Blindness and Disability 510-05-35-100

(Revised 4/1/06 ML #3021)

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(N.D.A.C. Section 75-02-02.1-14)

 

  1. The definition of blindness in the Social Security Act, Section 1614, for Title II benefits as set forth below, is the definition used in the SSI Program under Title XVI and will be utilized in determining eligibility for applicants for Medicaid who are basing their eligibility on blindness.

An individual shall be considered to be blind for purpose of this title, if he has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens.  An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered as having central vision acuity of 20/200 or less.

  1. The definition of disability in the Social Security Act, Section 1614, for Title II benefits as set forth below, is the definition used in the SSI Program under Title XVI and will be utilized in determining eligibility for applicants for Medicaid who are basing their eligibility on a disability.

An individual shall be considered to be disabled for purposes of this title if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months (or, in the case of a child under the age of 18, if he suffers from any medically determinable physical or mental impairment of comparable severity).

  1. SSA and SSI final determinations of blindness and disability are binding (42 CFR 435.541) and serve as evidence of the presence or absence of statutory blindness or of disability.  An exception to this provision is if the individual has applied for Workers with Disabilities coverage and Social Security's decision established that the individual is not disabled due to substantial gainful activity. In these situations, the State Review Team may make an independent decision.

Presumptive determinations of blindness and disability are not final determinations for Medicaid purposes.  Eligibility for Medicaid cannot be determined until a final determination is made.  If a final determination will not be made by the Social Security Administration within 90 days after the date of application for Medicaid, the State Review Team will make a determination.

 

In Title II benefit approvals, the evidence from the Social Security Administration contains the onset of disability for benefits.  The onset of disability month for Title II benefits would be the earliest medical approval month provided all other eligibility factors are met.

 

In SSI approvals, disability determinations are not made prior to the month of SSI application.  If the medical approval date is prior to the eligibility month for SSI, medical and social information must be submitted to the State Review Team for a disability determination for the period prior to the SSI approval month.

  1. The county agency will need to obtain and submit medical and social information to the State Review Team for their evaluation if:
  1. The applicant is requesting assistance for a month prior to the SSI application;
  2. The applicant is not eligible for SSI because of the SSI income and resource levels;
  3. The applicant refuses to apply for SSI;
  4. The applicant is not eligible for SSA disability due to not being insured;
  5. The applicant is applying for Workers with Disabilities coverage and is not eligible for SSA disability due to substantial gainful activity;
  6. The applicant has applied for SSA disability and a determination is not made within 45 days of the Medicaid application; or
  7. The applicant is within six months of reaching full retirement age
  8. The medical and social information is generally submitted along with SFN 451, "Eligibility Report on Disability/Incapacity" (05-100-40), and if the individual is applying for Workers with Disabilities coverage, SFN 228, "Workers with Disability Report Part II" (05-100-41).  
  9.  
  10. An individual refusing to apply for SSI should be informed of potential eligibility for SSI and that receipt of SSI may yield a larger amount of total income for the family.
  11.  
  12. The State Review Team shall decline to determine blindness or disability for a period of time that such a determination is made for SSI (Title XVI) or Title II disability benefits by the Social Security Administration, except that the State Review Team shall make a decision in those situations in which the individual has applied for Workers with Disabilities coverage and Social Security's decision established that the individual is not disabled due to substantial gainful activity.
  13.  
  14. The State Review Team will use the following in determining blindness or disability:
  1. DETERMINATION OF BLINDNESS:  In any instance in which a determination is to be made whether an individual is blind, the individual shall be  examined by a physician skilled in the diseases of the eye, or by an optometrist, whichever the individual may select.  The State Review Team shall review and compare that report with the state's definition of blindness and determine:

(1) Whether the individual meets the definition of blindness; and

(2) Whether and when reexaminations are necessary for periodic redeterminations of eligibility.

Redeterminations of blindness are established at the recommendation of the State Review Team, or at such time that activity or behavior on the part of a blind recipient raises doubts about his visual status.  The same procedure is utilized in redetermination of blindness as in the original determination.

  1. DETERMINATION OF DISABILITY: In any instance in which a determination is to be made as to whether any individual is disabled, each medical report form and social history will be reviewed by a review team consisting of technically competent persons, not less than a physician and an individual qualified by professional training and pertinent experience, acting cooperatively, who shall determine if the applicant meets the appropriate definitions of disability.
  1. When a Medicaid application, based on disability, is pending for 45 days, the SFN 451 or the SFN 228 must be sent to the State Review Team. The State Review Team will request the medical information from the applicant. A copy of the request will be sent to the county agency . A decision regarding disability will then be made within the 90 day time period if DDS has not made a decision. However, once the Social Security Disability Determination Services Unit (DDS) eventually makes a disability determination, Medicaid must follow that decision.
  2. Any medical bills incurred by an applicant upon request of the State Review Team to  obtain medical information to determine eligibility will be paid through Medicaid. If the applicant is determined to be ineligible for Medicaid, the medical bills, which are sent to the State Review Team, will be paid through administrative costs.  
  3. If an applicant or recipient of SSA/SSI disability is determined by the Social Security Administration to not be disabled or no longer continues to meet the disability criteria, the county agency must then deny or send a ten-day advance notice to close the Medicaid case.

Occasionally, individuals attending school or receiving vocational rehabilitation services will continue to receive a Social Security benefit though they no longer meet the disability criteria.  These individuals are not considered disabled and therefore are not eligible for Medicaid.