DDSD Referral Chart

While “reexaminations” are the most common reason for resubmitting a DDSD referral, other types of referrals are sometimes necessary.

EWs must use the chart below to identify the type of referral, the criteria, the forms to include in the DDSD packet, and to determine the client's eligibility status while a DDSD decision is pending.

Important: Include a copy of the previous MC 221 whenever possible, as failure to do so may result in an inadequate assessment of the person's overall medical condition or insufficient medical evidence.

Reexamination Referral Procedures

All medical reexaminations for Medically Needy Only (MNO) recipients must be performed timely. The Department of Health Care Services (DHCS) will assume the responsibility for tracking all reexamination disability referrals until the process has been completed. DHCS will send a listing of clients to corresponding counties requesting a full disability packet be sent to DDSD for these clients.” 

The following chart indicates who is responsible and describes the corresponding referral process.

 

Responsibility   Process Description
DDSD    

DDSD will:

  • Continue to generate monthly listings of MNO disability cases that are due or past due for a medical reexamination.
  • Forward the listings to DHCS to purge them and then distribute to affected counties. If the disability packet has not been received in DDSD within 90 days of the original listing date, DDSD will generate a 90-day past due listing and forward it to DHCS for appropriate action.
DHCS    

After receipt of the original case listing, DHCS will:

  • Purge the listing and forward it to the corresponding Medi-Cal Program Coordinator in each county for processing.
  • Forward a copy of the purge listing to DDSD Operations Analysts in both branches.
  • Send a letter (after DHCS receives the 90-day past due listing from DDSD) and enclose the past due listing to the corresponding MC Program Coordinator, informing them that the disability packet has not been received by DDSD.
  • Request counties through the letter to forward a full disability packet to DDSD within 45 days from the date of the letter or advise DHCS why a disability packet was not sent. The reason(s) for the delay should be annotated on the past due listing by the corresponding MC Program Coordinator and forwarded back to DHCS.
  • Follow up with counties as appropriate.
MC Program Coordinator  Upon receipt of the initial reexamination listing from DHCS, the MC Program Coordinator will forward the listing to DDSD Liaisons of the affected offices for distribution to EW Supervisors.
EW Supervisor  Instructs the assigned EW to submit a full disability packet to DDSD.
Eligibility Worker (EW) 
  • The EW must:
  • Submit a full disability packet on each identified case to DDSD within 45 days, and
  • Check the “Reexamination” box in Item 8 of the MC 221 or
  • Notify the EW Supervisor by documenting on the listing:
    • Why the disability packet was not sent (i.e., case discontinued because client refused to cooperate), or
    • The date the disability packet was sent to DDSD and the action taken.

Note: EWs must not discontinue any case if a reexamination is due/past due. A full disability packet must be submitted.
EW Supervisor 
  • The EW Supervisor must:
  • Review the full disability packet for completeness and forward it to the DDSD Liaison, or
  • Follow up and notify the DDSD Liaison of any other action taken by the assigned EW.
DDSD Liaison Must monitor the time frames and review the completeness of the referral packet before submitting it to DDSD, and return the listing to the Program Coordinator with actions taken indicated.

Reexamination Procedures

The reexaminations procedures are as follows:

Referral Sent When... What to Include Eligibility Status Pending Reexamination

An evaluation of disability is needed to see if medical improvement has occurred when:

  • DDSD has established a reexam date, or
  • Client becomes employed, or
  • Other circumstances lead EW to believe condition has improved, or
  • The monthly Reexamination List indicates a reexam is required.  
  • A copy of prior MC 221 (note on new MC 221 if not available), SP 2, and
  • A new MC 221 marked “Reexamination” in item 8 and state reason for reexam in item 10,
  • A new MC 223/223C (not a photocopy of old MC 223/223C),
  • MC 220 for every medical source, and
  • Any new medical records, if available. 

Eligibility continues unless:

  • The client fails to cooperate with DDSD, or
  • Whereabouts unknown, loss of contact, or
  • DDSD decides client is no longer disabled and there is no other linkage, or
  • Another reason for discontinuance exists (i.e., excess property).

Redetermination Referral Procedures

The redetermination procedures are as follows:            

Referral Sent When... What to Include Eligibility Status Pending Redetermination

Client meets all of the following criteria:

  • Previously determined federally disabled and DDSD adopted the federal decision, and
  • Was discontinued for a reason other than disability (break in aid), and
  • Reapplies for MC alleging that disability continues to exist, and
  • Is not currently in receipt of SSA/SSI disability benefit.
  • Complete a limited packet, or
  • Complete a full packet. 

Eligibility cannot be established:

  • Until DDSD decision is received, or
  • Until client has established linkage under another category.

Reevaluation Referral Procedures

The reevaluation procedures are as follows:

Referral Sent When... What to Include Eligibility Status Pending Reevaluation

EW believes that the DDSD denial is incorrect and it is within 90 days of DDSD's decision. Examples include:

  • DDSD independently reviewed claim and EW believes DDSD was unaware of medical evidence, conditions or recent events which could affect the decision, or
  • DDSD adopted an SSA denial and client has a totally new medical condition that was not considered by SSA and the client is not appealing SSA's decision.  
  • Copy of prior MC 221 (note on new MC 221 if not available), SP2 and
  • A new MC 221 marked “Reevaluation” in Item 8 and state reason for reevaluation in Item 10,
  • A new MC 223/223C (not photocopy of old MC 223/223C) only if additional impairments, condition, or treatment sources are being reported,
  • MC 220s for each medical source, and
  • Any new medical reports, if available. 
 Eligibility cannot be established until DDSD completes the reevaluation.

Related Topics

MAGI MC and DDSD

 

RSDI and Disability

Determined Disability

Failure to Cooperate

Reexaminations on Appealed DDSD Denials