SOCIAL AND HEALTH SERVICES
(Economic Services Administration)
Preproposal statement of inquiry was filed as WSR 03-13-033.
Title of Rule: Amending WAC 388-448-0001 Establishing incapacity for general assistance, 388-448-0010 How we decide if you are incapacitated, 388-448-0020 How and from whom you can get medical evidence for incapacity determination, 388-448-0030 The kind of medical evidence you need to provide for determination of incapacity, 388-448-0120 How we decide how long you are incapacitated, 388-448-0160 Review of your incapacity, 388-448-0180 How and when we redetermine your eligibility when we decide you are eligible for GAX, 388-448-0200 Eligibility for general assistance unemployable pending SSI eligibility, and 388-448-0210 Assignment and recovery of interim assistance.
Purpose: To clarify the general assistance (GA) program intent on how a person's physical or mental disorder is evaluated to decide if there is a medical condition that prevents the person from working (incapacity).
Statutory Authority for Adoption: RCW 74.04.005, 74.08.090.
Statute Being Implemented: RCW 74.04.005.
Summary: The rule changes clarify when the department decides incapacity exists without using medical evidence, how gainful employment is decided, what is required for medical evidence to be objective and complete, which health professionals may provide medical evidence, when benefits based on incapacity stop and how to get benefits continued, and the conditions for receiving GA while the person is applying for supplemental security income (SSI).
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Doug Sevin, 1009 College S.E., Lacey, WA 98504, (360) 413-3097.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: See Title of Rule, Purpose, and Summary above.
Proposal Changes the Following Existing Rules: See Purpose and Summary above.
No small business economic impact statement has been prepared under chapter 19.85 RCW. This proposed rule does not have an economic impact on small businesses, it only affects DSHS clients.
RCW 34.05.328 does not apply to this rule adoption. These amendments are exempt as allowed under RCW 34.05.328 (5)(b)(vii) which states in-part, "[t]his section does not apply to ... rules of the department of social and health services relating only to client medical or financial eligibility and rules concerning liability for care of dependents."
Hearing Location: Office Building 2, Auditorium (DSHS Headquarters), 1115 Washington Street, Olympia, WA 98504 (public parking at 11th and Washington), on February 10, 2004, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by February 6, 2004, phone (360) 664-6094, TTY (360) 664-6178, e-mail firstname.lastname@example.org.
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, mail to P.O. Box 45850, Olympia, WA 98504-5850, deliver to 4500 10th Avenue S.E., Lacey, WA, fax (360) 664-6185, e-mail email@example.com, by 5:00 p.m., February 10, 2004.
Date of Intended Adoption: Not earlier than February 11, 2004.
January 5, 2004
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3356.3
"Incapacitated" means that you cannot be gainfully employed as a result of a physical or mental impairment that is expected to continue for at least ninety days from the date you apply.
"Physical impairment" means a diagnosable physical illness. "Mental impairment" means a diagnosable mental disorder. We exclude any diagnosis of or related to alcohol or drug abuse or addiction.
(1) We determine you are incapacitated if you are:
(a) Eligible for payments based on Social Security Administration (SSA) disability criteria;
(b) Eligible for services from the division of developmental disabilities (DDD);
(c) Diagnosed as ((
mentally retarded)) having mental
retardation based on a full scale score of seventy or lower on
the Wechsler adult intelligence scale (WAIS);
(d) At least ((
sixty-five)) sixty-four years old and
(e) Eligible for long-term care services from aging and
adult)) disability services administration; or
(f) Approved ((
by)) through the progressive evaluation
(2) We consider you to be incapacitated for ninety days
following your release from:
(a) An inpatient psychiatric treatment facility if:
(i) You directly participate in outpatient mental health treatment; and
(ii) The release from in-patient treatment was not against medical advice)) after:
(a) You are released from inpatient treatment for a mental impairment if:
(i) The release from inpatient treatment was not against medical advice; and
(ii) There is no break in your participation between inpatient and outpatient treatment of your mental impairment.
(b) You are released from a medical institution where you
received long-term care services from the aging and ((
disability services administration.
(c) The Social Security Administration stops your Supplemental Security Income payments because you are not a citizen.
