2205 Aged, Blind, Disabled Requirement for ABD Medicaid | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Aged, Blind, Disabled Requirement for ABD Medicaid

Effective Date:

November 2023

Chapter:

2200

Policy Number:

2205

Previous Policy Number(s):

MT 69

Updated or Reviewed in MT:

MT-71

Requirements

To be eligible for ABD Medicaid, the applicant/recipient (A/R) must be determined to be aged, blind or disabled.

Basic Considerations

Verify that the A/R is aged if the A/R alleges to be 65 or older. Verify blindness or disability in all other situations.

Aged

Verify that the A/R is aged by use of one of the following:

birth certificate
baptismal record
SSA record that shows date of birth, e.g.
- BENDEX/SDX
- Medicare card issued prior to 1/74
- Any written verification from SSA
any State issued ID card or Driver’s License

OR
Two documents over 5 years old which record the same month and year

OR
Three reliable documents indicating the same year of birth.

If the A/R turns 65 during a month, approve as aged for that month, but process the case on or after the A/R’s 65^th birthday.

If the A/R is not aged, verify whether the A/R is blind or disabled.

Blindness or Disability

Verify blindness or disability using one of the following sources:

Prima facie evidence
Disability Adjudication Section (DAS) (Form 71 no longer in use as of 09/2013, please use SSA Form 831)
State Medicaid Eligibility Unit (SMEU)

Form DMA-6 or other LOC instrument is not verification of disability.

Prima Facie Verification

RSDI disability benefits
Railroad Retirement disability benefits
Medicare (See exception below)
For SSI approvals only, the SDX disability/blind date verifies when disability began.

If no prima facie evidence exists, verify disability or blindness by means of a disability decision from DAS or SMEU.

Receipt of Medicare as a result of a kidney transplant, renal failure or dialysis is not prima facie evidence of disability. The Medicare number will have a T as the Beneficiary Identification Code (BIC).

Procedures

When to Request DAS Verification

Form 71 no longer in use as of 09/2013, please use SSA Form 831.

Request the results of a disability determination from DAS when no prima facie evidence exists for any of the applicable months prior to an approved SSI application.

DAS usually determines the disability onset date, including months prior to an approved SSI application. If available, check SDX on approved SSI recipients to verify the disability onset date. If the verified disability onset date covers the prior months, this onset date is prima facie evidence of disability and no SMEU decision is required. If current SDX information is not available, send a Form 71 to DAS for any months prior to an approved SSI application and only use SMEU procedures in situations where DAS indicates that they did not establish disability for those months. DAS does not complete disability determinations for months prior to denied applications. Use SMEU procedures for these situations.

How to Request DAS Verification

Send Form 71 to DAS via U.S. mail at:

P.O. Box 57
Stone Mountain, GA 30086-9902

Review the decision when Form 71 is returned by DAS.

Use the following chart to determine how to use a DAS decision to verify blindness/disability.

Chart 2205.1 – Verifying Blindness or Disability with a DAS Decision
IF DAS	THEN
determines the A/R is disabled or blind in any of the months requested	disability requirement is met for these months. Proceed to other eligibility criteria.
determines the A/R is not blind or disabled in any of the months requested	deny the application for these months.
indicates a determination has not been made for any of the months requested	obtain a SMEU decision for these months.

When to Request SMEU Verification

Request a decision from SMEU when there is no prima facie evidence of blindness or disability, an individual alleges a disability, or a determination was not rendered by DAS for the prior months (Form 71 no longer in use as of 09/2013, please use SSA Form 831).

SMEU Request for Stroke, Heart Attack, or By-Pass Patients

Follow SMEU procedures to verify disability. Document circumstances explaining delay, awaiting SMEU decision on stroke, heart attack, or by-pass patient. Three months after the incident has occurred, submit current medical verification detailing what, if any, permanent or long-lasting damage has occurred.

How to Request SMEU Verification

Follow the steps below to request a SMEU disability decision to verify blindness or disability.

Step 1

The DFCS Case Manager completes Form 184 SMEU Data Report in detail. Form 188 is obsolete effective 12/1/22.

SMEU Data Report (Form 184) must be completed by DFCS Case Manager.

Step 2

Obtain any of the following medical information applicable to the A/R:

Form 115, Report of Eye examination (Dr. supplies this form)
Hospital records, including discharge summary, if available
Physician’s medical records
Psychiatric and/or psychological examination reports
Current therapy notes (speech, occupational or physical)
X-ray and laboratory reports

Death Certificate

The above list is not all-inclusive. If medical information is not available and/or is incomplete, the A/R will need to obtain additional information from an examining physician or risk denial of disability based on insufficient medical reports.

