N.M. Admin. Code § 8.102.420.11 - NMW/ TANF LIMITED WORK PARTICIPATION STATUS DETERMINATION PROCESS
A. Eligibility: To
be eligible for a limited work participation status, a participant must meet at
least one of the criteria below as verified by the HCA:
(1) Who is age 60 or older.
(2) A single parent, not living with the
other parent of a child in the home, or caretaker relative with no spouse, with
a child under the age of 12 months. A participant may be eligible for a limited
work participation status using this qualification for no more than 12 months
during the participant's lifetime.
(3) A single custodial parent caring for a
child less than six years of age or who is a medically fragile child if the
parent is unable to obtain child care for one or more of the following reasons
and the children, youth and families department (CYFD) certifies as to the
unavailability or unsuitability of child care:
(a) the unavailability of appropriate child
care within a reasonable distance from the parent's home or work site;
or
(b) the unavailability or
unsuitability of appropriate and affordable formal child care by a relative or
under other arrangements; or
(c)
the unavailability of appropriate and affordable formal child care by a
relative or under other arrangements;
(4) A participant who is a woman in her third
trimester of pregnancy, or six weeks post partum.
(5) A participant whose personal
circumstances preclude participation for a period not to exceed 30 consecutive
days in a calendar year.
(6) A
participant who demonstrates by reliable medical, psychological or mental
reports, court orders, police reports, or personal affidavits (if no other
evidence is available), that family violence or threat of family violence
effectively bars the parent from employment.
(7) A participant who is completely impaired,
either temporarily or permanently, as determined by IRU.
(8) A participant may be entitled to the
family violence option (FVO). This option allows for a parent in a domestic
violence environment to be in a limited work participation status for the
length of time certified by a trained domestic violence counselor. The
certification shall indicate that the parent is in a domestic violence
environment which makes them eligible for a limited work participation status.
(a) A participant's FVO limited work
participation status shall be reviewed every six months and shall be determined
by IRU based on the domestic violence counselor's certification.
(b) A participant who can continue to comply
with work requirements as certified by a trained domestic violence counselor
may be eligible for a limited work participation status for 24 weeks as
described in
8.102.461.15
NMAC.
(9) A participant
who is the sole provider of the care for an ill or incapacitated person. In
order to meet this exception, the participant must show that the parent is the
sole caretaker for a disabled person and must demonstrate that the participant
cannot be out of the home for the number of hours necessary to meet standard
work participation hours. The following apply to caretaker conditions in
determining if the standard work participation rate applies or if a limited
work participation rate will be granted:
(a)
Only those care activities around which work program activities cannot be
scheduled are taken into consideration.
(b) Food purchase and preparation activities,
home maintenance chores, etc. are activities which may be scheduled and
performed at time other than work program participation hours and are not taken
into consideration when determining the standard work participation
rate.
(c) A requirement to be on
call for the medical emergencies of a medically fragile person is taken into
consideration in determining the standard work participation rate for the
participant.
(10) A
participant may demonstrate good cause for the need for the limited work
participation status. A good cause limited work participation status may exist
and shall be determined by the HCA based on the participant's existing
condition(s) to include any barriers identified during the NMW assessment
process that impair an individual's ability to comply with the standard work
participation rate or capacity to work.
B. Determinations in general: The NMW/TANF
determination for a limited work participation status is made independently of
and using differing standards from those used for determining OASDI or SSI
eligibility, general assistance, workman's compensation, veteran's compensation
or in Americans with Disability Act (ADA) determinations. Medical and social
information (as appropriate) used by the HCA's reviewers may differ between
determinations for each type of program, and a participant's condition may
improve or worsen over time. As a result, a participant may be classified
disabled by one program, but not by another. A disability determination made
for another program or purpose is immaterial to the NMW/TANF limited work
participation status determination. NMW/TANF determinations shall be made by
applying NMW/TANF regulations and medical and nonmedical information (as
appropriate) known to the HCA. An applicant/ participant may have more than one
condition to qualify for limited work participation status. The limited work
participation rate and work activities will reflect accommodations for all
identified and approved qualifying conditions.
C. Medical and nonmedical based
determinations:
(1) Medical conditions: The
IRU shall review all documentation and make determinations for participants
requesting a limited work participation status or hardship extension due to a
medical condition. To be eligible for a limited work participation status from
or for a hardship extension, based on a medical condition, the HCA must find:
(a) evidence of a physical or mental
impairment(s) supported by medical documentation; and
(b) determine that the severity of the
impairment(s), as supported by appropriate medical documentation is sufficient
to significantly restrict the participant's capacity to fulfill the standard
work participation rate or capacity to work; requests for limited work
participation status or hardship extension must be supported by medical
documentation, but may be supplemented by non-medical documentation provided by
the applicant as requested by the IRU.
