The CAO will use DHS's Employability Assessment Form (PA 1663), the Temporary Disability Reassessment Form (PA 1664), or the Health-Sustaining Medication Assessment Form (PA 1671) to determine MA eligibility. The forms must be completed by a psychologist, medical doctor, or medical professional under the doctor’s supervision and control (for example, a physician’s assistant or certified registered nurse practitioner). Each form has instructions to help the medical provider complete the information that the CAO needs. The PA 1671 may be used alone or together with the PA 1663 and PA 1664.
NOTE: Retroactive PD may be authorized if:
It is verified that GA-related Medical criteria (need for health sustaining medications) is met during the period requested;
All other eligibility requirements for PD are met including meeting income and resource limits; and
The individual meets the retroactive NMP guidelines at Section 368.3.
NOTE: Some medical or mental health information that DHS may need from a provider to determine an individual’s eligibility depends on other federal and state requirements for information that the provider must release. To satisfy the additional requirements, DHS has developed the Drug and Alcohol Treatment Information Form (PA 1672). All medical and mental health information must be kept secret and must be used only for determining eligibility for public assistance. The information cannot be given out or used in any other way.
Reminder: An individual who proves that he or she has gotten SSA disability benefits or a DVA claim award that shows a 50 percent or more disability does not need to submit a PA 1663.
DHS will pay the cost of a medical examination for cash and MA applicants and recipients (Section 305.5).
When proof of an individual’s disability is needed using the PA 1663, the CAO will take the following steps:
1. Enter the case identification information required (above Section I) and stamp the CAO/District address in the "Return to" block.
2. Instruct the individual to:
Complete Section I, briefly telling why he or she cannot work and what physical, mental, or emotional disabilities prevent him or her from working;
Sign and date Section I; and
Contact his or her family doctor, medical center, or MH/MR Base Service Unit as soon as possible to schedule an appointment.
The CAO will help make the necessary arrangements if the applicant or recipient seems unable to follow through in scheduling the appointment.
3. Tell the applicant that the completed form must be returned before eligibility for MA can be determined, or tell the recipient that the form must be returned within 30 calendar days.
4. Tell the applicant that he or she is responsible for payment of the medical examination if he or she chooses a provider who does not participate in the MA program.
When the PA 1663 is returned, the CAO will determine MA eligibility by reviewing the medical records to learn whether the individual can work. Medical providers are requested to provide information about the individual’s diagnosis and related drugs on the PA 1663. If the doctor or psychologist chooses to do so, he or she can attach supporting records. The provider's statements must support the evaluation of the individual’s physical or mental capacity to prove his or her disability.
Using the information contained in the PA 1663, PA 1664, or PA 1671, the CAO will determine eligibility for applicants and recipients as follows:
NOTE: For retroactive MA coverage, the medical provider must submit the PA 1663 with a disability begin date. The applicant’s retroactive MA eligibility must be based on this date as long as the individual meets the criteria for permanent or temporary disability.
The "Examination Results" section is considered completed if a diagnosis is entered and at least one of the blocks labeled A to E is checked.
If block #1, “Permanently Disabled,” is checked and the "Examination Results" section is completed, the individual is eligible for PJ, TJ, or PH 00. See Section 305.26, Presumptive eligibility—PH/PJ/TJ, and refer the individual to the DAP for SSA/SSI benefits.
NOTE: Employment status: Exempt
If block #2, “Temporarily Disabled, 12 months or more,” is checked and the "Examination Results" section is completed, the individual is eligible for PJ, TJ, or PH. See Section 305.26, Presumptive eligibility—PH/PJ/TJ, and refer the individual to the DAP for SSA/SSI benefits. Set an alert to end-date the benefits and explain to the individual that benefits will stop on the date the disability is expected to end unless more information is given before that time. Give the individual a PA 1664 and explain that this form must be returned at least ten days before the eligibility end date to avoid having benefits interrupted.
If block #3, “Temporarily Disabled, less than 12 months,” is checked and the “Examination Results” section is completed, the individual is eligible for GA-Related MA (PD) benefits. Set an end date for benefits and explain to the individual that benefits will stop on the date the disability is expected to end unless more information is given before that time. Give the individual a PA 1664 and explain that the form must be returned at least ten days before the eligibility end date to avoid interruption of benefits.
NOTE: On the PA 1664, the doctor or medical professional also answers the question in this section that focuses on whether the patient complied with appropriate treatment. If the “No” block is checked, the individual is ineligible for continued GA-related MA (PD).
NOTE: The caseworker is required to send an advance notice before the temporary period expires.
NOTE: Employment status: Exempt for the period set by the medical provider
If block #4, “Employable,” is checked and no PA 1671 is attached, the individual is ineligible for GA-related MA (PD) benefits under this criterion. The CAO will reject the application or stop assistance, as appropriate.
If block #4, “Employable,” is checked and the “Yes” block is checked on the PA 1671 (indicating that the individual needs medicine to work or keep a job), then the individual is eligible for GA-related MA (PD) benefits.
If block #4, “Employable,” is checked and the “No” block is checked on the PA 1671 (indicating that the individual does not need medicine to work or keep a job), then the individual is ineligible. The CAO must reject the application for GA-related MA (PD) benefits or stop GA-related MA (PD) benefits, as appropriate.
NOTE: If the individual returns only the PA 1671, the “Yes” block must be checked for the CAO to allow or continue GA-related MA (PD) benefits.
Updated February 14, 2012, Replacing June 28, 2007