|
|
Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
|
|
Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
Presumptive Disability ( PD ) is a method for authorizing emergency MA coverage prior to a formal disability determination by DDB. To qualify for PD, the person must meet the following conditions:
S/he must be a patient in a hospital and his/her
discharge from the hospital is being delayed either because long-term
care is needed and the care facility will not admit her/him until MA is
approved, or because necessary in-home services cannot be obtained without
MA, or
S/he has a major health condition that would prevent all work activity for 12 months or result in death, or a major organ transplant (heart, lung, kidney, liver, or pancreas).
A request for a Presumptive Disability may be faxed to DDB at (608) 266-8297. The request must include a fully completed application form (see 3.6.2.2) and the appropriate number of release forms (see 3.6.2.3). Fax these materials under a copy of the Medicaid Disability Application ( HCF 10112 ). The name, telephone and Fax numbers of worker submitting the request must be included on the Request for Medicaid Presumptive Disability Decision fax cover request.
It is not necessary to obtain a statement from a physician, however the application should have detailed information concerning the alleged disabilities and current status.
If the applicant is currently hospitalized or was recently hospitalized, it is recommended that hospital records be submitted with the request. If such records are not immediately available, do not delay the request to obtain the records. DDB will make the records requests.
DDB will attempt to reply to faxed PD requests within 3 days The PD decision depends on the likelihood of the applicant being found disabled when full medical documentation is obtained for a final determination.
Federal regulations generally require the evaluation of certain disabilities after a three month period of recovery from the original injury or medical event (major head injuries, strokes, heart attacks, etc.) It may not be possible to establish disability, either on a presumptive or final basis during that period. However, all applications should be submitted and a complete medical review will be made.
PD-MA coverage begins on the date DDB makes the presumptive disability decision.
Do not grant retroactive eligibility until DDB makes a formal disability determination, (when the case folder is returned to the ESA). Once DDB does the final determination, the case may be backdated up to three months prior to the month of application but no earlier than the date of disability onset, provided all other eligibility requirements are met.
If there is evidence to justify denial for nonmedical reasons, you may terminate PD with proper notice without waiting for DDB's final disability decision. In such a case, notify DDB immediately at, (608) 266-1565, that a medical determination is no longer needed.
If the DDB reverses the PD decision, follow the usual discontinuance procedures (IMM, Ch. I). Eligibility based on PD does not continue during the period a person is appealing DDB's decision to deny PD.
This page last updated in Release Number: 01-04
Release Date: 07/01/01
Effective Date: 07/01/01
|
|