Step 3

Effective 10/11/22, the SMEU submission process has changed due to SMEU Automation. DFCS Case Manager gathers all necessary documents:

Medical records
SMEU Data Report (Form 184)
SMEU Cover Letter (Form 245)

Any other relevant documents to substantiate disability

If SMEU requests additional information after original submission, send a checklist to the AR requesting the new information. If the AR fails to return the additional information, close the case for failure to verify and notify SMEU of the closure.

DFCS Case Manager will submit SMEU request by email to smeu@dhs.ga.gov. The DFCS Case Manager who submitted the request, and their supervisor will receive automated email communications throughout the process, including:

If initial submission has been accepted or returned for correction
If additional information is needed, i.e., 90-day follow-up
When decision has been made

Step 4

DFCS Case Manager will receive a task when SMEU decision letter has been uploaded.

Step 5

If paper medical records were received, after the Approval/Denial has been received from SMEU (for active cases at review), check with the A/R or authorized representative to see if the medical information used to determine disability should be returned to them or shredded. Shred the SMEU Data report. Do not retain or upload paper medical records.

A re-evaluation by SMEU may be required when an approval decision is rendered for only a specified timeframe per SSA guidelines.

Use the following chart to determine how to use a SMEU decision to verify disability or blindness:

Chart 2205.2 – Verifying Blindness or Disability with a SMEU Decision
IF SMEU determines the A/R is	THEN
disabled or blind for any of the months requested	the ABD requirement is met for these months. Proceed to other eligibility criteria.
not disabled or blind for any of the months requested	the ABD requirement is not met for these months. Deny the application for these months.

Use the following chart to determine when to begin verification of blindness or disability with the DAS procedures and when to begin with the SMEU procedure:

Form 71 no longer in use as of 09/2013, please use SSA Form 831.

Chart 2205.3 – When to Use DAS Vs. SMEU Procedures
IF the AR	THEN
has an approved SSI application AND applies for Medicaid for any of the months immediately prior to the month of the SSI application	follow the DAS procedures, if onset date is not available from current SDX information.
has a pending SSI application AND applies for Medicaid for any of the months immediately prior to the SSI application	follow the SMEU procedures. If potentially eligible for RSDI, refer to SSA to apply. Abide by SSA disability determination if it differs from SMEU determination.
is potentially eligible for SSI and RSDI and has not applied AND requests Medicaid at DFCS for any of the months immediately prior to the current month	follow the SMEU procedures. If potentially eligible for RSDI, refer to SSA to apply. Abide by SSA disability determination if it differs from SMEU determination.
is financially ineligible for SSI for all of the months for which Medicaid is requested AND has a RSDI application pending or is potentially RSDI eligible,	follow the SMEU procedures. If potentially eligible for RSDI, refer to SSA to apply. Abide by SSA disability determination if it differs from SMEU determination.
is deceased AND has never filed an application for SSI AND the surviving spouse or another individual requests Medicaid to cover unpaid medical bills	follow the SMEU procedures.
has a pending SSI application AND dies prior to SSA’s approval of the SSI AND the surviving spouse requests Medicaid to cover any unpaid medical bills	follow the SMEU procedures. Abide by SSA disability determination if it differs from SMEU determination.
has a pending SSI application AND dies prior to SSA’s approval of the SSI with no surviving spouse AND the A/R’s personal representative requests Medicaid to cover unpaid medical bills	follow SMEU procedures.
has a denied SSI application AND requests Medicaid for any of the 3 months prior to the SSI application	follow SMEU procedures.
SSI application is denied due to failure to meet the disability criteria AND the A/R requests Medicaid ongoing through DFCS	If the SSI denial is within 12 months of the DFCS application for ongoing Medicaid, deny the application and refer the applicant to SSA to reapply for SSI or request a reconsideration of the SSI decision (unless A/R reports a worsening of condition or a new condition, then follow SMEU procedures).

Verification

File the disability verification obtained through prima facie evidence or from DAS or SMEU in the case record. Do NOT retain copies of medical information in the case record. Return to the A/R or authorized representative or shred.

Documentation

Document the method of verification.

Special Considerations

When SSA makes a determination of not disabled for either RSDI or SSI, this ruling is in effect for 12 months. However, if the A/R alleges a worsening of his/her condition or if a different disabling condition has occurred, DFCS must accept a new Medicaid application upon expiration of the 12 months disability determination from SSA.

Follow SMEU procedures to verify disability.
It is important to submit medical evidence that substantiates the worsening and/or different condition alleged.
Document the applicant’s allegation of the change in his/her condition on the Form 184, SMEU Data Report, completed as part of the SMEU procedures.

If an A/R’s SSI has been terminated for a financial or non-financial reason other than failure to meet the disability requirement and s/he has applied for Medicaid through DFCS, the prior receipt of SSI is prima facie evidence of disability for twelve months following the last month of receipt of SSI. At the expiration of the twelve-month period, obtain a disability decision from SMEU.