317:35-5-4(1)(F)

If the Social Security Administration (SSA) denies an application for not meeting the criteria for disability or blindness, the DHS application for ABD-related services is denied for “incapacity, disability or blindness not established (18)”.

After SSA denies the application, the applicant can file an appeal with SSA. This appeals process can take months or years. During the process, the appellant must respond when asked to provide information or documentation. If s/he responds to all the requests in a timely manner, SSA’s disability decision will usually go back to the original application date. If the medical evidence shows the disability started after the SSA application date or the client did not provide everything requested in a timely manner, the disability decision will not go back to the SSA application date.

If an appeal is found in the client’s favor, the DHS application that had been denied for “incapacity not established” can be used to certify a medical benefit, but not the SSP. [An application that was denied for “incapacity, disability or blindness not determined (18a)” can also be used again; this is because sometimes this code is used by mistake. No other denial codes can be revisited under this policy.] There are two requirements.

1. The SSI Eligibility Date (SDX Block 5) or RSDI Disability Onset Date (Bendex Block 59) must be in the same month or a previous month as the DHS application. (Example: If the DHS application date is 11/12/2017, the SSI Eligibility Date needs to be 11/2017 or earlier).
2. Client must meet all other factors of eligibility (income, resources, citizenship, etc.) for each of the months to be covered.

If the SSI Eligibility Date or RSDI Disability Onset Date does not cover the DHS application date, a new application will be needed to certify the medical benefit. (Example: The DHS application date is 08/01/2018 but the SSI Eligibility Date is 01/15/2019. The 08/2018 application can’t be used.)

If the client has more medical services received after the initial application date, s/he may want to submit a new application to make sure the new medical bill is covered. If a new application is submitted, it can be denied for “incapacity not established” until SSA decides the client is blind or disabled. If the client meets all facets of Social Security’s definition of disability, the disability decision will go back to the original application with SSA. (Example: The original application with DHS was on 08/01/2017. On 01/13/2018, the client goes to the emergency room. The client knows she hasn’t provided everything to SSA in a timely manner. She decides to submit a new application to make sure this service could be covered if SSA approves her.

Additional Examples:

• Mary applied for SSI on 07/12/2017. She turned in an application with DHS for ABD-related benefits on 08/30/2017. She was denied by SSI for having the capacity for substantial gainful activity, so DHS denied its application for incapacity not established. On 02/14/2018, she goes to the emergency room. She comes back to DHS on 12/11/2018 saying SSI has approved her and she wants her medical approved back to 02/2018 to cover the emergency room bill. SDX shows the SSI Eligibility Date is 10/12/2017.

The SSI Eligibility Date doesn’t go back to the 07/2017 application so it can’t be used. There is no application within 3 months of 02/2018 so there is no way to certify a medical benefit.  A new application is taken to certify ABD-related benefits from that date forward.

• Tom applied for SSI on 05/02/2016. He first applied for ABD-related benefits with DHS on 05/05/2016. SSI denied him because they found “applicant is not disabled”. The DHS application is denied for incapacity not established. He files an appeal with SSI.
  • He had an emergency room visit on 12/02/2016. He applies again with DHS on 01/10/2017. It is immediately denied since the SSI benefit is still denied. The denial is for incapacity not established.
  • He has another emergency room visit on 02/23/2018. He goes back to DHS to put in another application for ABD-related benefits on 04/05/2018. This application is also immediately denied since the SSI benefit is still denied; this application is also denied for incapacity not established.
  • He comes back to DHS on 12/31/2018 saying he was approved for SSI and he would like help with both emergency room bills. SDX shows an SSI Eligibility Date of 01/25/2018.

Since the SSI Eligibility Date doesn’t go back to 05/2016, that application can’t be used. SSI didn’t determine eligibility for 12/2016, that medical bill can’t be covered either. The SSI Eligibility Date does cover the 02/2018 bill. It is within three months of the 04/2018 application so it can be used to certify the medical benefit back to 02/2018.

• Aaron applied with SSI then DHS on 04/14/2016. He was initially denied by SSI for not meeting disability criteria, so the DHS application was denied for incapacity not established. Aaron filed an appeal with SSI. He did not come back to DHS till 12/20/2018, after the appeal went in his favor. He had a letter showing he was eligible for SSI to 04/14/2016. Aaron asked for the medical benefit to be certified from 04/2016. He is asked for income and resource verification back to 04/2016. He received $10,000 when his mother died on 01/20/2017. Bank records show it took three months to spend it under the QMBP standard.

Aaron’s medical benefit is certified effective 04/2016 then closed on income effective 01/2017. There is no other application so a new one is taken to re-certify his medical benefit effective 12/2018.