(2) Caretaker conditions: The IRU shall
review all documentation and make determinations for participants requesting a
limited work participation status or hardship extension due to caretaker
conditions. To be eligible for a limited work participation status or for a
hardship extension, as a caretaker, the HCA must find the participant is:
(a) the sole provider for an ill or
incapacitated family member living in the home who does not attend school on a
full time basis; and
(b) providing
necessary care to the extent that otherwise precludes the participant's
capacity to fulfill standard work participation rates or capacity to
work.
(3) Non-medical
conditions: The NMW service provider shall review documentation and make
determinations regarding requests for limited work participation status for
non-medical conditions. If a participant has a medical condition(s) in addition
to non-medical conditions, the IRU shall review documentation and make
determinations regarding requests for limited work participation status for
medical and non-medical conditions. To be eligible for a limited work
participation status from the NMW/TANF standard work participation rate based
on conditions that are not medical in nature, the HCA must find the participant
has one of the qualifications for a limited work participation status
identified in Subsection A above.
D. Case development process: The caseworker
shall be responsible for explaining hardship eligibility, work program
requirements, standard work participation rates, and for referring all
participants requesting a limited work participation status and hardship
extensions to the IRU and NMW service provider, as appropriate. Participants
must complete and return the requested information to request a limited work
participation status within 30 days of the request.
(1) Limited work participation status
requests for medical conditions: Requests for a limited work participation
status based on a medical condition shall be sent to the IRU for determination
and contain the following:
(a) a completed
assessment that has been conducted by the NMW service provider within the six
months prior to the date of the request for a change in status;
(b) a completed individual responsibility
plan conducted by the NMW service provider;
(c) copies of relevant medical reports made
within the last six months;
(d) a
work participation agreement with the proposed activity(ies); and
(e) additional documents for evidence of
other work related factors.
(2) Limited work participation status
requests for non-medical conditions: The NMW service provider shall utilize the
following documents to determine eligibility for the limited work participation
status:
(a) a completed assessment that has
been conducted by the NMW service provider within the six months prior to the
date of the request for a change in status; and
(b) a completed individual responsibility
plan conducted by the NMW service provider.
E. Provision of documentation: It shall be
the responsibility of the participant requesting limited work participation
status or hardship extension to provide recent (within the last six months)
medical and non-medical information necessary to make a determination.
Non-medical evidence will not be considered in the absence of medical
documentation for requests based on medical conditions. A participant, who has
not provided the necessary information as requested by the HCA, contractor or
its designee to make a determination within 30 days of the request for the
limited work participation status or hardship extension, shall be subject to
meeting full participation requirements. Participants who fail to provide the
requested documentation within 30 days of the request, but are also eligible
for a limited work participation status on the basis of a non-medical
condition, shall be referred to the NMW service provider to determine the
limited work participation status based on the nonmedical condition. The
participant is not responsible for providing documentation produced by the HCA,
its contractors, or its designee.
(1) Medical
documents: Written paperwork must be submitted to verify the existence of
physical, mental impairment(s) or both; as well as the extent of the caretaking
needs. It is the responsibility of the participant to get all information to
the IRU for review. Determinations are based on the written evidence provided
in a timely manner to IRU.
(a) Source: Medical
documents must be obtained from approved source(s), limited to: medical
doctors, physician assistants, doctors of osteopathy or podiatry,
ophthalmologists, psychiatrists or psychologists, state-licensed providers, and
individuals that meet the minimum mental health professional qualifications set
by their community mental health services employer.
(b) HCA assistance: The HCA, contractor or
its designee shall offer assistance to the participant to include obtaining
medical documents or other reasonable accommodations as requested by the
participant. If the HCA is assisting the participant with obtaining
documentation or other accommodation, the participant is still responsible for
providing accurate and timely information.
(c) Timeliness of report: The participant
shall provide medical records from the past six months. Medical documents over
six months old from the date of the request for the limited work participation
status or hardship extension may be useful to support a pattern of recurring
impairment, but must be accompanied by current medical documents.
(d) Independent medical review: The HCA may
request additional documentation in order to make a determination regarding a
participant's request for limited work participation status. The IRU may
request additional documentation in the form of an independent medical review
of the participant's condition(s). If the participant is also a recipient of
medicaid, the HCA may assist with a referral to a medicaid provider, as
appropriate.
(2) Non
medical information: Non-medical information may not be used for medical
condition determinations without the provision of medical documents.
