process' procedures as outlined in the New Procedure Document. Follow the process in purple under "existing APD/AAA clients losing eligibility for current APD program. Do not close the program, _5 until Due Process has been followed.
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.
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:
- SDS 0620- Request for Presumptive Medicaid Disability Decision
- MSC 2099- Authorization for Use & Disclosure of Information
- Enclose new 2099's for SSA and each medical/mental health provider seen in the past two years. 2099's must be completed fully and correctly to ensure that medical records will be provided to PMDDT. Incomplete forms will result in decisional delays.
When completing the DHS 2099 be sure to review the instructions above:
- Include a separate DHS 2099 for each provider.
- Include the full name of the provider (i.e., first and last name for individuals). Do not use acronyms for hospitals, clinics or mental health providers.
- Include the provider’s address. If the provider’s exact address is unknown, please note City and State.
- Under the column titled, “Specific Information to be Disclosed,” the following statement must be included: “Medical records to include mental health, alcohol, drug, genetic testing and HIV/AIDS.”
- Ensure that the client initials in the spaces between Sections B and C. If the client refuses to initial these HIPAA-related spaces, please narrate this in the Oregon ACCESS.
- In the “Release To” section, enter “DHS.” PMDDT may also be specified. Please Note: If a specific local office is entered in this section many providers will only release to that office, making it difficult for PMDDT to obtain medical records.
For further instructions, please see the MSC 2099 I.
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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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
2099 - Authorization for Use and Disclosure of Health Information
0620 - Request for Presumptive Title XIX Decision
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