Disability Advocacy Program (DAP) Changes, OPS180302 (Published March 13, 2018)
An individual who is under age 65, including a child under age 21, is considered disabled for Healthy Horizons if the individual meets any of the following conditions: 55 Pa. Code § 140.221(2)
He or she receives Social Security Disability benefits.
He or she used to receive Social Security or SSI disability benefits and was determined to be disabled by the SSA or the Medical Review Team (MRT), and the disability certification is still valid.
NOTE: If the individual had been receiving SSI or disability RSDI and benefits were stopped for a reason other than disability status, the disability condition is still valid if the medical condition has not changed. If the medical condition has changed, the MRT must review the disability condition.
He or she is certified as permanently and totally disabled under RSDI/SSI criteria or by the MRT. (See Chapter 305, Category.)
NOTE: The MRT will not consider the Substantial Gainful Activity (SGA) limit of the SSA process in determining disability.
NOTE: The applicant or recipient’s doctor should provide medical proof of a disability that falls under the SSA disability criteria.
55 Pa. Code § 140.311(b)(2)(ii)
He or she has (a) been referred to the Disability Advocacy Program (DAP) for a determination of permanent and total disability by the MRT or has (b) applied for Social Security Disability benefits as referred by the DAP. The CAO must authorize presumptive eligibility until the decision is made. (See Chapter 305, Category), and Supplemental Handbook, Chapter 820, Disability Advocacy Program, for referral information.
An individual should be encouraged to sign a PA 731, DAP Referral Form, but a signature is not required. By signing the PA 731, the individual is indicating intent to cooperate with both the CAO and the SSA. If an individual does not sign the PA 731 as part of the DAP referral, he or she must verify application for Social Security Disability benefits before the CAO authorizes MA.
NOTE: The CAO may authorize presumptive eligibility during the retroactive period if medical documentation confirms that the disability existed.
NOTE: If an individual receives unemployment compensation, the CAO will not take it as proof that he or she is employable.
The CAO must authorize Healthy Horizons categorically needy eligibility pending a decision on disability by the MRT or the SSA if the referral to SSA was made by a DAP advocate. The CAO will encourage all individuals who might be considered disabled applicants or recipients to use the services provided by the DAP advocate.
NOTE: Individuals must apply for Social Security benefits, including SSI. If an individual does not want to apply for Social Security benefits, he or she may choose to apply for Medical Assistance for Workers with Disabilities (MAWD) instead of Healthy Horizons benefits. An individual is not required to apply for Social Security benefits to be eligible for MAWD. He or she must meet the work requirements and pay monthly premiums.
NOTE: If it looks like a child will be denied SSI because of parental income or resources, the CAO must refer the child to the DAP advocate for an MRT.
Blindness alone does not meet the disability requirements. If a blind individual meets the Healthy Horizon categorically needy disability requirements, he or she may choose to receive either State Blind Pension (SBP) or Healthy Horizons. (See Supplemental Handbook, Chapter 700, State Blind Pension.)
If an SBP recipient is eligible for Medicare and meets the income and resource requirements of the Healthy Horizons cost-sharing program, the CAO must assign the appropriate program status code to the SBP category for the individual to enroll in Medicare Buy-In. (See Chapter 305, Category.)
Updated August 21, 2018, Replacing February 14, 2012