Medical Assistance for People Who Are Age 65 or Older or People Who Are Blind or Have a Disability

2.3.2.2 Certification of Disability (Archive)

Disability or blindness must be certified by the Social Security Administration (SSA) or the State Medical Review Team (SMRT). The certification process is also called a disability determination.

People receiving the following benefits may or may not be certified disabled by SSA or SMRT.

• Short-term disability

• Long-term disability

• Long-term care insurance

• Veterans' Administration (VA)

• Railroad Retirement Board (RRB)

• Worker’s Compensation

Medicare

An individual does not need a disability determination if they are eligible for Medicare, and lose their RSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level. These people are eligible for the Medicare extension (as long as SSA considers these people to remain disabled during the Medicare extension, they continue to meet a disabled basis for MA).

Only a SSA or SMRT certification of disability is valid for the purposes listed below.

Disability Certification for MA Eligibility

People must be certified disabled and use the disabled or blind basis of eligibility to:

• Enroll in MA for Employed Persons with Disabilities (MA-EPD)

• MA-EPD enrollees who lose their certification of disability with SSA must be referred to SMRT for a certification of disability. An MA-EPD enrollee who is referred to SMRT remains eligible for MA-EPD during the time SMRT is making its determination.

• Access MA under the TEFRA option for children with a disability is named after the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 that created the option. Children with a disability and household income above the MA income limit need a disability certification and level of care determination to use the TEFRA option.

• SMRT makes the level of care determination.

• Receive home and community-based services through the:

  • Brain Injury (BI) waiver

  • Community Alternative Care (CAC) waiver

  • Community Access for Disability Inclusion (CADI) waiver

A disability certification is not needed for services under the Developmentally Disabled (DD) waiver. The county case manager determines if the person meets the criteria for a developmental disability.

Children turning 18 need a new disability certification under the adult standards to continue using a blind or disabled basis of eligibility.

Disability Certification for Other Reasons

Some MA enrollees get a disability certification for managed care reasons including:

• To be excluded from managed care enrollment

  • A person does not have to use a disability basis of eligibility for Medical Assistance in order to be excluded from managed care enrollment

• To enroll in Special Needs Basic Care (SNBC), a specialized managed care plan for people age 18-64 with a certified disability

Additional reasons for needing a disability certification include:

• Family Support Grant (FSG) eligibility

• Aged 65 and older and establishing a pooled trust

• Establish an asset transfer penalty exception

• Creating certain trusts

State Medical Review Team Certification of Disability

SMRT completes disability determinations for people not certified disabled by SSA. SMRT certifies disability using the same disability criteria as the SSA.

Referral Process

SMRT referrals must be made even if the person has been referred to SSA because the SSA disability determination process can be long. The county, tribal or state servicing agency completes a SMRT Referral for a Disability Determination. Referrals are sent in only through the Integrated Service Delivery System ( ISDS).

Expedited Case Criteria

SMRT expedites the disability determination process in the following situations where the person is likely to meet disability criteria:

• The person has a condition that appears on the SSA Compassionate Allowance Listing (CAL)

• The person is awaiting discharge from a facility and can be discharged immediately if MA is approved

• The person has a potentially life-threatening situation and requires immediate treatment or medication

• Other circumstances that may jeopardize a client's benefits. The circumstance is reviewed and accepted on a case by case basis

Continuing Disability Review

People certified disabled by SMRT need a continuing disability review every one to seven years. Disability standards are different for children and adults, so at age 18, a child must be evaluated under the adult standards. Newborns certified disabled due to a low-birth weight must be reviewed prior to age one.

Additional SMRT Referrals:

The following people need a SMRT referral:

• People whose Supplemental Security Income (SSI) or Retirement, Survivors, and Disability Insurance (RSDI) application is pending or being appealed.

• People who are not eligible for SSI or RSDI, because they earn more than the substantial gainful activity (SGA) level.

• People whose SSI, RSDI, or 1619(a) or 1619(b) benefits are terminated.

• People who have extended Medicare but who are no longer receiving RSDI. Some people may remain disabled but lose RSDI because they earn more than the substantial gainful activity (SGA) level. Because SSA considers them to remain disabled, they continue to meet a disabled basis of eligibility for MA. A referral to SMRT should be made two months before the Medicare extension ends.

Legal Citations

Code of Federal Regulations, title 20, sections 404.1501 to 404.1599

Code of Federal Regulations, title 20, sections 416.901 to 416.999d

Code of Federal Regulations, title 42, section 435.541

Minnesota Statutes, section 256.01

Published: September 1, 2020

Archived: June 1, 2022