DDSD - Presumptive Disability (PD)

Presumptive Disability (PD) decisions allow applicants/recipients with specific MC conditions to be temporarily granted MC pending a formal determination by DDSD or Social Security.

PD categories and verification requirements are established according to federal regulations.
Social Security Administration (SSA) can grant SSI Title XVI (but not SSA benefit Title II) to an individual based on PD. When an applicant provides verification that SSA allowed SSI-PD, county staff may activate the individual on MEDS and/or issue MC card per client’s request.
If retroactive onset date is requested after DDSD has adopted an SSI-PD decision, a limited packet should be sent to DDSD if the final federal decision is favorable (i.e., determined disabled). Item 10 of the MC 221 must be annotated that “a retro onset date is needed and that SSI has been allowed since PD decision.” There is a possibility that the individual’s determined disability onset date is earlier than the month that the SSI-PD was granted.
DDSD may grant PD on a case that meets their medical severity criteria and may grant PD outside the PD categories. Only DDSD or Social Security can authorize PD for medical conditions not listed on the PD condition list.
The EW must make a complete DDSD referral within ten days of receipt of the completed MC 223/223C.

PD Criteria

The EW may approve Medi-Cal based on presumptive disability when all of the following criteria is met:

The client has a Presumptive Disability condition.
The condition is verified by a doctor/medical source.
There has not been a Social Security (Title II or SSI) disability denial in the past 12 months (unless a new medical condition is alleged which was not previously considered by the Social Security Administration).
The client is not performing Substantial Gainful Activity (SGA).
The client is otherwise eligible for MC.

Effective Date

Presumptive Disability (PD) is:

Granted prospectively only.
The EW must never grant PD for any past month. Retroactive MC can be approved later once the disability onset date is known.
Approved as of the month that the MC 221 is completed and the medical verification is obtained.
PD MC is granted effective the month in which the determination is made that the disabling condition meets the PD requirements. Do not grant PD from the month of application, unless the required MC verification and the MC 221 are completed in the month of application.
Granted only after the client has been determined otherwise eligible for MC (i.e., property eligible, etc.).

3 Month Retro

Presumptive disability does NOT apply to 3-month retroactive Medi-Cal. The purpose of presumptive disability is to enable patients to receive immediate medical care, not to expedite payments to providers for prior month medical treatments. Once an DDSD approval is received, 3-month retro can be granted if otherwise eligible for MC. Under no circumstance is the EW to grant PD for past months.

Federal Denial

If a DDSD applicant has had an RSDI or SSI disability denial within the past 12 months, the federal denial is binding on MC for 12 months from the date of the most recent federal decision or until the decision is changed by Social Security (i.e., decision is changed through the Social Security appeal process). In such cases, the EW must not grant presumptive disability unless the client alleges a new condition which was not previously considered by the Social Security Administration (SSA).

Presumptive Disability (PD) Categories

In order to be determined presumptively disabled, the applicant/recipient must provide the county with a medical statement from his/her physician verifying one of the following conditions:

Reserved for future use.
Amputation of leg at the hip.
1. Note: Individuals with a leg amputated at the hip are unable to wear a prosthesis and thus must use two crutches or a wheelchair.
Allegation of total deafness.
Allegation of total blindness.
Allegation of bed confinement or immobility without a wheelchair, walker, or crutches, due to a long-standing condition excluding recent accident and recent surgery.
1. The length of time that the bed confinement or immobility will last must be evaluated. Individuals who are convalescing and expected to improve are not presumptively eligible.
2. Note: Paraplegia (permanent paralysis of both legs) and quadriplegia (permanent paralysis of both arms and both legs) were previously a separate category of presumptive disability. Individuals with these disabilities are to be considered presumptively disabled under this category if the physician's statement verifies either of these conditions.
Allegation of stroke (cerebral vascular accident) occurring more than three months in the past and continued marked difficulty in walking or using a hand or arm.
1. A three-month delay in evaluating the applicant's condition is required by federal law, as improvement in the individual's condition may occur during this period. DDSD cannot process the disability case until that three-month delay is completed. The three-month period begins the date of the stroke, not the application date.
2. Forward the disability packet to DDSD as usual. Do not hold the packet for the three-month period. DDSD must delay case processing until three months after the stroke. While presumptive disability is also delayed until the expiration of the three-month period, once that period has expired, the EW must grant presumptive disability back to the date of application, provided that the applicant is still having marked difficulty in walking or using a hand or arm.
Allegation of cerebral palsy, muscular dystrophy or muscle atrophy and marked difficulty in walking (e.g., use of braces), speaking or coordination of hands or arms.
Reserved for future use.
Allegation of Down Syndrome.
1. Note: Down Syndrome may be characterized by some indication of mental retardation and by abnormal development of the skull (lateral upward slope of the eyes, small ears, protruded tongue, short nose with a flat bridge, small and frequently abnormally aligned teeth); short arms and legs; and hands and feet that tend to be broad and flat.
Allegation of severe mental deficiency (i.e., mental retardation) made by another individual filing on behalf of a client who is at least 7 years of age.
1. The applicant alleges that the client:
  1. Attends (or attended) a special school, or special classes in school, because of his or her mental deficiency, or is unable to attend any type of school (or if beyond school age, was unable to attend), and
  2. Requires care and supervision of routine daily activities (i.e., the client is dependent upon others for personal needs which is grossly in excess of what would be age-appropriate).
    1. Note: “Mental deficiency” means mental retardation. This PD category pertains to individuals whose dependence upon others for meeting personal care needs (e.g., hygiene) and in doing other routine daily activities (e.g., fastening a seat belt) grossly exceeds age-appropriate dependence as a result of mental retardation.
A child has not attained his or her first birthday and the birth certificate or other evidence (i.e., hospital admission summary) shows a weight below 1200 grams (2 lbs. 10 oz.) at birth.
1. A disabled or presumptively disabled premature newborn who is born in a facility and remains an inpatient for the remainder of the month is in his/her own MFBU beginning with the month of birth rather than in the following month.
Human Immunodeficiency Virus (HIV) infection. EWs may approved PD for a client with HIV whose medical source confirms, on an HIV form (DHS 7035A or DHS 7035C), that the client has specific disease manifestations.
1. PD is allowed when specific secondary conditions are present.
A child has not attained his or her first birthday and available evidence (i.e., hospital admission summary) shows a gestational age at birth with the corresponding birth weight indicated below:
1. A disabled or presumptively disabled premature newborn who is born in a facility and remains an inpatient for the remainder of the month is in his/her own MFBU beginning with the month of birth rather than in the following month.
2. Note: Gestational Age (GA) is the number of weeks from conception to birth. The age at birth based on the date of conception may be shown as “GA” and noted in the available evidence, the EW forwards the referral to DDSD for consideration of PD.

