EAEDC Disablity Process

(A) An EAEDC applicant or client younger than 65 years old is disabled if he or she has an impairment or combination of impairments that is expected to last 60 days or more and that substantially reduces or eliminates the applicant’s or client’s ability to support himself or herself. An applicant or client shall be considered as having such an impairment or combination of impairments if he or she: (1) has an impairment or combination of impairments verified by a competent medical authority as defined in 106 CMR 701.600: Definition of Terms, on a medical report prescribed by the Department, which meets the requirements of 106 CMR 703.191(D). The competent medical authority and the agency or organization under contract/agreement with the Department to provide disability evaluation services (hereafter referred to as the Department’s agent), when required, determines that the impairment: (a) meets a standard as specified in 106 CMR 703.192; (b) is included in the SSI Listing of Impairments as specified in 20 CFR, Part 404, Subpart P, Appendix 1; or (c) substantially reduces or eliminates the applicant’s or client’s ability to support himself or herself when consideration is given to the vocational factors as specified in 106 CMR 703.193; or (2) has written notification from SSA or an administrative law judge that he or she is considered disabled for purposes of SSI or SSDI and/or that he or she is eligible for SSI or SSDI. However, this provision does not apply to those who are not currently receiving SSI or SSDI payments due to the recoupment of an overpayment by SSA. Such person is not eligible for EAEDC. (B) An EAEDC applicant or client must apply for SSI and cooperate in the SSI application and/or appeal process when required by the Department or the Department’s agent. (C) An EAEDC client must submit verifications at times determined by the Department and/or the Department’s agent of his or her: (1) disability as defined in 106 CMR 703.191(A)(1) from a competent medical authority as defined in 106 CMR 701.600: Definition of Terms; or (2) being determined disabled for purposes of SSI or SSDI as specified in 106 CMR 703.191(A)(2). (D) The medical report required by 106 CMR 703.191(A)(1) must be completed within 30 days of providing it to the Department and must be based on an examination conducted within the preceding 30 days from completion unless: (1) the medical report is for an applicant; and (2) the impairments listed are chronic and no improvement could be expected. (E) The Department’s agent shall make the determination of disability for EAEDC eligibility except when: (1) a competent medical authority as defined in 106 CMR 701.600: Definition of Terms verifies that the applicant or client has an impairment or combination of impairments that: (a) is expected to last at least 60 days but not more than 90 days; and (b) meets or is equivalent to a medical standard defined in 106 CMR 703.192 or impairment included in the SSI Listing of Impairments. (2) the applicant’s or client’s medical report is not completed by a competent medical authority, is not completed within 30 days of filing with the Department, or is not based on an examination conducted within 30 days from completion as required by l06 CMR 703.191(D); (3) a competent medical authority verifies that the EAEDC applicant or client does not have an impairment that affects his or her ability to work and/or that the applicant’s or client’s impairment or combination of impairments is not expected to last for 60 days or more; or (4) the applicant or client verifies that he or she is eligible for SSI or SSDI or considered disabled for purposes of SSI or SSDI (see 106 CMR 703.191(A)(2)). (F) If a disability determination by the Department’s agent is: (1) required and the competent medical authority states that the applicant or client meets a medical standard, SSI Listing of Impairments, or has an impairment affecting his or her ability to work, and if otherwise eligible, the applicant or client shall receive EAEDC benefits pending a review by the Department’s agent; or (2) not required because of 106 CMR 703.191(E), the EAEDC applicant or client shall be considered disabled upon giving the Department the necessary medical report or verifications and shall receive EAEDC benefits if otherwise eligible. (G) When the Department’s agent is required to make a disability determination (see 106 CMR 703.191(E)), it shall determine in the order listed whether the applicant or client has an impairment or combination of impairments that: (1) meets the MassHealth disability standards; (2) meets or is equivalent to a medical standard specified in 106 CMR 703.192; (3) does not meet a medical standard specified in 106 CMR 703.192, but meets or is equivalent to an impairment included in the SSI Listing of Impairments; or (4) neither meets nor is equivalent to a medical standard specified in 106 CMR 703.192 or an impairment included in the SSI Listing of Impairments, but the impairment, or combination of impairments, substantially reduces or eliminates the applicant’s or client’s ability to support himself or herself when consideration is given to the vocational factors specified in 106 CMR 703.193. In making the determination in 106 CMR 703.191(G)(4), the impairment, or combination of impairments, shall not be compared to the medical standards specified in 106 CMR 703.192 or the SSI Listing of Impairments. The determination shall be based on the applicant’s or client’s functional capacity and his or her ability to do work in light of the vocational factors as specified in 106 CMR 703.193. (H) The Department’s agent shall make a determination that an applicant or client is not disabled only if: (1) the agent has considered all evidence submitted by the applicant or client and/or obtained by the Department (see 106 CMR 702.315(B)(2)). The Department shall consider a test completed and diagnosis made more than 30 days prior to the completion of the applicant’s or client’s medical report if it is still relevant to his or her current impairments; (2) the clinical information available establishes that one or more of the findings required to meet or equal the applicable medical standard or the SSI listed impairment, is not satisfied and additional clinical information would not enable the applicant or client to meet or equal the applicable medical standard or the SSI listed impairment; and (3) a vocational determination of not disabled is made pursuant to 106 CMR 703.193. In making this determination, the Department’s agent shall rely on the functional capacity assessment made by the competent medical authority who completed the applicant’s or client’s medical report unless: (a) the assessment is inconsistent with the clinical findings or the clinical findings are not sufficient to make this determination; or (b) the assessment is inconsistent with the statements made by the applicant or client. In either of these situations, the Department’s agent shall obtain whatever additional information is needed to determine the applicant’s or client’s functional capacity. (I) When an applicant, who has previously been denied by the Department’s agent, makes another claim of disability, an eligibility determination shall be completed: (1) when the Department’s agent makes a decision on this new disability claim; or (2) if such a determination is not made in time to allow initial benefits to be provided within 30 days of the date of application, a presumptive finding of eligibility based on the disability shall be made pending the decision from the Department’s agent. (J) When a client who has been previously denied by the Department’s agent, makes another claim of disability within a continuous 60-month period, the eligibility determination shall be based on the applicant or client not being disabled, pending a decision by the Department’s agent. (K) The decision of the Department’s agent as to whether an applicant or client is disabled shall be the decision of the Department. A Department hearings referee may affirm, modify or reverse the finding of the agency or organization providing the disability evaluation services.