New Informational Letter Limits Medicaid Determinations

March 1, 2009

Author: Catherine M. Callery (Kate)| Louise M. Tarantino

Ann Biddle, Esq., Paul M. Ryther, Esq.

Medicaid determinations done by local Departments of Social Services can sometimes prove invaluable to pending Social Security and SSI disability claims.  But it may be harder for advocates to take advantage of those determinations under a change in policy issued by the New York State Department of Health (DOH) last year.

As noted in the July 2008 edition of the Disability Law News, in accordance with 42 C.F.R. §435.541, an SSA disability determination is binding on a Medicaid case until the determination is changed by SSA or there is a change in the individual’s circumstances. On June 11, 2008, however, DOH issued 09 OHIP INF-3, which limits when such evaluations will be done.

Generally, Medicaid disability reviews are required if a determination of disability would yield a Medicaid benefit for the Applicant/Recipient or a financial benefit for the Medicaid program. According to 09 OHIP INF-3, however, once a subsequent Social Security review determines that an individual is not disabled, a favorable disability determination that had been made for Medicaid purposes is negated. The recipient/applicant must be removed from the SSI-related category for public assistance and Medicaid purposes.  If at a later date, the Social Security disability determination is overturned on appeal, the category will be changed back for Medicaid purposes.

Under this new policy, a local disability team may refuse to do a “Medicaid only” determination for an individual who has already been denied by SSA, even if an appeal is pending.  On the other hand, if an individual applies for Medicaid after an SSA denial, the state or local disability review team still must make a disability determination if the claimant alleges a different disabling condition than that considered by SSA, or alleges, under certain circumstances,  that his/her condition has deteriorated.  Advocates with claimants in this situation may want to make that argument - if at all possible - to local Medicaid agencies, since a favorable Medicaid determination may help the Social Security appeal in the long run.
The Informational Letter is available from the Online Resource Center, or directly from the NYSDOH at http://www.health.state.ny.us/health_care/medicaid/publications/docs/inf/08inf-3.pdf January 2008.