Tutorial

1

DISABILITY EVALUATION SERVICES

The Disability Determination Process:

Medicaid Eligibility for Individuals with Disabilities

Presented by: A.E. Adams Ph.D. Director

Disability Evaluation Services Commonwealth Medicine

UMass Medical January 2010

2

Section 1: Introduction

Traditional Medicaid is available to five groups or “categories” of individuals: Children and their parents/caretaker relatives (aka

TANF-eligible under Title IV of the Social Security Act or TANF-related)

Individuals who are aged, blind, or disabled (aka SSI-eligible under Title XVI of the Social Security Act or SSI–related)

TANF-related and SSI-related individuals are those who meet the categorical requirements except for having excess income

3

Introduction

For the “category” of disability , an individual without children, ages 19 through 64, must meet the SSA/SSI definition of disability to be eligible for Medicaid.

Individuals who are disabled may fall into either a mandatory or optional coverage groups depending on their income level.

Individuals with disabilities must be found disabled and meet other non-financial requirements as well as the financial requirements of their state of residence in order to access Medicaid health care coverage.

4

Section 2: State Plan Choices for Administering the Medicaid Disability Determination Function

Three state options for disability determinations under Medicaid 1634 States adopt SSA’s disability eligibility determination .

1634 states typically also have their own disability determination function for applicants whose income is over SSI limits. There are thirty-two 1634 states.

The seven SSI criteria states make all their own disability determinations using SSI criteria

209(b) states make all their own disability determinations and have chosen to have at one or more Medicaid eligibility rules that is more stringent than federal SSI rules.

5

Section 3: Organizational Placement of the Disability Determination Function

Disability Determination Unit (DDU) may reside within the state Medicaid Agency and be performed by state employees (New Hampshire, Maine, Rhode Island)

Disability determination function may be contracted out: To another state agency (Vermont) To a state university (Massachusetts) To a private company (Connecticut)

6

Section 4: Staffing the Medicaid Disability Determination Function

SSA defines the disability determination team Disability Examiner or Reviewer who develops

medical and vocational evidence and assesses the vocational aspects of a claim and

A licensed physician and/or psychologist who is responsible for evaluating the medical and psychological information and assessing work-related functionality

Both team members must be trained in the disability determination process

7

Staffing the Medicaid Disability Determination Function

Advantages of using licensed medical professionals (registered nurses, physical therapists) as Disability Examiner/Reviewers team member Shortens the learning curve; only legal and

administrative aspects need to be learned post-hire Enhanced federal funding for functions performed

by Skilled Professional Medical Personnel (SPMP) 75/25 federal match for SPMP services instead of the

usual 50/50 administrative cost match rate

8

Section 6: Training Medicaid Disability Determination Staff

SPMP staff on-the-job training Social Security rules and regulations Social Security Medical Standards Development of the advanced case management skills

required to meet federal timeliness requirements

The most effective training has the following characteristics: Systematic and competency-based Progressive goals measured regularly to assure

acquisition of necessary skills and knowledge

9

Section 7: The Disability Determination Process

Federal disability definition requires the applicant demonstrate “permanent and total disability”.

“Total” means inability to perform any “substantial gainful activity” due to functional limitations posed by severe impairment(s).

“Permanently” means that the disability has lasted or is expected to last 12 months or longer or result in death.

10

The Disability Determination Process: The Application Process

The process begins with an application to a Medicaid field office.

An applicant with a disability must provide: income/resource information, a description of the physical and/or mental problems

that prevent work, information about treatment sources, hospitalizations

and tests, and permission to obtain this information, educational and work history

The applicant’s completed disability packet is then transmitted to the state’s DDU for a determination.

11

The Disability Determination Process: The Development Process

DDU requests applicant’s records for all treating sources

If sufficient information is not received in a timely fashion, the DDU employs these strategies to complete the file: Re-contacts treating sources to obtain needed information

or to supplement or clarify existing information Arranges and pays for a Consultative Examination (CE) Every effort is made to obtain sufficient information

without resorting to a time-consuming and costly CE that may also be inconvenient and stressful for the applicant

12

The Disability Determination Process: Sequential Analysis

Federal regulations describes a five-step decision sequence for determining disability as follows:

Step One: Is the applicant engaging in substantial gainful activity? If yes, the applicant is not disabled. If no, analysis proceeds.

Step Two: Does the applicant have a ‘severe’ impairment? If no, the applicant is not disabled. If ‘yes’, is the impairment(s) expected to last at least 12 months or

result in death in less than 12 months? If no, the applicant is not disabled? If yes, then analysis proceeds.