[Statutory Authority: RCW 74.04.057, 74.08.090. 00-15-018, § 388-448-0001, filed 7/10/00, effective 9/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-448-0001, filed 7/31/98, effective 9/1/98.]
(1))) If you are gainfully employed at the time of your
application for ((
GAU)) GA, we deny incapacity. (( "Perform))
"Gainful employment" means you (( can perform)) are performing,
in a regular and predictable manner, an activity usually done
for pay or profit.
(1) We do not consider work to be gainful employment when you are working:
Working)) Under special conditions(( , like)) that
go beyond the employer providing reasonable accommodation,
such as in a sheltered workshop we have approved; or
Working)) Occasionally or part-time (( if your
medical condition)) because your impairment limits the hours
you (( can)) are able to work compared to unimpaired workers in
the same job as verified by your employer.
(2) We decide if you are ((
able to perform gainful
employment)) incapacitated when:
We receive an application for)) You apply for GA
benefits. We may waive this decision if (( medical
documentation requirements are waived under)) we use the
criteria in WAC 388-448-0001 except the PEP to determine you
(b) You become employed; ((
(c) You obtain work skills by completing a training program; or
(d) We get new information that indicates you may be employable.
(3) Unless ((
medical documentation requirements are
waived under)) you meet the other incapacity criteria in WAC 388-448-0001, we (( determine if incapacity exists using the
progressive evaluation process (PEP). When we receive your
medical evidence, we use the PEP to decide if there is a
medical impairment that prevents you from being gainfully
employed. The PEP is a sequence of seven-steps)) decide
incapacity by applying the progressive evaluation process
(PEP) to the medical evidence that you provide that meets WAC 388-448-0030. The PEP is the sequence of seven steps
described in WAC 388-448-0035 through 388-448-0110.
(4) You are not eligible for ((
GAU)) GA benefits if you
are incapacitated only because of alcoholism or drug
addiction. If you have a physical or mental impairment and
you are impaired by alcohol or drug addiction, we decide if
you are eligible for general assistance. If you qualify for
both (( GAU)) GA and the ADATSA Shelter program, you may choose
(5) In determining incapacity, we consider only your ability to perform basic work-related activities. "Basic work-related activities" are activities that anyone would be required to perform in a work setting. They consist of: Sitting, standing, walking, lifting, carrying, handling, seeing, hearing, communicating, and understanding and following instructions.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0010, filed 8/2/00, effective 9/1/00.]
We accept medical evidence from ((
the)) these sources
(( listed below)):
(1) For a physical impairment, ((
we only accept reports
from the following licensed medical professionals as primary
evidence)) a health professional licensed in Washington state
or where the examination was performed:
(a) A physician((
;)), which for GA program purposes,
(i) Medical doctor (M.D.);
(ii) Doctor of osteopathy (D.O.);
(iii) Doctor of optometry (O.D.) to evaluate visual acuity impairments;
(iv) Doctor of podiatry (D.P.) for foot disorders; and
(v) Doctor of dental surgery (D.D.S.) or doctor of medical dentistry (D.M.D.) for tooth abscesses or temporomandibular joint (TMJ) disorders.
(b) An advanced registered nurse practitioner (ARNP)
in)) for physical impairments that are within the ARNP's
area of certification to treat;
(c) The chief of medical administration of the Veterans' Administration, or their designee, as authorized in federal law; or
(d) A physician assistant when the report is co-signed by the supervising physician.
(2) For a mental impairment, ((
we only accept reports
from one of the following licensed)) professionals (( as
primary evidence)) licensed in Washington state or where the
examination was performed:
(a) A psychiatrist;
(b) A psychologist;
(c) An advanced registered nurse practitioner ((
certified in psychiatric nursing; or
(d) At our discretion:
(i) A person ((
who provides)) identified as a mental
health (( services in a community mental health services agency
and meets the minimum mental health)) professional within the
regional support network mental health treatment system
provided the person's training and qualifications (( set by
them, which consist of)) at a minimum include having a
Master's degree and two years of mental health treatment
(e))) (ii) The physician who is currently treating you
for a mental (( disorder)) impairment.
