The Medicaid program has long had a procedure for determining disability for individuals who have not yet been determined disabled by the Social Security Administration.[1]   There are different reasons for determining disability.

  • The procedure is primarily used for Medicaid recipients between ages 21 and 65 who are in the “single adult or childless couple” category (S/CC). Not having children in their care who are under age 21, these individuals are eligible only for state-funded Medicaid, which does not allow spend-down of income, and uses less favorable budgeting rules than the federally-funded Medicaid groups – the aged, blind and disabled, and families with children under age 21.   A determination of disability for these individuals, who are often pursuing appeals of denials of Social Security or SSI disability benefits, helps both the individual but the state, by drawing down federal funding.  If a Medicaid or Family Health Plus recipient would not be eligible for Medicaid unless they are determined to have a disability, their Medicaid or Family Health Plus must be continued while a determination of disability is made, if they allege a disabling condition.[13]
  • A Medicaid disability determination may also allow a disabled working individual who isn’t receiving SSI or SSD to qualify for the Medicaid Buy-In for Working People with Disabilities (MBI-WPD).

  • Another situation where the Medicaid program makes a determination of disability is when an applicant uses a Supplemental Needs Trust to shelter excess income or resources.[2]

  • The same procedure can also be used to determine an adult child’s disability for establishing an exemption from the transfer penalty.   For example, Mrs. Jones is 95 years old and is entering a nursing home.  She transfers assets to her 70-year-old daughter.  If her daughter is determined disabled using the procedure described below, there is no transfer penalty.

Three  forms must be completed and submitted to have disability determined.  These forms were revised in June 2012 by NYS DOH GIS 12MA027 – Medical Evidence Gathering for Disability Determinations – Adult Cases [3]

  1. DSS-486T (revised 6/2012) or Medical Statement of Disability, which is completed and signed by the treating physician, describing diagnoses, symptoms, functional limitations, and medical history.  A January 2013 Medicaid Alert states that applicable medical records must be included  in addition to the 486T form.   NOTE:  The 486T form revised in June 2012 shortens this form from the former 25-page form two a one-page form, which will be less intimidating to doctors.   The old form consisted of numerous attachments that elicited information about the different body systems, such as a musculoskeletal or cardiac impairments.  Those former attachments, while burdensome, were helpful to show the criteria for “meeting the listings”– Step Three in the sequential evaluation process described below.   While no longer required, you might find some of these attachments helpful as a guide for the physician to provide information about particular conditions.  Click here for the old 486T.

  2. LDSS-1151 (revised 6/2012)  Disability Questionnaire– completed by client or her advocate or family member, describing the disabled child’s education, work history, and functional limitations.  

  3. LDSS-1151.1 (6/201) Disability Questionnaire Continuation Sheet – provide names, addresses of all medical providers and hospitals where care received in order for State to obtain medical records.

In determining whether an applicant is disabled, the Medicaid program uses the same standards used by the Social Security Administration to determine eligibility for SSI and SSDI. The New York State Dep’t of Health Medicaid Disability Manual[4] describes the five-step “sequential evaluation” process.[5]   The State has expressly acknowledged that various steps of this process must be slightly modified for people over age 65, and especially those over age 72, pursuant to Social Security Administration Ruling SSR 03-3p, Evaluation of Disability and Blindness in Initial Claims for Individuals Aged 65 or Older [hereinafter SSR 03-3p].[6]

A short summary of the sequential evaluation follows

  1. Is the allegedly disabled individual working,  that is performing “substantial gainful activity” [SGA] as defined in Social Security regulations? If the individual is not earning an average of $980/month, she is not performing SGA. Continue to the next step.[7]

  2. Does the individual have any severe medically determinable impairment? If so, continue to the next step.   On this factor, SSR 03-3p is helpful. It provides that “If an individual aged 72 or older has a medically determinable impairment, that impairment will be considered to be ‘severe.’” Moreover, the ruling requires consideration of any impairments the individual has, including those that are often found in older individuals.  

  3. Does the impairment meet or equal the medical “Listing” of impairments? If so, the individual is disabled. The listings are criteria for clinical and laboratory signs and symptoms of impairments of the various body systems that, if met, indicate an impairment so severe that the individual is found disabled without considering their age, education, or work experience.[8]   Advocates should review the listings applicable to the disabled adult child’s impairments, and work with the physician to document the criteria. The DSS-486 form attachments track the listings. If the listings are not me, go to the next step.

  4. Does individual retain the Residual Functional Capacity [RFC] to perform past relevant work?    This step asks whether the individual can perform their last actual job. 

    Social Security regulations define “relevant” work as work performed within the last 15 years. If the individual last worked more than 15 years ago, then continue to the next step.    If the individual did work in the last 15 years, then the ability to meet the physical, exertional and mental demands of the relevant past work – heavy, medium, or sedentary – is assessed. If the individual lacks the RFC to return to past work, go to the next step. 

  5. Does the individual meet one of the special medical-vocational work profiles that are deemed to indicate that the individual cannot work?
    • There are three medical-vocational work profiles that apply to adults of all ages seeking to prove disability.[9]
      1. If the individual has no more than a marginal education (6th grade or less) and work experience of 35 years or more during which s/he did only arduous unskilled physical labor, or

      2. If the individual is at least 55 years old, has no more than a limited education (11th grade or less), and has no past relevant work experience, or

      3. If the individual is age 60 or older, has no more than a limited education, has a lifetime commitment (30 years or more) to a field of work that is unskilled, or is skilled or semi-skilled but with no transferable skills,

    • SSR 03-3p establishes an additional medical-vocational profile that applies to people age 72 and over.  If the individual is age 72 or over, any medically determinable impairments are deemed to be severe.   If she is limited to “sedentary” or “light” work, has no transferable skills from any past relevant work done in the last 15 years, and is not a high school graduate, she is disabled.[10]

  6. If no special profile is met, then the Medical-Vocational Guidelines, known as “the grid,” are  used to determine whether the individual can work, based on his or her ability to perform medium, light or sedentary work, level of education, and skill level.[11]  If the result on the “grid” is unfavorable, non-exertional impairments such as allergies, environmental restrictions, and mental and sensory impairments must be considered.[12]

[1] DOH GIS 08 MA/004; DOH GIS 06 MA/005

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.


Go to Source

Medicaid Disability Determinations – NYS Forms & Procedures (with updated forms July 2012)