Determined Disability

When the disability status of a MC client is established by DDSD, the EW must periodically submit the appropriate DDSD referrals in order to determine if the client continues to be disabled.

Types of Referrals to DDSD

The are three instances when periodic DDSD referrals may be necessary:

Reexamination
Redetermination
Reevaluation.

The type of referral must be clearly identified on the MC 221. Include a copy of the prior MC 221 as well as the attached SP2 DDSD 221R or SP4 DDSD 221R whenever possible to provide a more complete picture of the client’s overall medical condition.

Reexaminations

Most reexaminations occur when a mandatory reexam date set for expected medical improvement is due. The reexam date is shown on the prior SP2 DDSD 221R. In most cases, the client will continue to be considered disabled until his/her medical condition has improved and has been determined no longer disabled. Medical reexams are needed whether a federal decision is involved or not.

DDSD determines a Medical Reexamination Diary (MRD) date when the disability status is approved for a MC recipient. The MRD date is the “Reexam Date” indicated on the DDSD decision. The due dates range from six months to seven years depending on the individual’s likelihood of medical improvement.

Do not send a disability referral if the reexam date is not yet due even if there is a break in aid, unless the client’s medical condition has improved significantly.

If the client’s case shows that Social Security Administration (SSA) determined the client to be disabled and DDSD adopted SSA’s decision, the EW must contact SSA to determine whether the disability continues. If SSA benefits continue, no referral to DDSD is needed when the reexam date is due, as SSA’s determinations are binding until SSA revises its decision. However, SSA will not perform a reexam if client is no longer in pay status and SSA’s record show that the individual was discontinued for non-disability reasons.

If DDSD adopted an SSA approval and SSA finds that the client is no longer disabled, procedures listed under “Federal Disability Decision Involved” must be followed.

MC benefits can not be discontinued until the SSA decision has become final, meaning that the client no longer has an appeal pending at SSA on the cessation issue. In this instance, EWs will need to check (i.e., at each annual redetermination) with the client or with SSA to obtain status of the SSA appeal.

No Federal Decision Involved

A medical reexam is needed when one of the following occurs:

DDSD through DHCS notifies the MC Program Coordinator of cases currently due or past due for medical reexam. Referrals should be submitted to DDSD within 90 days from the notification date.
The EW observes or receives information that the client’s medical condition may have improved.
During a case review, the EW notices that the medical reexam date is past due.

The EW will submit a full disability packet to DDSD for each reexam case.

Federal Decision Involved

A medical reexam is needed when one of the following occurs:

When DDSD initially granted disability status and a reexam is due, if subsequent SSA Title II disability claim is allowed, DDSD will adopt the federal medical reexam date if it is not pending or if it is set at a future date.
- If DDSD receives a referral from the EW on a case where an SSA Title II medical reexam is no longer pending, DDSD will return the MC 221 with the following comment: “Medi-Cal for this individual is based on current federal Title II disability benefits; the federal case takes precedence and SSA’s determination is binding until SSA revises its decision.”
- If DDSD receives a referral from the EW on a case where the federal Title II medical reexam IS pending, DDSD will return the MC 221 with the following comment: “Medi-Cal for this individual is based on current federal Title II disability benefits; the federal case takes precedence and SSA is currently conducting a reexam. The EW should follow up on disability status with SSA in 60-90 days.”
When DDSD initially granted disability status, however, a subsequent federal disability denial determination was made. The client has filed an SSA appeal on the federal denial. The SSA appeal is pending or it is less than 90 days since the most recent SSA denial. DDSD will not
complete a reexam on these cases. Instead, DDSD will close the case as a “No Determination” and reset the medical reexam date to a future date. DDSD will return the MC 221 with the annotation: “An appeal is pending on a federal Title II/SSI denial/cessation; the case remains under SSA jurisdiction. A revised reexam date has been set for (date). At that time, DDSD will determine whether a medical reexam is necessary.”

Under federal and state regulations the following applies: “If an individual receiving MC based upon disability is later determined by SSA not to be disabled, and the client is not eligible for MC on some other basis, this client is entitled to receive continued MC eligibility if he/she timely appeals the SSA disability determination.”

Therefore, EWs will continue to aid a MC client who was approved MC eligibility due to disability and who subsequently receives a disability denial determination from SSA, if the client timely appeals the SSA denial. Once the SSA disability appeal is no longer pending, and the SSA’s final decision is a denial, DDSD will complete their medical reexam at that point.

Exception

A referral to DDSD for a reexamination is NOT required when all of the following conditions exist:

DDSD initially grants disability status, and
Subsequently, a federal disability denial determination was made within 12 or more months prior to DDSD’s reexam date, and
The client has exhausted all federal appeal rights.