(3) "Supplemental medical evidence" means ((
a report from
a practitioner that can be used to support)) information from
a health professional not listed in subsection (1) or (2) of
this section and who can provide supporting medical evidence
(( given)) for impairments identified by any of the
(( practitioners)) professionals listed in subsections (1)
(( and)) or (2) of this section. We (( accept)) include as
supplemental medical evidence (( reports from)) sources:
(a) A ((
practitioner who is providing)) health
professional who has conducted tests on or provides on-going
treatment to you, such as a physical therapist, chiropractor,
nurse, physician assistant; or
(b) Workers at state institutions and agencies ((
who are not health professionals and are providing or have
provided medical or health-related services to you.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. 01-14-059, § 388-448-0020, filed 6/29/01, effective 8/1/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0020, filed 8/2/00, effective 9/1/00.]
(1) We only accept written medical evidence. It must contain clear, objective medical documentation that includes:
(a) A diagnosis for the incapacitating condition;
(b) The effect of the condition on your ability to perform work-related activities; and
(c) Relevant medical history and sufficient medical documentation to support conclusions of incapacity.
(2) The medical evidence must be based on an exam within the last ninety days.
(3) When making an incapacity decision, we do not use your report of symptoms as evidence unless medical findings show there is a medical condition that could reasonably be expected to produce the symptoms reported. In those cases, you must provide us with clear and objective medical information, including observation by the medical practitioner and relevant medical history that supports conclusions about:
(a) The existence and persistence of the symptom(s); and
(b) Its effect on your ability to perform basic work activities.
(4))) if you have an impairment and how that impairment prevents you from being capable of gainful employment. Medical evidence must be in writing and be clear, objective and complete.
(1) Objective evidence means:
(a) For physical impairment:
(i) Laboratory test results;
(ii) Pathology reports;
(iii) Radiology findings including results of X-rays and computer imaging scans;
(iv) Clinical finding, including but not limited to ranges of joint motion, blood pressure, temperature or pulse; and observations from physical examination; or
(v) Hospital history and physical reports and admission and discharge summaries; or
(vi) Other medical history and physical reports.
(b) For mental impairment:
(i) Examination results including:
(A) Clinical interview observations, including mental status exam results and interpretation; and
(B) Explanation of how examination findings meet the clinical and diagnostic criteria of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
(ii) Testing results, if any, including:
(A) Description and interpretation fo tests of memory, concentration, cognition or intelligence; or
(B) Interpretation of medical tests to identify or exclude a connection between the mental impairment and physical illness.
(2) To be complete, medical evidence must include:
(a) Diagnosis for the impairment;
(b) A clear description of how the impairment relates to your ability to perform the work-related activities listed in WAC 388-448-0010(5) including signs and observations of drug or alcohol abuse and whether any limitations on ability to perform work-related activities would continue after sixty days of abstinence from use of drugs or alcohol;
(c) Facts in addition to objective evidence to support the medical provider's opinion that you are unable to be gainfully employed, such as proof of hospitalization; and
(d) Based on an examination done within the ninety days of the date of application or the forty-five days prior to the month of incapacity review.
(3) When making an incapacity decision, we do not use your report of symptoms as evidence unless objective evidence shows there is an impairment that could reasonably be expected to produce those symptoms.
(4) If you cannot get medical evidence without cost to you and you meet the eligibility conditions other than incapacity in WAC 388-400-0025, we pay the costs to obtain objective evidence based on our published payment limits and designated fee schedules.
(5) We decide incapacity based solely on the objective information we receive. We are not obligated to accept a decision that you are incapacitated or unemployable made by another agency or person.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0030, filed 8/2/00, effective 9/1/00.]
Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 01-14-059, filed 6/29/01, effective 8/1/01)
WAC 388-448-0120 How we decide how long you are incapacitated. We ((
use the medical evidence and expected
length of recovery from the incapacitating condition to decide
the length of time you are eligible for GAU as follows:
(1) If you are eligible for GAU, a maximum of twelve months; or
(2) If we decide you are eligible for general assistance expedited Medicaid (GAX), a maximum of thirty-six months from the date of the latest incapacity approval)) decide how long you are incapacitated, up to the maximum period set by WAC 388-448-0160, using medical evidence on the expected length of time needed to heal or recover from the incapacitating disorder(s).
