D-2100  When a Medical Determination Is Not Required

Receipt of Medicare is an indication that the person is either:

• age 65 or older; or
• has been determined blind or disabled based on the Social Security Administration (SSA) criteria for RSDI Title II or SSI Title XVI disability.

A medical determination is not required to establish blindness or disability if the person has Medicare. The receipt of the Medicare is satisfactory verification that the person has been determined to meet the SSA's criteria for aged, blind or disabled. This includes a person determined blind or disabled by SSA in the 24-month period before receiving Medicare. Upon verification of the receipt of a disability benefit, a medical determination is not required to establish blindness or disability if a person is currently receiving disability benefits from:

• SSI;
• RSDI; or
• Railroad Retirement.

For an eligibility determination during the retroactive coverage months, a medical determination is not required to establish blindness or disability during that retroactive coverage period if a person:

• has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
• has a date of onset for RSDI Title II blindness or disability based on SSA query records; and
• the date of onset for the RSDI Title II blindness or disability covers the retroactive coverage months prior to the application.

Note: Do not use the Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for:

• retroactive coverage;
• current coverage; or
• future coverage.

A medical determination is not required to establish blindness or disability if a person:

• applies with HHSC for SSI-related medical assistance only (MAO);
• is under age 65; and
• lost SSI for reasons other than a decision that the disability or blindness has stopped.

D-2200  When a Medical Determination Is Required

If a person does not have Medicare or is not receiving a disability benefit from SSI, RSDI or Railroad Retirement, a medical decision for either disability or blindness is required to determine eligibility for Medicaid. (Civil Service disability is not acceptable.) The medical decision for disability or blindness also requires the date of onset. The date of onset can affect the beginning date for Medicaid.

Individuals under age 65 who live in an institutional setting and who would, except for income, be eligible for SSI if they lived outside the facility, must meet the SSA's definition of disability or blindness. These individuals may or may not have applied for SSI cash benefits.

If a medical decision for determining blindness or disability is required, request a decision from the Disability Determination Unit (DDU). See Section D-2300, Requesting a Decision from the Disability Determination Unit.

Do not request a decision from the DDU in the following circumstances:

When determining Medicaid eligibility, a medical determination of disability or blindness is required if a person:

• is under age 65; and
• does not have RSDI Title II blindness or disability established.

To determine if there is RSDI Title II blindness or disability established, query the SSA records available. Based on the query, do not use the SSI Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability.

D-2300  Requesting a Decision from the Disability Determination Unit (DDU)

When a medical decision for determining blindness or disability is necessary, request a decision from DDU, 10205 North Lamar, Austin, TX 78753 or P.O. Box 149030, Austin, TX 78714-9947, Mail Code 2094, by completing and submitting these forms:

• Form H3034, Disability Determination Socio-Economic Report
• Form H3035, Medical Information Release/Disability Determination

In addition to these forms, submit the following when available:

• Minimum Data Set information (physician's signature page);
• medical treatment records for a waiver applicant; and
• medical records for an applicant for primary home care services through Community Attendant Services (CAS).

DDU may request more complete medical documentation.

On receipt of Form H3034, Form H3035 or other medical records, DDU uses this information to determine whether the person meets SSA's definition of disability or blindness and makes the final decision about disability or blindness.

DDU will consider the date of onset for the retroactive period if needed. Specify the retroactive months needed on Form H3034. DDU's date of onset, however, cannot precede the RSDI Title II disability onset date indicated on the SSA query.

D-2400 Disability Determination Unit (DDU) Request Required

When the application is for a person who is younger than age 65 and has never had a disability determination, an override for the application due date default of 45 days is needed. The application due date will be 90 days from the file date. Follow the steps in the system procedure instructions for this override.

Sometimes an application cannot be certified within 90 days because a disability determination is pending past the initial 90 days. In these cases, send Form H1247, Notice of Delay in Certification, to the applicant and the facility administrator, if applicable.

