Or. Admin. R. 461-125-0370 - Disability as the Basis of Need
(1) In the OSIP and OSIPM programs (except
OSIP-EPD and OSIPM-EPD), an individual meets the eligibility requirement to
have a disability if the requirements of one of the following subsections are
met:
(a) The individual is receiving Social
Security Disability Income (SSDI) or Supplemental Security Income (SSI) based
on disability. Eligibility continues as long as the individual remains eligible
for SSDI or SSI.
(b) The individual
was eligible for and received Aid to the Disabled benefits in Oregon in
December 1973. These individuals continue to be eligible as long as they are
continuously disabled as defined by Oregon requirements that were in effect in
1973.
(c) The Department has
determined the individual meets the listing of impairments found in 20 C.F.R.
Part 404, Subpart P, Appendix 1; meets the medical vocational guidelines found
in 20 C.F.R. Part 404, Subpart P, Appendix 2 for SSI; or meets the definition
of disability in
20 C.F.R. section
404.1505 or
416.905.
(d) The Social Security Administration (SSA)
has determined the individual meets the listing of impairments found in 20
C.F.R. Part 404, Subpart P, Appendix 1; meets the medical vocational guidelines
found in 20 C.F.R. Part 404, Subpart P, Appendix 2; or meets the definition of
disability in
20 C.F.R. section
404.1505 or
416.905.
(2) If the Department finds the
individual eligible for OSIPM in the absence of a disability determination by
SSA, the individual remains eligible, provided that the individual continues to
meet the disability criteria for eligibility for OSIPM, until SSA denies the
disability claim in a final administrative decision.
(3) For OSIP and OSIPM, a disability
determination made by SSA that is unfavorable to an individual is binding on
the Department unless the requirements of at least one of the following
subsections are met (see
42 C.F.R. section
435.541(c)(1) and (c)(4)):
(a) SSA made the determination for a reason
other than disability.
(b) The
individual alleges a disabling condition different from, or in addition to,
that considered by SSA in making its determination.
(c) More than 12 months after the most recent
SSA determination denying disability, the individual alleges that his or her
condition has changed or deteriorated since that SSA determination, and the
individual has not made application to SSA based on these
allegations.
(d) The individual
alleges less than 12 months after the most recent SSA determination denying
disability that the condition which SSA evaluated has changed or deteriorated
since that SSA determination; and one or both of the following apply:
(A) The individual has requested
reconsideration or reopening of the most recent SSA determination denying
disability and SSA has declined to consider the new allegations.
(B) It is clear that the individual no longer
meets SSI eligibility requirements unrelated to disability status but may
satisfy comparable Medicaid eligibility requirements.
(4) If a binding SSA disability
determination is not in place, the determination of disability to qualify for
OSIPM is made by the Presumptive Medicaid Disability Determination Team
(PMDDT), composed of a medical or psychological consultant and another
individual who is qualified to interpret and evaluate medical reports, other
evidence relating to the individual's physical or mental impairments, and (as
necessary) to determine the capacities of the individual to perform substantial
gainful activity, as specified in 20 C.F.R. Part 416, Subpart J (see
42 C.F.R. section
435.541(f)(2)).
(5) The Presumptive Medicaid Disability
Determination Team (PMDDT) obtains and reviews medical reports and other
non-medical evidence pertaining to the individual and the claimed disability.
The medical report and non-medical evidence must include diagnosis and other
information in accordance with the requirements for evidence applicable to
disability determinations under the SSI program specified in 20 CFR Part 416,
Subpart I. The PMDDT then makes a decision about medical eligibility and
whether and when a redetermination will be made (see
42 C.F.R. section
435.541(f)(1) and
(3)).
(6) In the OSIP-EPD and OSIPM-EPD programs,
an individual is disabled (see OAR 461-001-0035) or has a disability (see OAR
461-001-0035) if the individual has a physical or mental impairment, or a
combination of these impairments, that meets the definition of disability used
by SSA when determining eligibility for SSI or SSDI under 20 C.F.R. Part 404.
The determination is made as follows:
(a) A
determination by SSA that the individual is disabled or has a disability is
accepted by the Department.
(b) If
the individual was determined to have a disability by SSA and lost their SSDI
eligibility due to their own income, the SSA determination remains effective
for one year from the date that the individual loses eligibility for
SSDI.
(c) If there is no currently
effective SSA determination finding the individual has a disability, the case
is referred to the Department's central office for a disability determination
(see OAR 461-001-0035) using the standards of 20 C.F.R. Parts 404 and 416 and
considering all relevant medical and vocational information.
(d) For OSIPM-EPD, an individual is engaging
in substantial gainful activity (SGA, see OAR 461-001-0035) if the earnings of
the individual are at or above the EPD Income Standard.
(e) For OSIPM-EPD, any work activity engaged
in during the OSIPM-EPD application process or certification period is not
evaluated as past relevant work (PRW, see OAR 461-001-0035).
(7) An individual who is served by
a branch office (see OAR 461-001-0000) and who has been determined by the
Presumptive Medicaid Disability Determination Team (PMDDT) to have a disability
(see section (1) of this rule) may receive free assistance from the Department
with applications and administrative appeals for Social Security benefits based
on a disability for purposes including, but not limited to, meeting the
requirement to pursue assets under OAR 461-120-0330.
(8) An individual may receive free assistance
from the Department with applications and administrative appeals for Social
Security benefits based on a disability for purposes including, but not limited
to, meeting the requirement to pursue assets under OAR 410-200-0220 if the
individual:
(a) Is determined to have a
disability under subsection (1)(c) of this rule;
(b) Receives benefits from one of the
HSD medical programs (see OAR 461-001-0000); and
(c) Is served by an AAA (Area Agency on
Aging) or APD (Aging and People with Disabilities) office.
Notes
Publications: Publications referenced are available from the agency.
Statutory/Other Authority: ORS 409.050, 410.070, 411.060, 411.070, 411.121, 411.404, 411.706, 411.816, 413.085 & 414.685
Statutes/Other Implemented: ORS 409.010, 409.050, 410.010, 410.020, 410.070, 411.060, 411.070, 411.121, 411.404, 411.704, 411.706, 411.816, 413.085 & 414.685
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