Disability, as defined and used by the Social Security Administration (SSA), is the individual's inability to be gainfully and substantially employed for one year or longer due to a physical or mental incapacity. The FSD Medical Review Team (MRT) uses this definition to determine if an applicant or participant is considered disabled for MO HealthNet for the Aged, Blind, and Disabled (MHABD) programs.
MRT, rather than the FSD office, determines medical eligibility per 13 CSR 40-2.200(1). Before a MO HealthNet for Aged, Blind, and Disabled (MHABD) application can be rejected or a case closed on the factor of disability, the Eligibility Specialist (ES) outside St. Louis City must send a referral packet to the MRT-Processing Center (MRT - PC) for a medical determination. St. Louis City has a separate MRT and processes.
EXCEPTION: Medical eligibility is established and a medical determination by the MRT is not required for MHABD if the applicant/participant:
NOTE: A hard copy of the IIVE is required to be filed in the case record at the initial eligibility and each annual review for verification of disability.
NOTE: Disability is verified effective the date the Social Security Administration determined the individual became disabled. MRT must determine eligibility for months prior to the SSA disability start date.
NOTE: Presumptive SSI Eligibility is not a guarantee that the participant is disabled, and an MRT decision is required.
NOTE: If the individual earns more than SGA, an MRT decision is required.
Do not refer to the MRT – PC any cases that are obviously ineligible on any eligibility factor other than disability or resources. If a case, already referred to MRT – PC and pending a determination of disability, is later rejected or closed on a factor other than disability, notify MRT - PC immediately upon rejection/closing by emailing MRT.Personnel@dss.mo.gov
Do NOT hold the MRT - PC packet to determine eligibility on other factors. The MRT - PC must receive the packet in a timely manner to allow sufficient time for processing.
If the claimant does not receive SSDI, disability-based SSI, or Medicare under the conditions noted above in the months in which coverage is requested, medical evidence must be submitted to the Medical Review Team (MRT). St. Louis City has a separate MRT and processes that must be followed.
Offices outside of St. Louis City must submit the MRT - PC packet immediately upon receipt. The packet must contain sufficient information for the MRT - PC to request and obtain the medical information to determine eligibility. The MRT - PC is responsible for obtaining the medical documentation and/or setting any medical appointments.
Completed packets are submitted to the MRT - PC by scanning the information into the Work Site at ssmrt@ip.sp.mo.gov. Field staff do not request medical records. However, any medical documentation submitted by the applicant/participant or the Authorized Representative must be sent to the MRT - PC along with the completed packet.
The MRT - PC packet consists of:
NOTE: Medical information submitted to MRT containing reports restricted from disclosure (confidential reports) by the examining physician or issuing source must be called to the attention of MRT.
If the MRT - PC packet is incomplete or illegible and MRT-PC is unable to quickly correct the packet, it will be returned and not considered submitted.
The MRT – Processing Center (MRT - PC) will:
If the applicant/participant has failed to attend a scheduled medical evaluation and:
NOTE: Prior to closing the MRT- PC action, MRT- PC staff will review EUMEMROL comments to determine if there were extenuating circumstances related to the missed appointment. If there is note of extenuating circumstances, such as comments from the FSD Info Center that the applicant/participant had been attempting to reach someone to reschedule prior to the appointment or notes regarding illness or hospitalization of the applicant/participant at the time of the appointment, the MRT- Processing Center will reschedule the appointment rather than closing their actions.
For new applicants received by offices outside of St. Louis City, forward the MRT - PC packet and any medical information provided to the MRT - PC via Work Site at ssmrt@ip.sp.mo.gov. St. Louis City has a separate MRT and processes. An MRT decision is always required for new applicants who:
NOTE: If an applicant is approved for SSDI/SSI during the application process, MRT must still determine medical eligibility for any months he/she is requesting coverage and did not receive a SSDI/SSI payment
The Substantial Gainful Activity (SGA) limit is defined by the Social Security Administration and is usually updated annually. Refer to Appendix D for information regarding Substantial Gainful Activity.
Submitting information to MRT is:
For applicants who claim to incur IRWE, it is important to gather accurate documentation regarding these expenses and income so that the MRT can make an appropriate decision regarding MHABD or Ticket to Work Health Assurance (TWHA) eligibility.
IRWE are expenses related to the participant's disabilities that are necessary to enable him/her to work. IRWE may include, but are not limited to:
It is the responsibility of the local FSD to obtain Verified Earned Income and Verified Medical Expenses. The FSD will exclude sick leave and vacation pay from the determination of SGA for disability purposes. For the Medical Review Team (MRT) to make an accurate determination of SGA:
For offices using the MRT –PC, ensure that income recorded on the MRT Checklist has been converted to monthly amounts.
