Presumptive Medical Disability: Coverage, Process, and Program Impact

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Presumptive Medical Disability Coverage,
Process, and Program Impact
Andrew Allison, PhD Deputy Director, Kansas
Health Policy Authority
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Presumptive Medical Disability (PMD) Description

• PMD is a program in which Medicaid agencies are
  permitted to make internal disability decisions
  and provide Medicaid coverage on a presumptive
  basis
• Is referred to as presumptive because the
  determination is provided prior to the Social
  Security Administration (SSA) decision

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Presumptive Medical Disability Advantages

• Provides earlier access to full Medicaid coverage
• Permits the State to receive federal match prior
  to the final SSA disability decision (MediKan is
  not matched)
• Provides applicants who meet presumptive
  disability determination criteria full Medicaid
  coverage

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Presumptive Medical Disability Process

• Provides a presumptive disability determination
  for people seeking
• Disability-based Medicaid coverage, and
• General Assistance (GA)/MediKan coverage
• Uses a two tier evaluation for benefits
• Medicaid standards
• MediKan standards

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Relationship to Cash Benefits

• MediKan and GA cash criteria are one and the
  same. New applicants who do not meet Medicaid or
  MediKan criteria are also not eligible for GA
  cash.
• If PMD criteria are met, the applicant may also
  receive GA cash.
• Per legislative proviso (through 3/1/07) existing
  GA/MediKan recipients continue to receive cash
  and MediKan benefits until completing their
  annual review.

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Presumptive Medical Disability Team

• Is a new unit within KHPA as of July 2006
• Is composed of
• An R.N./Unit Manager
• Disability Examiners
• Case Development Specialists
• A Senior Administrative Specialist
• Primary responsibilities
• Accepting referrals from SRS eligibility staff
• Preparing the disability cases for review by
  Disability Determination Services (DDS), an SRS
  unit KHPA contracts with to complete the
  disability assessment.
• The disability assessment is communicated to SRS
  eligibility staff for the final eligibility
  decision

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Presumptive Medical Disability Team (continued)

• Preparing a disability case
• Conducting telephone consultations
• Requesting relevant medical records
• Obtaining work history
• Scheduling medical exams as needed
• Obtaining other information relevant to the
  disability
• Recording information in a cumulative data base

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Presumptive Medical Disability Outcomes to Date

• Between September 1 and December 1, 2006 the
  total number of cases referred to the PMDT was
  3,313
• Of these 3,313 cases, work has been completed on
  1,203
• 166 applicants were determined to be
  presumptively disabled
• 373 applicants were determined to meet GA/MediKan
  criteria
• 130 applicants did not meet either criteria
• 534 cases were closed due to non-cooperation
• The remaining 2,110 cases are pending until a
  telephone consultation is completed and/or
  medical records are obtained
• Average number of telephone consultations per
  week 255
• Building database for analysis of program impact