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. 01-14-059, § 388-448-0120, filed 6/29/01, effective 8/1/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0120, filed 8/2/00, effective 9/1/00.]
(2) We cannot extend GAU eligibility beyond the current eligibility end date if we do not receive current medical evidence that we decide is enough to show that you continue to be incapacitated)) The maximum period of eligibility for general assistance is twelve months before we must review additional medical evidence. We use medical evidence and the expected length of time before you are capable of gainful employment to decide when your benefits will end.
(2) Your benefits stop at the end of your incapacity period unless you provide additional medical evidence that demonstrates during your current incapacity period that there was no material improvement in your impairment. No material improvement means that your impairment continues to meet the progressive evaluation process criteria in WAC 388-448-0010 through 388-448-0110, excluding the requirement that your impairment(s) prevent employment for ninety days.
(3) Additional medical evidence must meet all of the criteria defined in WAC 388-448-0030.
(4) We use additional medical evidence received after your incapacity period had ended when:
(a) The delay was not due to your failure to cooperate; and
(b) We receive the evidence within thirty days of the end of your incapacity period; and
(c) The evidence meets the progressive evaluation process criteria in WAC 388-448-0010 through 388-448-0110.
(5) You must provide information about your cooperation and progress with treatment or agency referrals we required according to WAC 388-448-0130.
(6) We stop assistance before the end of your incapacity period when we discover that the previous incapacity decision was made:
(a) Using faulty or insufficient information; or
(b) Against the rules in effect at the time.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0160, filed 8/2/00, effective 9/1/00.]
(1) The maximum period of eligibility for GAX is twelve
months before we must review additional medical evidence. If
you remain on GAX at the end of the ((
twelve-month period, we determine your eligibility using
current medical evidence.
(2) If your application for SSI is denied, and the denial
is upheld by an SSI/SSA administrative hearing before the end
of the ((
thirty-six-month)) twelve-month incapacity period, we
change your program eligibility from GAX to (( GAU)) GA and
adjust the incapacity review date to be sixty days after the
administrative hearing date.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. 01-14-059, § 388-448-0180, filed 6/29/01, effective 8/1/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0180, filed 8/2/00, effective 9/1/00.]
Apply for SSI, follow through with your
application, and do not withdraw your application;
(2) Agree to assign the initial or reinstated SSI payment to DSHS as provided under WAC 388-448-0210; and
(3) Are otherwise eligible according to WAC 388-400-0025)) You may receive general assistance benefits while you are waiting to receive Social Security Supplemental Security Income (SSI) benefits only when you:
(a) Have filed your SSI application with the Social Security Administration (SSA), follow through with SSA directions and requirements to process your application including keeping all interview and consultative examination appointments, and do not withdraw your application;
(b) Agree to assign the initial or reinstated SSI payment to us provided under WAC 388-448-0210;
(c) Are otherwise eligible according to WAC 388-400-0025; and
(d) Meet incapacity criteria listed in WAC 388-448-0001.
(2) When we obtain certification that you are likely to qualify for SSI, we also approve categorical needy medical coverage under WAC 388-505-0110.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. 01-14-059, § 388-448-0200, filed 6/29/01, effective 8/1/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0200, filed 8/2/00, effective 9/1/00.]
(1) "Assign" means that you sign a written authorization
for the Social Security Administration (SSA) ((
will pay DSHS
directly from your reimbursement amount. The assignment will
be up to the amount of)) to send the SSI back payment to us.
We will deduct the interim assistance we (( provide)) provided
(2) "Interim assistance" means the ((
state)) GA funds we
(( provide to you to meet basic needs)) paid to you or on your
(a) The time between your SSI application date and the month recurring SSI payments begin; or
(b) The period your SSI payments were suspended or
terminated, and later reinstated ((
for that period)).
(3) We pay up to twenty-five percent of the interim
assistance reimbursement that we receive from the SSA to the
attorney who ((
has)) successfully represented you in your
effort to receive SSI.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, § 388-448-0210, filed 8/2/00, effective 9/1/00.]
The following sections of the Washington Administrative Code are repealed:
|WAC 388-448-0170||Termination requirement -- How we determine you are no longer incapacitated.|
|WAC 388-448-0190||Reinstating your eligibility after termination due to lack of medical evidence.|