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.
SSI-Related & MAGI-Related
Disability not verified by Social Security Administration (SSA) or Medical Review Team (MRT)
1. If all eligibility factors to make a MAGI eligibility determination are verified at application, the CAO will review the individual for MAGI MA.
If the individual meets criteria for a MAGI category, the CAO will open the individual in the appropriate MAGI category and request the individual to provide a completed PA1663 to verify the disability. If the individual lists resources on the application, the CAO will enter the resource information in eCIS but will not request verification of resources (the CAO will enter “P- Verification pending” in the verification field for resources in eCIS).
If the individual returns the PA 1663 indicating a permanent disability or a temporary disability of 12 months or more, the CAO will update the Disability screen on the case and initiate the Disability Advocacy Program (DAP) referral. The individual continues to be eligible in a MAGI category until either SSA or MRT determines the individual to be disabled.
NOTE: The individual is required to cooperate with the DAP process and pursue potential benefits. If the individual later indicates he/she is no longer disabled, the CAO will accept that person’s statement and maintain the eligibility in a MAGI category if they meet other eligibility requirements. If the individual fails to cooperate but maintains they are disabled, the CAO will terminate MA for failure to pursue potential benefits.
If the individual returns the PA 1663 which indicates a temporary disability of less than 12 months, the CAO will update the Disability screen and rerun eligibility. There will be no change to the MAGI category.
If the individual returns PA 1663 which indicates employability OR the individual does not return the PA 1663, the CAO will document the outcome of the form request in the Case Comments and will take no action on the case. The individual will stay open in a MAGI category if he/she continues to be eligible.
2. If all eligibility factors to make a MAGI eligibility determination are NOT verified at application (through an electronic data source or available in the case record) or if the individual is not eligible for MAGI MA, the CAO must request verification that is necessary to make both MAGI and non-MAGI MA eligibility determinations.
The CAO will request verification of income, resources (if applicable to the non-MAGI determination), a PA1663 to verify disability, and any other required verification. The CAO will determine the correct MA category once required verifications are returned.
If the individual meets criteria for a MAGI category, the CAO will open an appropriate MAGI category and follow instructions above in regard to the PA 1663 action (see section 1). The CAO will not reject an MA application if the individual does not return verification of resources or the PA 1663.
If the individual is not eligible for MAGI MA, the CAO will review the individual for non-MAGI MA.
Once SSA or MRT determines the individual to be disabled, the CAO must complete the appropriate entries on the Disability screen. The CAO must rerun eligibility to move the individual to the correct category.
Note: If the Applicant/Recipient (AR) group has unverified resources in the system, the CAO will request verification of resources.
Once the individual returns verification of resources, the CAO will update the case with the resource information and rerun eligibility to determine the correct category. If the resources are over the resource limit for Healthy Horizons OR if the individual fails to provide verification of resources, the individual will be evaluated for MAGI MA.
Disability verified by SSA or MRT
At application, if an individual reports a disability, which has been verified by SSA or the individual is MRT certified, the CAO will determine eligibility for non-MAGI MA first.
The CAO must request verifications necessary to make an eligibility determination for SSI-related MA (non-MAGI MA) and MAGI MA if verification cannot be obtained from an electronic data source or it is not available in the case record.
If all required verification is obtained or provided and the individual meets all conditions of eligibility for Healthy Horizons, the CAO will authorize PH 00 M.
If all required verification is obtained or provided with the exception of resources or if resources are over the limit for Healthy Horizons (if resources are applicable to the Non-MAGI determination), the CAO will review the individual for MAGI MA.
If verification of resources is provided after a MAGI category is opened, the CAO will update resource information in eCIS and rerun eligibility.
NOTE: Once the individual is placed in a MAGI category, the CAO will not request any new resource verification unless the individual makes a request to be evaluated for non-MAGI MA or unless the individual begins receiving Medicare benefits.
If the individual is ineligible for MAGI MA, the CAO will review the individual for eligibility for SSI-related MA (non-MAGI MA) including NMP and MNO.
NOTE: If an individual with a disability verified by SSA or MRT begins receiving Medicare benefits, the individual must promptly be evaluated for non-MAGI MA and be discontinued from MA in the MG 91 or MG 90 category. Refer to Attachment 3 for an overview of categories affected by the FMAP initiative implementation and Attachment 4 for Scenarios that demonstrate the CAO action for various situations involving authorizing new categories.
GA-Related
GA-related MA can only be authorized for:
Permanent non-citizens under the 5-year bar
Temporary non-citizens
Retroactive PD may be authorized if:
It is verified that GA-related MA 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 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 they are responsible for payment of the medical examination if they choose 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, they 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 may be eligible for GA-Related MA (PD) benefits if they are a non-citizen eligible to be reviewed for GA-related MA. 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 disability-related MA 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 may be eligible for GA-related MA (PD) benefits if they are a non-citizen eligible to be reviewed for GA-related MA.
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 based on disability. 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 August 21, 2024, Replacing February 14, 2012