D-2200, When a Medical Determination Is Required

Revision 16-4; Effective December 1, 2016

When an individual does not have Medicare or is not receiving a disability benefit from SSI, RSDI, or Railroad Retirement (See E-4200, Railroad Retirement Benefits), a medical determination, including date of onset, of either disability or blindness is required. The date of onset can affect the start date of Medicaid.

The following must not be used to establish disability for MEPD programs:

a Civil Service disability determination;
a medical certification an individual submits to an Achieving a Better Life Experience (ABLE) program or to the Internal Revenue Service as proof of meeting ABLE program requirements.

An individuals under age 65 who lives in an institutional setting and who would, except for income, be eligible for SSI if they lived outside the facility, must meet the SSA's definition of disability or blindness. These individuals may or may not have applied for SSI cash benefits.

If a medical decision for determining blindness or disability is required, request a decision from the Disability Determination Unit (DDU). See Section D-2300, Requesting a Decision from the Disability Determination Unit (DDU).

Do not request a decision from the DDU in the following circumstances.

If an individual …	then …
resides in a state supported living center or the Rio Grande State Center,	the staff at these facilities, and not HHSC staff, is responsible for ensuring the completion of the forms for a disability determination.
requests an eligibility determination during a retroactive period and the individual: has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application; has a date of onset for RSDI Title II blindness or disability based on SSA query records; and the date of onset for the RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application,	the DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability because federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset.

If an individual …

then …

resides in a state supported living center or the Rio Grande State Center,

the staff at these facilities, and not HHSC staff, is responsible for ensuring the completion of the forms for a disability determination.

requests an eligibility determination during a retroactive period and the individual:

has unpaid or reimbursable covered Medicaid expenses during the retroactive coverage months prior to the application;
has a date of onset for RSDI Title II blindness or disability based on SSA query records; and
the date of onset for the RSDI Title II blindness or disability does not cover any of the retroactive coverage months prior to the application,

the DDU cannot establish an earlier date of onset for RSDI Title II blindness or disability because federal regulations prevent a state's disability determination to conflict with the RSDI Title II date of onset.

A medical determination of disability or blindness is required when RSDI Title II blindness or disability is not established and an individual is:

under age 65;
either under or over age 65 and applying for the Medicaid Buy-In (MBI) program; or
either under or over age 65 and presumed to be a child with a disability to meet exception to transfer penalty.

To determine whether RSDI Title II blindness or disability is established, query the SSA records available.

Do not use the SSI Title XVI "Dsblty Onset Date" as the basis to establish blindness or disability.