Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.10 - State-Administered Community Medicaid Disability Determinations

Current through June 14, 2024
1.10.1
Scope and Purpose
Disability determinations are made by the State's Medicaid
					 Assessment and Review Team (MART) in accordance with the applicable
					 requirements of the SSA based on information supplied by the applicant and by
					 reports obtained from treating physicians and other health care professionals.
					 Anyone who is blind and is seeking IHCC group Community Medicaid who does not
					 qualify for SSI or has never received a determination of disability on that
					 basis by a government agency, is subject to an evaluation by the
					 MART.
1.10.2
Disability Standards for Community Medicaid
A. For the purposes of IHCC groups providing
				  Community Medicaid, the standards for determining whether a person has a
				  disability centers on:
1. Duration - The
				  disabling impairment or chronic condition is expected to result in death or has
				  lasted or can be expected to last for at least twelve (12) consecutive
				  months;
2. Substantial Gainful
				  Activity - The impairment or condition adversely affects the person's ability
				  to engage in substantial gainful activity or SGA. For these purposes, SGA is
				  work activity that involves doing significant physical or mental activities.
				  Work may be substantial even if it is done on a part-time basis or if a person
				  does less, gets paid less or has less responsibility than during prior
				  employment. Gainful work activity is the kind of work done for pay or profit
				  whether or not a profit is realized.
3. Application of Standards - The disability
				  determination standards that apply for Community Medicaid vary by age:
a. Persons age eighteen (18) or older.
				  Disability determinations for applicants in this age group are made by the MART
				  using the SSI criteria and standards. The determination is based on an
				  assessment of whether the person seeking coverage is unable to engage in any
				  substantial gainful activity due to any medically determinable physical or
				  mental impairment, or combination of impairments, expected to result in death,
				  or last or could be expected to last for a continuous period of not fewer than
				  twelve (12) months. To meet this definition, there must be a severe impairment,
				  which makes the person unable to do his or her previous work or any other
				  substantial gainful activity existing in the national economy. To determine
				  whether a person is able to do any other work, the MART considers residual
				  functional capacity, age, education, and work experience.
b. Children under age nineteen (19) - MN
				  Only. The MART is not usually responsible for making disability determinations
				  for persons under nineteen (19). In general, these disability determinations
				  are made formally by the SSA in conjunction with SSI eligibility, evaluations
				  conducted by professionals for educational or child welfare services or through
				  a qualified Medicaid provider. The SGA standard does not apply; however. The
				  child must have a physical, mental, or behavioral health impairment, or
				  combination of impairments, resulting in marked and severe functional
				  limitations, expected to result in death or that have lasted or are expected to
				  last for at least twelve (12) consecutive months. The MART may make such
				  disability determinations for MN applicants under age nineteen (19) using the
				  applicable SSI standards.
c.
				  Disability based on Blindness. Applicants seeking eligibility for a disability
				  based on blindness who do not qualify for SSI because their income is too high
				  must meet the duration and SGA standard and have central visual acuity of
				  20/200 or less, even with glasses, or a limited visual field of twenty degrees
				  (20°) or less in the better eye with the use of a correcting
				  lens.
d. Working Persons with
				  Disabilities - No LTSS. Applicants who have disabilities but who are working
				  are exempt from the SGA step of the sequential evaluation of the disability
				  determination. This exemption applies if the person otherwise meets the
				  requirements set forth for coverage under the Sherlock Plan in the Medicaid
				  Code of Administrative Rules, Sherlock Program, or other related provisions for
				  adults with disabilities.