DDSD Referral Limited by SSA Decision

The Social Security Administration (SSA) controls disability determinations. DDSD is not allowed to make an independent disability determination if the applicant claims the same disabling condition previously considered by Social Security within the past 12 months. Social Security's determination is binding unless revised by them.

It is important to know if a client has been denied Social Security disability or SSI within the past 12 months. Clients must first be screened to determine if a DDSD referral should be completed. Then, determine if a client requesting a DDSD disability determination has also filed for RSDI and/or SSI disability benefits within the last two years. If it is found that the client has filed for Social Security disability benefits within the past two years, EWs must determine if the applicant should still be referred to DDSD.

The client’s answers to Questions 5 a-d on the MC 223 (Part 3 questions A-D on the MC 223C for applicants under the age of 18) determine whether the disability based Medi-Cal application should be referred to DDSD or denied. The “Screening Form/SP-DDSD Applicants” (SCD 96), duplicating these questions may also be used. The form is completed by individuals applying for MC based upon disability. Prior to issuing the MC 223/223C, EWs must review this form to determine if a DDSD packet is necessary.

Conditions

A DDSD referral will not be made by EWs under the following conditions:

Social Security has denied a claim based on disability within 12 months of the client's Medi-Cal application, and
The applicant states on the MC 223/223C that the same disabling condition(s) denied by Social Security has not worsened or changed, and that no new condition(s) exist, or
The applicant states on the MC 223/223C that the same disabling condition denied by Social Security has worsened or changed. (Only if additional or new changes are declared, will a DDSD referral be made.)

ExampleExampleClient’s claim for the current condition was denied by SSA eight months ago. His condition has worsened and now meets the presumptive disability criteria. Do not send a referral to DDSD as this condition was denied by SSA within the last 12 months.

An applicant who is not sure if a Social Security denial was received within the past 12 months will have a DDSD referral completed by the EW. DDSD will inform the EW through the MC 221 of their decision.

Completion of MC 223 or MC 223C

Once a client begins to fill out the MC 223/223C, the following actions are required:

EWs may stop after question 5d of the MC 223 (Part 3, question D on the MC 223C) if the client's answers indicate a DDSD referral need not be completed. EWs must note in the right hand margin of the MC 223/223C: “Client informed and understands that due to a Social Security disability/SSI denial within the last 12 months, a DDSD packet cannot be sent.”
The client must sign and date page 7 of the MC 223 (page 9 of the MC 223C for applicants under the age of 18), as evidence that the client received this verbal information.

Informing Notice/NOAs

An applicant whose Medi-Cal application based upon disability is denied due to a prior Social Security decision must be referred back to SSA. When a DDSD referral is denied, the EW must give the client special notice “Important Information Regarding your Appeal Rights” (MC Information Notice 13) and document this was done. A Notice of Action “Denial Due to a Federal Social Security Disability Determination” (MC 239 SD) must also be issued to the client, advising of the denial for Medi-Cal benefits based upon disability.

Referring Clients to Social Security

When a DDSD referral is denied and the client is referred back to Social Security, every effort should be made to confirm that there has been a Social Security disability denial determination within the past 12 months. The client should take the MC Information Notice 13 to Social Security when appealing a disability denial. This will help minimize confusion and aid in the client's appeal with Social Security.

The applicant’s IEVS report includes information about Social Security/SSI denial, if or when the client filed a Social Security/SSI appeal, and the status of the appeal.

Clients who appeal Social Security Administration's denial of disability have three options:

File for a reconsideration. For a denied claim to be reconsidered by Social Security, clients must file the reconsideration within 60 days from the date the notice denying disability was received. Good cause may be considered by Social Security for clients who file after 60 days.
File for a reopening. Social Security may reopen an SSI determination made within one year for any reason and within two years for good cause. Social Security is not obligated to reopen, and has the discretion to determine if there is cause to reopen a claim.
File a new application for disability with Social Security.

Note: Clients who have additional questions regarding their appeal rights should be referred to the Social Security Administration.

SSA Approves Disability After Originally Denying Claim

If the EW denies Medi-Cal based on a Social Security Administration (SSA) denial within the last 12 months and SSA subsequently approves the disability claim, the EW must rescind the denial and approve Medi-Cal, if the client is otherwise eligible.

A new application or DDSD referral is not needed if the SSA disability onset date coincides with our beginning date of aid.

If retroactive Medi-Cal is needed, send a full DDSD packet to the DDSD office including the SSA award letter. Indicate on Item #5 of the MC 221 the initial Medi-Cal application date and specify “client was originally denied and referred to SSA for reopening.”

Reminder: A request for retroactive Medi-Cal must be made within one year of the month for which retro is requested.

Discontinuance of SSA Disability Benefits - “Cessation of Disability”

When a MC client is discontinued from Social Security Disability Benefits due to “cessation of disability”, linkage to the MC program as a disabled person continues until the SSA disability decision becomes final.

The SSA disability decision becomes final only when the client does not or cannot appeal the decision any further.

Social Security Appeal Process

Social Security has 3 levels of appeal:

Reconsideration,
Administrative Law Judge (ALJ) Hearing, and
Appeals Council Review.

SSA allows the client 65 days to file an initial appeal request or an appeal request at the next level. The 65 day period starts from the:

Date of the SSA termination notice, or
Date of the latest appeal decision.

The client may choose to pursue all three levels of appeal or may not file an appeal at all. Therefore, the SSA decision will take anywhere from 65 days to 3 years or longer to become final.

EW Action

When a MC client reports the termination of SSA disability benefits, the EW must determine if the termination is due to “cessation of disability” and when the SSA decision becomes final by:

Asking the client if an appeal has been or will be filed.
Verifying the SSA appeal status via “Referral To/From Social Security” (SCD 169) or another form of verification submitted by the client.

Once it is verified that an SSA appeal is pending, the EW must set up a case flag in CalSAWS for SSA appeal status follow-up at each annual redetermination until a final decision is rendered. Only after the SSA decision has become final must the EW take action to redetermine ongoing MC eligibility under another linkage factor (i.e., AFDC-MN), or discontinue MC with a 10 day NOA if no other linkage exists.

To set up a case flag in CalSAWS [Refer to Chewable Byte 2023-03: How to add a case flag]

Discontinuance of SSI/SSP Disability Benefits - “Non-Disability Reasons”

When the client’s SSA benefits have been suspended or terminated for non-disability related reasons (such as excess income or property), the client’s case must be processed as an initial referral.

Submitting the claim as an initial referral, rather than a reexamination, requires a full disability packet. Also, any current work activity must be evaluated by the EW to determine if Substantial Gainful Activity (SGA) exists. Cases in which the applicant is working and the EW has not made an SGA determination will be returned without a disability determination.

Exception: SGA determinations are not applicable to clients applying for the 250% Working Disabled Program.