GIS 10 MA/014: Notice of Medicaid Disability Determination Revisions

The purpose of this General Information System (GIS) message is to inform local Departments of Social Services of revisions to the "Notice of Medicaid Disability Determination" (LDSS-4141).

This manual notice was first introduced with 90 ADM-17 as DSS-4141 and subsequently became LDSS-4141. The 92 INF-41 gave LDSS workers further options for completing the form. The form has recently been revised and given an OHIP number (OHIP-0040 and OHIP-0040S, Spanish version). Effective immediately, the revised notice is to be used by all local districts and blank copies of the LDSS-4141 notice destroyed. The OHIP-0040 and OHIP-0040S are available on CentraPort and the DOH intranet library. The intranet library can be accessed at http://health.state.nyenet/revlibrary2.htm.

Similar to the LDSS-4141, the revised "Notice of Medicaid Disability Determination" (OHIP-0040) provides individuals with a written decision of the disability determination made by the State or local Disability Review Team (DRT). The first section of the revised form is identical to the LDSS-4141 and is completed in the same way by the worker. A second section has been added to allow a worker to notify an individual that a disability determination was not performed by the DRT. This is to be used in the event that a DRT discovers, prior to the completion of a disability review, that the individual has already received a disapproval of disability from the Social Security Administration (SSA) and the conditions provided in 08 OHIP/INF 03 are not met.

08 OHIP/INF-03, "Disability Determinations for Medicaid Applicants/Recipients," instructs districts that a disapproval of disability made by SSA is binding on a Medicaid case until SSA changes the determination; however, under certain instances, the State or local DRT must make a disability determination.

The DRT must make a disability determination despite disapproval by SSA for medical reasons if the individual:

• alleges a different or additional disabling condition than that considered by SSA in making its determination; or
• alleges less than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated, alleges a new period of disability which meets the duration requirement, and SSA has refused to reopen or reconsider the allegations, or the individual is now ineligible for SSA benefits for a non-medical reason; or
• alleges more than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated since the SSA determination and alleges a new period of disability which meets the duration requirement, and has not applied to SSA regarding these allegations.

For all cases that have been disapproved by SSA and do not fall within the conditions listed above, the DRT must not complete the disability review and the district must notify the individual by using the second section of the new OHIP-0040 (see attachment).

For example, an individual applies for Medicaid and a referral is made for a disability review because there is no indication that a disability review has been or is in the process of being completed by SSA. At some point in the disability review process, it becomes apparent that the applicant has received a disapproval of disability by SSA and does not meet the conditions in 08 OHIP/INF-03 that allow the DRT to proceed with the disability review.

To summarize, the first section of the new OHIP-0040/0040S is used to notify an individual of the decision of a disability determination performed by the State or local DRT. This section is completed by checking Roman numeral I and completing the remainder of the section as for the previous LDSS-4141.

The second section is to be used when the State or local DRT must not continue with the disability review process as described above. In this instance, the worker checks the box for Roman numeral II, fills in the applicant's name and mails the notice to the individual. A copy of the notice must be kept in the case file.