EXAMPLE: Mr. Smith's pay stubs show he works 40 hours per week at a rate of pay of $7.00 per hour. 40 hours x $7.00 = $280.00 per week x 4.333= $1213.24. Mr. Smith does not claim impairment-related work expenses. $1213.24 is recorded on the Checklist.
NOTE: Do not hold submission of the MRT - PC Packet awaiting verification of earned income and medical expenses as the packet is time sensitive. There is a field to indicate that the income and/or expenses are pending at the time of submission. Provide the verification of either/both upon receipt.
If the income and expenses are not verified at the time the packet is submitted, they are emailed to MRT-PC at MRT.Personnel@dss.mo.gov when received. The email should be titled “Additional Information” and should include the individual’s name, date of birth, and DCN in the body of the email. If the ES chooses to submit the MRT Checklist form again in this email, including the updated/verified information, the ES must clearly indicate on the form that it is a duplicate submission with updated information.
EXAMPLE: Ms Jones applied for MO HealthNet for the Aged, Blind, Disabled on February 2. During the discussion with the ES, she claims work-related equipment and assistive devices totaling $590.00 necessary to maintain employment. At the point of the application, Ms Jones does not have verification of the income or expenses. The ES completes the MRT - PC packet, marking the box that the verification is pending, and submits it within 5 business days to the MRT-Processing Center. Ms Jones submits her paystubs and verification of her expenses. Ms. Jones' pay stubs show she works 40 hours per week at a rate of pay of $7.00 per hour. 40 hours x $7.00 = $280.00 per week x 4.333 = $1213.24. She provides verification of the expenses for the total $590. The ES submits this verification by email to the MRT-Processing Center.
For all cases previously reviewed by MRT in which the participant does not currently receive disability-based SSI, SSDI, or Medicare based on the conditions noted above, submit medical information to the MRT for a redetermination. For office outside of St. Louis City, submit a new MRT - PC packet, completed in the same manner as an initial submission. St. Louis City has a separate MRT and processes.
In cases where MRT has specified that future medical review is unnecessary, no forms are sent to MRT unless a change occurs that might indicate that the participant is no longer permanently and totally disabled. If such a change occurs, submit a new MRT - PC packet.
Many cases are determined eligible on the disability factor because of receipt of SSI or RSDI. However, this determination becomes invalid when the claimant:
In either situation, obtain medical information and submit immediately to MRT along with the Social Information Summary (IM-61) to establish the claimant's eligibility on this factor.
EXCEPTION: An individual whose SSI benefits are suspended due to a balance in an Achieving Better Life Experience (ABLE) account in excess of $100,000 shall be treated for purposes of MO HealthNet as if the individual continued to be receiving payment of SSI benefits.
When MRT has waived re-examination, further evaluation on this factor is unnecessary unless, there has been improvement to the extent a re-determination of medical eligibility is advisable. In such cases, submit medical information to the MRT. St. Louis City has a separate MRT and processes. Offices outside of St. Louis City do this by completing the MRT - PC packet and submitting it MRT-PC via the Work Site at ssmrt@ip.sp.mo.gov.
The MRT decision regarding continued disability is completed outside of the eligibility reinvestigation process. Do not wait for the eligibility reinvestigation to complete a medical re-determination. These are two separate determinations.
When MRT approves the claimant for a specific period of time (for example, one year), obtain the MRT – PC packet information early enough so the necessary information is available to MRT two weeks before the date specified. Ensure the packet is received by the MRT - PC sufficiently early to allow the Processing Center time to request and obtain the needed medical data for MRT.
When MRT finds a claimant medically ineligible based on disability, but medically eligible for General Relief (GR), immediately explore eligibility based on other GR factors (unless the investigation disclosed the claimant would not be eligible for GR on another factor or the GR program is not in effect).
NOTE: A Hearing decision reversing the agency’s disability determination is valid until the next redetermination, unless otherwise specified in the decision.
MRT, rather than the caseworker, decides eligibility on this factor. The decision is generally made at the time of initial approval or at time of reinvestigation. The caseworker may request review of this factor between reinvestigations because of a recent rejection of an offer of vocational rehabilitation or healing treatment by the claimant.
Include on the Social Information Form (IM-61) all information regarding referral to vocational rehabilitation or to medical treatment (including institutional care) available to the claimant, as well as information regarding acceptance or rejection of such help. In cases where the claimant has rejected VR or medical treatment, full information should be given as to the reasons the individual was unwilling to except such service.
MRT reviews all information submitted, and requests additional information on an individual case basis. When a case must be closed or an application rejected based on refusal to accept VR or medical treatment, FSD receives an administrative decision from MRT.
Attention to the VR/medical treatment eligibility factor during a case investigation is necessary only when notified by MRT that the factor is applicable to the individual case.