Gestational Age (in weeks)	Weight at Birth
37-40’	Less than 2000 grams (4 lbs., 6 oz.)
36’	1875 grams or less (4 lbs., 2 oz.)
35’	1700 grams or less (3 lbs., 12 oz.)
34’	1500 grams or less (3 lbs., 5 oz.)
33’	1325 grams or less (2 lbs., 15 oz.)

A physician or knowledgeable hospice official confirms an individual is terminally ill. An individual is considered terminally ill if he or she has a medical prognosis that his or her life expectancy is six months or less. However, if an individual has a medical prognosis of life expectancy of more than six months, an “Urgent Case Request” must be sent to DDSD. DDSD may approve PD on its own.
1. PD is granted to all terminally ill individuals whether they are receiving hospice services or not.
Allegation of inability to ambulate without the use of a walker or bilateral hand held assistive device for more than two weeks following a spinal cord injury with confirmation of such status from an appropriate medical professional.
End stage renal disease with ongoing dialysis and the file contains a completed “End Stage Renal Disease Medical Evidence Report-Medicare Entitlement and/or Patient Registration” Form (HCFA-2728) from the applicant’s medical provider. This form is necessary before PD can be approved.
Allegation of Amytrophic Lateral Sclerosis (ALS, Lou Gehrig’s Disease).

Note: Any condition which does not exactly match a category listed below is not to be granted presumptive disability without prior authorization from DDSD.

HIV/AIDS Policy

Presumptive disability based on Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) can only be established when the diagnosis is confirmed through laboratory tests or clinical findings and specific secondary conditions are present.

EWs must ensure that specific medical conditions are verified on the “Medical Report - Allegation of HIV Infection” (DHS 7035A or DHS 7035C) before approving Medi-Cal based on presumptive disability.

When an applicant alleges HIV/AIDS but does not meet the specific criteria needed to establish presumptive disability, the EW must:

Follow regular DDSD referral procedures, and
Note in the County Comments Section of the MC 221, “Expedite, need for immediate medical care due to HIV/AIDS”.

Presumptive HIV/AIDS Procedures

EWs must follow these procedures to establish PD when a Medi-Cal applicant/recipient alleges HIV/AIDS:

Step	Action
1.	Complete the MC 220. Complete the “Appointment of Representative” (MC 306) if a representative is used. Note: A recipient's representative may not sign the MC 220 unless the applicant is comatose, incompetent, amnesic or deceased.
2.	Complete the DHS 7035A or DHS 7035C as follows: Check the “Medical Release Information” space at the top of the form. Enter the doctor's name in the “Medical Source's Name” space. Enter the applicant's name, SSN, and date of birth.
3.	Give the applicant (or mail to the physician) the following: DHS 7035A or DHS 7035C as appropriate. MC 220. Return envelope
4.	Immediately forward the disability packet to DDSD, noting “Presumptive Disability based on HIV is pending” in the County Comments Section of the MC 221.
5.	Once the DHS 7035A or DHS 7035C is returned: Determine if presumptive disability criteria are met, by using the decision charts which follow this section. Forward the original DHS 7035 (A or C) with any other medical evidence to DDSD. Attach a completed MC 222 LA. Note: First call DDSD Master Files to determine which analyst has been assigned to the case. IMPORTANT: Send the DHS 7035 (A or C) even if presumptive disability cannot be approved. Scan a copy of the DHS 7035A or DHS 7035C into Imaging.

