209.13 Incapacity: Case Tech Determines Incapacity SR 94-04, 04/94 (FAM-A)

The determination of incapacity is made by either the case technician or by OMS, depending on case circumstances.

Case Technician

Automatically make a determination of incapacity for an individual:

• who is currently receiving SSI or SSA based on disability or is eligible but not receiving it due to recoupment. Because OMS must also keep an incapacity file, provide OMS with Form 177, Social Information, and Form 940, Cover Memo for Eligibility Information.

• who returns a Form 921, Determination of Incapacity Status, on which a physician or psychologist certifies the individual as incapacitated for 30 days or more. Set a review date for the end of the incapacity (as stated on the form) or for the first redetermination, whichever is earlier. Send the Form 921 to OMS for review; include Form 177, Social Information, and Form 940, Cover Memo for Eligibility Information.

• whom OMS has previously established as permanently incapacitated.

• who reapplies within 90 days of being denied or terminated from a case in which their incapacity has already been established. The reason for the denial or termination must not be related to incapacity or earnings from employment.

• who is convalescing after being treated in an institution for the mentally ill, or who was discharged within 90 days prior to applying for assistance.

• who is needy and mentally retarded, has resided in a state-operated ICF/MR, and was officially discharged within 90 days of applying for assistance. Require documentation of congenital mental retardation confirmed by a psychological evaluation at any time after age ten, or a psychological evaluation before age ten confirming an IQ of 40 or less.

Notify OMS of changes in an incapacitated parent’s medical status.

If the incapacity meets the 30-day minimum time period but ends before an application can be processed within time frames, the case is eligible only for medical assistance and not for financial assistance.

OMS

OMS makes a determination of incapacity when the applicant is unable to return a Form 921 which clearly defines an incapacity. OMS initiates decision-making upon receiving one or both of the following forms from the case technician: Form 915, Report of Medical Findings, or Form 920, Report of Mental Status.

When there is a potential for change in the status of an incapacity, OMS is alerted by DFA to review continuing medical eligibility:

• when the case is due for medical review, or

• when the case is due for redetermination.

If the medical review date is later than the redetermination date, a redetermination of incapacity is not necessary until the medical review date.