ExampleExamplePer case information, DDSD determined Jane Doe disabled as of September 2010 with a reexamination date of January 2018. She applied for SSI on January 2011 and Social Security Administration (SSA) granted her SSI-PD (presumptive disability). SSI-PD is usually given to individuals who meet the SSI-PD criteria during the time SSA is making a formal disability determination. In July 2011, SSA made an unfavorable decision. SSA’s disability decision is binding and overrides DDSD’s initial decision making DDSD’s reexamination date invalid. If she has exhausted all federal appeal rights (the EW can check the INQP screen on MEDS or contact SSA to find out), she is no longer considered disabled and must be denied/discontinued unless there are other linkage/deprivation or she claims a new condition of disability.

HIV Exception

DDSD exempts HIV cases from their reexamination process. If DDSD allows an initial case that has HIV involvement, they will annotate on the SP2 DDSD 221R that the case will be exempt from the reexamination process until further notice. DDSD will set a seven year reexam date; however, EWs must not require a client with HIV to complete the reexamination when it becomes due.

Redeterminations

This type of referral is made for a client who was previously determined federally disabled and DDSD previously adopted the federal decision and meets ALL of the following conditions:

Is discontinued from MC for a reason other than disability, and
Reapplies for MC alleging that disability continues to exist, and
Is not currently in receipt of RSDI or SSI/SSP.

A limited DDSD referral packet is sent if the reexam date is not yet due or past due. Otherwise, a full DDSD referral packet must be submitted in the following circumstances:

Client has been discontinued for more than 12 months,
There is no reexam date or it is unknown (Exception: Craig v. Bonta individuals whose SSI were terminated due to a reason other than disability, a limited packet may be sent to find out the reexam date if the information is unobtainable from SSA, MEDS, and/or IEVS.)
Reexam date is due or past due,
Client’s condition noticeably improved,
SSA’s claim is pending, or
SSA’s denial determination was made more than 12 months in the past.

Note: A copy of the prior MC 221 must be included with either a limited or a full DDSD referral packet. Unless there is linkage other than disability and the reexam date is due or past due, the case must be placed in pending status and not granted MC benefits until DDSD returns the case with a determination.

Upon receipt of a disability packet, DDSD will check with SSA to determine if there has been a subsequent federal RSDI or SSI disability determination within the past 12 months. If there has been a subsequent federal disability denial/cessation determination that is binding on the State, DDSD will adopt the denial/cessation and instruct the EW to refer the client back to SSA.

If the EW receives a no determination decision from DDSD due to the above, the EW must deny the case if there is no other linkage for MC.
ExampleExampleDDSD adopted a federal disability determination in January 2015 with a June 2018 reexam date. Client’s MC was discontinued in April 2017 for reasons other than disability and reapplied for MC in November 2017. The client is not currently in receipt of disability benefits. The EW must pend the application if there is no other linkage and submit a limited disability packet.

Reevaluations

This type of referral is made within 90 days of the decision from DDSD when the EW believes that the DDSD is incorrect. In general, a full DDSD referral packet is needed.

Exception: When a DDSD referral packet is sent within 30 days of DDSD’s decision, or an earlier onset date on an approved case is needed, and no new treating sources are alleged in either situation, limited packets may be sent. DDSD will attempt to make a decision with the available information. However, if additional information is needed, DDSD may return the referral packet.

DDSD Independent Review Claim

Send a DDSD referral packet when a client, or someone acting on the client’s behalf, alleges any of the following:

Client’s condition has worsened,
There is new medical evidence not previously presented, and
A new medical condition was not previously considered.

ExampleExampleOn 10/7/18, DDSD denied a client who alleged disability due to heart disease. On 11/27/18, the client’s husband called to inform the EW that his wife had a serious heart attack and was admitted to the hospital. Submit a full DDSD referral packet, as it is over 30 days since the prior decision.

DDSD Adopted SSA’s Decision

New Condition

If DDSD adopted SSA’s denial and client has a totally NEW physical or mental condition that was not previously considered by SSA and client has decided not to appeal SSA’s decision, refer case to DDSD.
ExampleExampleAn SSI claim was denied because client’s leg problem was not disabling. Client then learned that he/she has cancer, which was not considered in SSA’s decision, and client decided not to appeal the SSI denial. Refer claim to DDSD.

Same Condition

If DDSD adopted SSA’s denial and client alleges a worsening of the same condition which was evaluated by SSA, or has new medical evidence on the same condition which was not previously considered by SSA, either of which occurred within 12 months of SSA’s denial, refer the client back to SSA to appeal.

If it has been over 12 months since SSA’s denial, and client has not returned to SSA to reapply, send disability referral packet to DDSD.