Applications for which delay-in-certification procedures have been followed are excluded from the delinquent count in timeliness reports. These applications are excluded for 180 days (90 days + 90-day extension); however, if the application is still pending on the 181st day, it will be counted as delinquent. Applications that cannot be certified within the normal 90-day limit, plus the 90-day extension, must be denied. A new application will be necessary to reconsider eligibility.

D-2500  Supplemental Security Income (SSI) Applicants and Retroactive Coverage

An applicant for Social Security disability benefits is evaluated for both SSI Title XVI and RSDI Title II disability eligibility. HHSC determines Medicaid eligibility for retroactive coverage for up to:

• three months before the date of SSI application for a person who has been denied SSI; or
• two months before the month in which an SSI recipient's Medicaid coverage automatically begins.

In these cases, after receiving the medical records and Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, the Disability Determination Unit (DDU) makes the final decision (disability or blindness) during the retroactive coverage months. DDU uses Form H3035 for notification about the decision, including the date of onset of the disability or blindness.

Federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset and DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability. As a result, deny an application based on the person not meeting Blind (Not Blind) or Disabled (Not Disabled) criteria when a person applies for Medicaid and the person:

• has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
• has a date of onset for RSDI Title II blindness or disability based on Social Security Administration (SSA) query records; and
• the date of onset for RSDI Title II blindness or disability does not cover any the retroactive coverage months prior to the application.

Note:  Do not use the SSI Title XVI "Dsblty Onset Date" on the SSI Entitlement screen as the basis to establish blindness or disability for a retroactive coverage.

Federal regulations prohibit a state from making a disability decision that conflicts with an SSA decision. DDU cannot make an independent decision until all appeals to SSA regarding the date of disability onset for both RSDI Title II and SSI Title XVI are settled.

Request medical records covering the period for which eligibility is being tested when:

• there is no date of onset for RSDI Title II disability; or
• 90 days have elapsed since the SSI/RSDI file date and SSA has not completed a disability determination.

Submit the following items to DDU, 10205 North Lamar, Austin, TX 78753 or P.O. Box 149030, Austin, TX 78714-9947, Mail Code 2094:

• medical records
• Form H3034
• Form H3035

Occasionally, Form H4116, State of Texas Purchase Voucher, is needed to provide payment to medical providers for medical records submitted. If Form H4116 is required, this form should be submitted to the DDU with the medical records, Form H3034 and Form H3035.

D-2600  Disability Determination Unit (DDU) Decision

DDU will return Form H3035, Medical Information Release/Disability Determination, for notification about the decision, including the date of onset of the disability or blindness.

• Do not make a final eligibility decision until Form H3035 is received.
• Medicaid cannot begin and the medical effective date cannot precede or be earlier than the first day of the month in which the onset of the disability or blindness occurred.
• Before certifying a person under age 65 for Medicaid, Form H3035 must be received from DDU or the eligibility specialist must document contact with staff in DDU concerning the disability decision.

D-2700  Use of Existing Form H3035, Medical Information Release/Disability Determination

Some applicants for Medicaid in an institutional setting are former recipients of Medicaid.

If a person was certified for Medicaid in an institutional setting based on the medical decision for either disability or blindness reflected on Form H3035 in the case record, continue to use Form H3035 to reinstate the Medicaid in an institutional setting, unless Form H3035 indicates a review of the disability or blindness is needed.

In addition, if Form H3035 indicates the applicant is permanently excused from further medical review, staff can continue to use that Form H3035 for ME-A and D-Emergency.

Do not use an existing Form H3035 to process an application in any other situations, except those mentioned above.

D-2800  Disability Determination at Time of Review

At each periodic review, determine whether the decision about disability or blindness is current. Unless Form H3035, Medical Information Release/Disability Determination, indicates that the applicant is permanently excused from further medical review, complete a new Form H3034, Disability Determination Socio-Economic Report, and Form H3035 before the date of review indicated on Form H3035.