HIV/AIDS, Adults (Presumptive Criteria Met)

EWs must review the completed DHS 7035A to determine if presumptive disability can be established. Approve presumptive disability only if any of the following combinations of sections and boxes have been completed as indicated below:

SECTION	COMPLETED OR CHECKED
B C	Either box is checked, and One or more boxes are checked
	OR
B D	Either box is checked, and Both Items 1 and 2 are completed as follows: Item 1 must indicate the presence of “repeated manifestations of HIV infection” as listed below; and, One or more boxes in Item 2 are checked.

Important: In all cases, presumptive disability cannot be established unless the medical source's name, address and signature are completed at the bottom of the DHS 7035A, Sections F and G.

Individuals who may sign the DHS 7035A include a physician, nurse, or other member of the hospital or clinic staff who is able to confirm the diagnosis of HIV. If the signature is questionable, the EW must call the provider for verification/ clarification before granting presumptive disability.

IF: HIV manifestations listed in Section D includes diseases mentioned in Section C; Items 1-41 of the DHS 7035A, but without the specified findings discussed there (e.g., carcinoma of the cervix not meeting the criteria shown in Item 22 of the form, diarrhea not meeting the criteria shown in Item 33 of the form); or any other manifestations of HIV not listed in Section C (e.g., oral leukoplakia, myositis)*:

AND the number of episodes of HIV Manifestations in the same 1-year period is:	AND the duration of each episode is:	THEN:
At least 3	At least 2 weeks	Requirement is met
Substantially more than 3	Less than 2 weeks	Requirement is met
Less than 3	Substantially more than 2 weeks	Requirement is met
Unable to determine	Unable to determine	Refer to DDSD

* REMINDER: If there is any question as to whether the manifestation listed is a manifestation of HIV, refer to DDSD. Do not approve “PD”.

Important: The same manifestations need not be represented in each episode.

HIV/AIDS, Children, Birth Through Age 17 (Presumptive Criteria Met)

Establish presumptive disability only if any of the following combinations of sections and boxes on the DHS 7035C have been completed as indicated below:

SECTION	COMPLETED OR CHECKED
B	Either box is checked, and
C	One or more boxes are checked Important: Item 6 only applies to a child under age 13.
OR
B	Either box is checked, and
D	Item 1 is completed, and Birth to age 1: One or more of the boxes in Item 2a are checked, OR Age 1 through age 2: One or more of the boxes in Item 2b are checked, OR Age 3 through age 17: At least two of the boxes in Item 2c are checked.

Important: In all cases, presumptive disability cannot be established unless the medical source's name, address and original signature are completed at the bottom of the DHS 7035C, Sections F and G.

Individuals who may sign the DHS 7035C include a physician, nurse, or other member of the hospital or clinic staff who is able to confirm the diagnosis of HIV. If the signature is questionable, the EW must call the provider for verification/ clarification before granting presumptive disability.

EW Grants PD

Prior to the EW granting PD, the EW must ensure that:

The applicant’s medical condition matches the PD category list exactly.
The PD reminder check list is reviewed before sending a disability referral to DDSD.
The “PD approved” box in Item 10 of the “Disability Determination and Transmittal” (MC 221) is checked. This box must not be checked when EWs are requesting DDSD to consider PD on a case or if sending an urgent case request.
All information used to grant PD (i.e., medical documentation, laboratory results, etc.) is included in the disability packet before sending it to DDSD.
Disability packets are not faxed to DDSD when the EW has already granted PD.

EW Requests PD Consideration from DDSD (For Urgent Case Requests)

When an applicant does not meet any of the PD categories but meets the criteria for an urgent case requests, the following guidelines apply:

The District Office DDSD Liaisons must send the disability packet to the MC Program Coordinator. Since urgent case requests are time-sensitive, the Coordinator must be notified via email or phone immediately.
Item 10 “PD approved” box of the MC 221 must NOT be checked.

Urgent Case Request

In limited situations, an EW may make an urgent case request to DDSD when they encounter a client who:

Is in dire need of an immediate disability decision because of a disabling condition which prevents work activity for 12 months or longer, and
Cannot wait for a formal decision because the delay will cause significant problems to his/her functioning and well-being.

The doctor/medical facility must be willing to support the client's statement of urgent need by supplying the county with medical records which verify the severity of the client’s condition.

Prior to submitting an Urgent Case Request, the EW must screen the case for presumptive disability criteria and ensure that the client is otherwise eligible (i.e., does not exceed property limit, is not performing SGA).

Note: A PD/Urgent Case request should not be initiated for an individual who is currently getting medical treatment unless immediate aggressive therapy is needed or a required special medical procedure cannot be done without a MC coverage.

DDSD Criteria to Grant PD for Urgent Case Requests

DDSD may grant presumptive disability once certain criteria are evaluated and available evidence shows a strong likelihood that:

Disability will be established when complete evidence is obtained, and
Evidence establishes a reasonable basis for presuming the individual is currently disabled, and
The disabling condition has lasted or is likely to last at least 12 months.