13

The Disability Determination Process: Sequential Analysis

Step Three: Do the applicant’s impairment(s) meet the requirements of the

Social Security Listings of Impairments? If yes, the applicant is disabled. If no, do the applicant’s impairment(s) singly or in combination

equal the severity of the Listings? If yes, the applicant is disabled. If no, then analysis proceeds.

Residual Functional Capacity (RFC): At this point, the physician and/or psychologist carefully constructs a physical and/or mental RFC, a detailed description of the maximum work-related functional abilities an applicant retains despite their impairments, which becomes the basis for applying Step Four and Five of the sequential process.

14

The Disability Determination Process: Sequential Analysis

Step Four: Is the client capable of performing past relevant work? SGA performed within the last 15 years is relevant work. If yes, the applicant is not disabled. If no (or the client has never worked), then analysis proceeds.

Step Five: Is the client capable of performing other work that exists in significant numbers in the national economy? This step takes into account the vocational factors of advancing age,

educational level, ability to communicate in English, and transferability of acquired work skills. Certain SSA regulations, known as the vocational grid, provide detailed guidance for determining disability at this step.

If it is determined the client cannot adjust to other work, a finding of disabled is made. If there are a sufficient number of jobs the applicant can do, a finding of ‘not disabled” is made.

15

The Disability Determination Process: Sequential Analysis

Issues confronting a state Medicaid DDU in the application of sequential analysis: Construction of detailed and well-reasoned RFC’s Development of effective policies for resolution of

differing opinions and solution to substantive adjudicative problems

Obtaining expert vocational input as appropriate Maintaining a high quality product while meeting

federal timeliness standards

16

Section Eight: Timeliness of Decision-Making

Medicaid regulations require completion of disability-based applications within 90 days unless there are unusual circumstances that are not the responsibility of the Medicaid agency

Concern about timeliness flows from several sources: The client waiting for health care coverage deserves

an answer as soon as possible. Collection of the necessary information to establish a

disability can be time-consuming. A Medicaid agency that meets federal timeliness

standards may avoid legal action by consumer advocates.

17

Timeliness of Decision-making

Meeting the timeliness requirement poses organizational challenges:

The 90-day window from the application date to the date of the client’s notice, mandates that Medicaid DDU’s complete the disability decision in less than 90 days to allow for non-disability case processing.

Many aspects of the disability determination process are externally dependent: Waiting for treating sources to respond Scheduling consultative examinations

18

Section Nine: Quality of Decision-Making

Quality of disability decision-making is key:

To assuring that eligible persons with disabilities receive the Medicaid coverage for which they qualify

To enabling the Medicaid agency to avoid losing appeals

To providing fair and equitable treatment to all applicants

19

Quality of Decision-making

Elements of an effective quality assurance system may include: Clearly articulated standards Agency-wide random sample case reviews by

agency experts Ongoing tracking of agency performance and

trends Targeted supervisory reviews Systematic feedback to the individual Staff training to raise the bar in response to

trends

20

Section Ten: Customer Service

DDUs should strive to make the disability determination process as simple and transparent as possible

An applicant’s successful pursuit of a disability claim involving a consultative examination may require the DDU provide the following: Transportation Physical or architectural accommodations Language interpretation

21

Customer Service

Ongoing evaluation of the customer experience helps meet client needs, for example:

Customer satisfaction questionnaires Categorization of call records Classification of complaints

22

Section Eleven: Benchmarking for Performance Improvement

Development of core measures of quality, timeliness and customer service is critical to improving/maintaining Medicaid DDU performance

Comparing agency performance to “industry” leaders drives service improvement

Some data sources for disability determination benchmarking are these: Annual SSA Performance and Accountability Report

for nation-wide data Freedom of Information Act requests for SSA’s

individual state Disability Determination Services data

23

Recap

Medicaid DDU Topics in this presentation: Background State plan choices Organizational placement of Medicaid DDU function Staffing the Medicaid DDU Training DDU staff The disability determination process Timeliness of decision-making Quality of decision-,making Customer service Benchmarking for performance improvement

In the future, look for expanded discussion on these and other topics .

24

Contact Information

Gus Adams, PhD.DirectorDisability Evaluation Services, UMMS11 Midstate DriveAuburn, Massachusetts 01501Telephone: 508-721-7200Email: gus.adams@umassmed.edu

25