Non-medical information may be submitted to the IRU or the NMW service provider
and will be considered if the source is public and private agencies, schools,
participants and caregivers, social workers and employers, and other relevant
and independent sources to assist in the determination of whether the barriers
are of sufficient severity to restrict the participant's capacity to fulfill
the standard work participation rate, or that the need to care for an
individual are so great as to limit or exclude participation.
F. Case disposition:
(1) Medical based conditions: The IRU shall
have sole responsibility for reviewing all medical documents. When making a
determination regarding a participant's capacity to fulfill the standard work
participation hours, the IRU will within 30 calendar days of receipt complete
the following:
(a) conduct a thorough review
of the documentary evidence;
(b)
make a determination as to whether a medical condition or caretaking need is
supported by the evidence provided by the participant;
(c) determine the anticipated duration of the
impairment;
(d) adopt or propose
participation activities based on the work participation agreement submitted
with the participants request packet; and
(e) establish the reduced limited work
participation hours if a limited work participation status or hardship
extension of the 60 month time limit is granted.
(2) Nonmedical based impairments: The NMW
service provider shall review all non-medical information and make a
determination that a participant is eligible for a limited work participation
status. The determination shall identify one of the criteria qualifying for a
limited work participation status. The NMW service provider shall identify the
non-medical barrier and establish the participation activity(ies) and the
limited work participation rate to be included in the approved work
participation agreement. All of the non-medical information is considered in
assessing the participant's capacity to fulfill the standard work participation
rate. Case disposition shall include:
(a) a
thorough review of documentary evidence;
(b) a determination as to whether the claim
of a non-medical impairment is supported; and
(c) the anticipated duration of the
impairment.
(3) Duration
of condition(s): The duration of the condition shall be evaluated based on
documentation provided and must be expected to last at least 30 days in order
to grant a limited work participation status.
(4) Evaluation of medical report(s): Reports
shall be reviewed by the IRU for completeness and detail sufficient to identify
the caretaking needs, limiting effects of impairment(s), probable duration of
the impairment(s), and capacity to perform work program participation
standards.
(a) Anatomical and physiological
reports shall be reviewed for a description of the medical history, clinical
findings, laboratory findings, diagnosis, prescribed treatment and prognosis,
and to identify the participant's ability to sit, stand, move, lift, carry,
handle objects, hear, speak and travel.
(b) Psychological assessments shall be
reviewed for a description of the participant's behavior, affect, orientation,
capacity for appropriate decision-making, response to stress, cognitive
function (awareness, memory and intellectual capacity), contact with reality
and need for occupational, personal and social adjustment(s).
G. Notification: The HCA
shall notify the participant regarding the disposition of their request for
limited work participation status in compliance with the requirements of
adequate notice and notice of adverse action, as applicable.
H. Re-evaluation of status: A participant's
limited work participation status shall be re-evaluated on a periodic basis, as
determined by the IRU or the NMW service provider, as appropriate. At the time
of reevaluation, it shall be necessary to get an update of the medical or
non-medical impairment, caretaking need, and any changes in other work-related
factors. The IRU shall remain responsible for deciding whether a medical
impairment or caretaking need still exists, and the date of the next
re-evaluation for continued approval of limited work participation status. The
NMW service provider shall remain responsible for deciding whether the
non-medical impairment still exists and the date of the next evaluation for
continued approval of limited work participation status.
I. Determining the limited work participation
rate: after a participant is approved for limited work participation status
either at the initial determination or re-evaluation, the IRU or NMW may
prescribe conditional work program activities and requirements designed to
assist the participant to help accommodate and eliminate barriers. The
participant may be assigned to core, non-core and other activities which may
include, but not be limited to, one of the contingencies below:
(1) follow treatment plans as prescribed by a
physician or mental health provider;
(2) seek and utilize available community
based resources;
(3) accept
treatment as recommended by a physician or mental health provider;
(4) pursue a referral for DVR, or other
available services;
(5) apply for
SSI, if applicable; or
(6) any
other activity specific to the participant's circumstance and
conditions.
J. Transition
of currently waived participants to the limited work participation status:
(1) Currently waived: Participants who are
waived on or before the effective date of this regulation shall be evaluated
for a limited work participation status at their next recertification for TANF
benefits or at the next waiver review, whichever is earlier.
(2) Pending waiver determination:
Participants who are pending a waiver determination on or before the effective
date of this regulation shall be considered for a waiver of the work
participation status. They will be determined for a limited work participation
status at their next recertification for ongoing TANF benefits or at the next
waiver review, whichever is earlier.
Notes
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No prior version found.