Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 1 - DETERMINATION OF QUALIFYING CATEGORICAL RELATIONSHIP › Section 317:35-5-4 - Determining categorical relationship to the disabled

Current through Vol. 41, No. 20, July 1, 2024
An individual is related to disability if he/she 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 twelve (12) months.
(1)
Determination of categorical
				  relationship to the disabled by Social Security Administration (SSA).
The procedures outlined in (A) through (G) of this paragraph are applicable
				  when determining categorical relationship based on a SSA disability decision:
(A)
Already determined eligible for
				  Social Security disability benefits.
If the applicant states he/she is
				  already receiving Social Security benefits on the basis of disability, the
				  information is verified by seeing the applicant's notice of award or the Social
				  Security benefit check. If the applicant states an award letter approving
				  Social Security disability benefits has been received but a check has not been
				  received, this information is verified by seeing the award letter. Such award
				  letter or check establishes categorical relationship. The details of the
				  verification used are recorded in the case record.
(B)
Already determined eligible for
				  Supplemental Security Income (SSI) on disability.
If the applicant,
				  under age sixty-five (65), states he/she is already receiving SSI on the basis
				  of his/her disability (or that a written notice of SSI eligibility on
				  disability has been received but has not yet received a check) this information
				  is verified by seeing the written notice or check. If neither are available,
				  the county clears on the terminal system for the Supplemental Data Exchange
				  (SDX) record. The SDX record shows, on the terminal, whether the individual has
				  been approved or denied for SSI. If the individual has been approved for such
				  benefits, the county uses this terminal clearance to establish disability for
				  categorical relationship. The details of the verification used are recorded in
				  the case record.
(C)
Pending
				  SSI/SSA application or has never applied for SSI.
If the applicant says
				  he/she has a pending SSI/SSA application, an SDX record may not appear on the
				  terminal. Therefore, it is requested that the applicant bring the notice
				  regarding the action taken on his/her SSI/SSA application to the county office
				  as soon as it is received. The other conditions of eligibility are established
				  while awaiting the SSI/SSA decision. When the SSI/SSA notice is presented, the
				  details of the verification are recorded in the case record and the indicated
				  action is taken on the Title XIX application. If the applicant says he/she has
				  never applied for SSI/SSA but appears potentially eligible from the standpoint
				  of unearned income and has an alleged disability which would normally be
				  expected to last for a period of twelve (12) months, he/she is referred to the
				  SSA office to make SSI/SSA application immediately following the filing of the
				  Title XIX application.
(D)
Already determined ineligible for SSI.
If the applicant says
				  he/she has been determined ineligible for SSI, the written notice of
				  ineligibility from SSA is requested to determine if the denial was based on
				  failure to meet the disability definition. If the SSI notice shows
				  ineligibility was due to not meeting the disability definition, and the
				  applicant says the medical condition has not worsened since the SSI denial, the
				  Title XIX application is denied for the same reason. If written notice is not
				  available, the SDX record on the terminal system is used. This record shows
				  whether the individual has been determined eligible or ineligible for SSI. If
				  he/she has been determined ineligible, the payment status code for
				  ineligibility is shown. The definition of this code is found on OKDHS Appendix
				  Q in order to determine the reason for SSI ineligibility. If the reason for SSI
				  ineligibility was based on failure to meet the disability definition, the Title
				  XIX application is denied for the same reason and the details of the
				  verification are recorded in the case record. If the reason for SSI
				  ineligibility was based on some reason other than failure to meet the
				  disability definition (and therefore, a determination of disability was not
				  made), the Level of Care Evaluation Unit (LOCEU) must determine categorical
				  relationship. In any instance in which an applicant who was denied SSI on
				  "disability" states the medical condition has worsened since the SSI denial,
				  he/she is referred to the SSA office to reapply for SSI immediately following
				  the filing of the Title XIX application.
(E)
Already determined ineligible for
				  Social Security disability benefits.
If the applicant says he/she has
				  been determined ineligible for Social Security disability benefits, he/she is
				  requested to provide written notice of ineligibility to determine if the denial
				  was based on failure to meet the disability definition. If the SSA notice shows
				  ineligibility was due to not meeting the disability definition, and the
				  applicant says the medical condition has not worsened since the denial, the
				  Title XIX application is denied for the same reason. The details of the
				  verification used are recorded in the case record. If the written notice is not
				  available, third party query procedure (TPQY) is used to verify the denial and
				  the reason for ineligibility. If the reason for ineligibility was based on
				  failure to meet the disability definition, the Title XIX application is denied
				  for the same reason and the details of the verification are recorded in the
				  case record. If the reason for ineligibility was based on some reason other
				  than failure to meet the disability definition (and a determination of
				  disability was, thus, not made), the LOCEU must determine categorical
				  relationship. In any instance in which an applicant who was denied Social
				  Security benefits on disability states the medical condition has worsened since
				  the denial, he/she is referred to the SSA office to reapply immediately
				  following the filing of the Title XIX application.
(F)
Determined retroactively eligible
				  for SSA/SSI due to appeal.
If an individual becomes retroactively
				  eligible for SSA/SSI due to a decision on an appeal, categorical relationship
				  is established as of the effective date of the retroactive disability decision.
				  Payment will be made for medical services only if the claim is received timely,
				  per Oklahoma Administrative Code (OAC)
				  317:30-3-11.
				  After the submission of a timely claim, a claim may be resubmitted, per OAC
				  317:30-3-11.1.
				  If the effective date of the retroactive disability decision does not cover the
				  period of the medical service because the SSA/SSI application was made
				  subsequent to the service, a medical social summary with pertinent medical
				  information is sent to the LOCEU for a categorical relationship decision for
				  the time period of the medical service.
(G)
SSA/SSI appeal with benefits
				  continued.
A Title XIX recipient who has filed an appeal due to SSA's
				  determination that he/she is no longer disabled may continue to receive SSA
				  benefits. The recipient has the option to have Title XIX benefits continued
				  until the appeal decision has been reached. After the decision has been
				  reached, the appropriate case action is taken. If SSA's decision is upheld, an
				  overpayment referral is submitted for any Title XIX benefits the recipient
				  received beginning with the month that SSA/SSI determined the recipient did not
				  meet disability requirements.
(H)
Applicant deceased.
Categorical relationship to the disabled is
				  automatically established if an individual dies while receiving a medical
				  service or dies as a result of an illness for which he/she was hospitalized if
				  death occurs within two (2) months after hospital release. The details of the
				  verification used are recorded in the case record.