Section 441.75.20. Disability requirements for SSI-related Medicaid.

         75.20(1) Applicants receiving federal benefits. An applicant receiving supplemental security income on the basis of disability, social security disability benefits under Title II of the Social Security Act, or railroad retirement benefits based on the Social Security law definition of disability by the Railroad Retirement Board, shall be deemed disabled without further determination of disability.

         75.20(2) Applicants not receiving federal benefits. When disability has not been established based on the receipt of social security disability or railroad retirement benefits based on the same disability criteria as used by the Social Security Administration, the department shall determine eligibility for SSI-related Medicaid based on disability as follows:

            a.               A Social Security Administration (SSA) disability determination under either a social security disability (Title II) application or a supplemental security income application is binding on the department until changed by SSA unless the applicant meets one of the following criteria:

             (1)             The applicant alleges a disabling condition different from, or in addition to, that considered by SSA in making its determination.

             (2)             The applicant alleges more than 12 months after the most recent SSA determination denying disability that the applicant’s condition has changed or deteriorated since that SSA determination and alleges a new period of disability which meets the durational requirements, and has not applied to SSA for a determination with respect to these allegations.

             (3)             The applicant alleges less than 12 months after the most recent SSA determination denying disability that the applicant’s condition has changed or deteriorated since that SSA determination, alleges a new period of disability which meets the durational requirements, and:

            1.      The applicant has applied to SSA for reconsideration or reopening of its disability decision and SSA refused to consider the new allegations, or

            2.      The applicant no longer meets the nondisability requirements for SSI but may meet the department’s nondisability requirements for Medicaid eligibility.

            b.               When there is no binding SSA decision and the department is required to establish eligibility for SSI-related Medicaid based on disability, initial determinations shall be made by disability determination services, a bureau of the Iowa department of education under the division of vocational rehabilitation services. The applicant or the applicant’s authorized representative shall complete and submit Form 470-4459 or 470-4459(S), Authorization to Disclose Information to the Department of Human Services, and either:

             (1)             Form 470-2465, Disability Report for Adults, if the applicant is aged 18 or over; or

             (2)             Form 470-3912, Disability Report for Children, if the applicant is under the age of 18.

            c.               When an SSA decision on disability is pending when the person applies for Medicaid or when the person applies for either Title II benefits or SSI within ten working days of the Medicaid application, the department shall stay a decision on disability pending the SSA decision on disability.

         75.20(3) Time frames for decisions. Determination of eligibility based on disability shall be completed within 90 days unless the applicant or an examining physician delays or fails to take a required action, or there is an administrative or other emergency beyond the department’s or applicant’s control.

         75.20(4) Reviews of disability. In connection with any independent determination of disability, the department will determine whether reexamination of the member’s disability will be required for periodic eligibility reviews. When a disability review is required, the member or the member’s authorized representative shall complete and submit the same forms as required in paragraph 75.20(2)“b.”

         75.20(5) Members whose disability was determined by the department. When a Medicaid member has been approved for Medicaid based on disability determined by the department and later is determined by SSA not to be disabled for SSI, the member shall continue to be considered disabled for Medicaid eligibility purposes for 65 days from the date of the SSA denial. If at the end of the 65 days there is no appeal to the SSA, Medicaid shall be canceled with timely notice. If there is an appeal within 65 days, the member shall continue to be considered disabled for Medicaid eligibility purposes until a final SSA decision.

         75.20(6) Disability redeterminations for members who attain age 18. If a member is eligible based on an independent determination of disability made under the standards applicable to persons under 18 years of age, the department shall redetermine the member’s disability after the member attains the age of 18 years. The member’s disability shall be redetermined:

            a.               Using the standards applicable to persons who are 18 years of age or older, and

            b.               Regardless of whether a review of the member’s disability would otherwise be due.

This rule is intended to implement Iowa Code section 249A.4.

[ARC 9044B, IAB 9/8/10, effective 11/1/10]