WSR 01-14-059

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Economic Services Administration)

[ Filed June 29, 2001, 4:00 p.m. , effective August 1, 2001 ]

Date of Adoption: June 29, 2001.

Purpose: Chapter 388-448 WAC, Incapacity, this revision is being done to clarify treatment and referral requirements for general assistance unemployable recipients and remove ambiguity from the language in related incapacity rules.

Citation of Existing Rules Affected by this Order: Amending WAC 388-448-0020, 388-448-0070, 388-448-0120, 388-448-0130, 388-448-0140, 388-448-0180, and 388-448-0200.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090.

Adopted under notice filed as WSR 01-11-106 on May 21, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 7, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 7, Repealed 0.
Effective Date of Rule: August 1, 2001.

June 29, 2001

Brian Lindgren, Manager

Rules and Policies Assistance Unit

2947.4
AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0020   How and from whom you can get medical evidence for incapacity determination.   Before we can ((find out)) decide if you are eligible for GAU, you must give us medical evidence that meets the requirements in WAC 388-448-0030. Medical evidence provides us with the details of your impairment and how it affects your ability to be gainfully employed. If you cannot get medical evidence without cost to you and you are otherwise eligible according to WAC 388-400-0025, we will pay the fees or other expenses based on our published policies and payment limits.

We accept medical evidence from the sources listed below:

(1) For a physical impairment, we only accept reports from the following licensed medical professionals as primary evidence:

(a) A physician;

(b) An advanced registered nurse practitioner (ARNP) in the ARNP's area of certification;

(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:

(a) A psychiatrist;

(b) A psychologist;

(c) An advanced registered nurse practitioner when certified in psychiatric nursing;

(d) A person who provides mental health services in a community mental health services ((setting)) agency and meets the minimum mental health ((practitioner)) professional qualifications set by ((the local community mental health agency)) them, which consist of having a ((Master of Arts (MA))) Master's degree and two years experience; or

(e) The physician who is currently treating you for a mental disorder.

(3) "Supplemental medical evidence" means a report from a practitioner that can be used to support medical evidence given by any of the practitioners listed in subsections (1) and (2) of this section. We accept as supplemental medical evidence reports from:

(a) A practitioner who is providing on-going treatment to you, such as a chiropractor, nurse, physician assistant; or

(b) ((DSHS)) State institutions and agencies that are providing or have provided services to you.

[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.]


AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0070   PEP step IV -- How we determine the severity of multiple impairments.   (1) If you have more than one impairment we decide the overall severity rating by deciding if your impairments have a combined effect on your ability to be gainfully employed. Each diagnosis is grouped by affected organ or function into one of ((twelve)) thirteen "body systems." The ((twelve)) thirteen body systems consist of:

(a) Musculo-skeletal,

(b) Special senses and speech,

(c) Respiratory,

(d) Cardiovascular,

(e) Digestive,

(f) Genito-urinary,

(g) Hemic and lymphatic,

(h) Skin,

(i) Endocrine and obesity,

(j) Neurological,

(k) Mental disorders,

(l) Neoplastic, and

(((l))) (m) Immune systems.

(2) We follow these rules when there are multiple impairments:

(a) We group each diagnosis by body system.

(b) When you have two or more diagnosed impairments that limit work activities, we assign an overall severity rating as follows:

Your Condition Severity Rating
(i) All impairments are in the same body system, are rated two and there is no cumulative effect on basic work activities. 2
(ii) All impairments are in the same body system, are rated two and there is a cumulative effect on basic work activities.

(iii) All impairments are in different body systems, are rated two and there is a cumulative effect on basic work activities.

 3
(iv) Two or more impairments are in different body systems and are rated three.

(v) Two or more impairments are in different body systems; one is rated three and one is rated four.

 4
(vi) Two or more impairments in different body systems are rated four. 5
(c) We deny incapacity when the overall severity rating is two.

(d) We approve incapacity when the overall severity rating is five.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, 388-448-0070, filed 8/2/00, effective 9/1/00.]


AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0120   How we decide how long you are incapacitated.   We ((decide the maximum length of time you are eligible for GAU based on incapacity according to)) 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) ((Thirty-six months when we decide it is evident you meet federal disability criteria to receive Social Security Supplemental Security Income (SSI))) If you are eligible for GAU, a maximum of twelve months; or

(2) ((Twelve months)) 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.

[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.]


AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0130   Treatment and referral requirements.   We refer you to medical providers for available medical treatment or other agencies for treatment ((or)), rehabilitation ((to)) or work activities when we decide it will improve your ability to ((engage in gainful employment)) be gainfully employed or reduce your need for GAU. "Available medical treatment" means medical, surgical, chemical dependency, or mental health services, or a combination of them.

(1) When you are first approved and at each review determination, we give you written information regarding your treatment requirements ((when you are initially approved, and at each redetermination)).

(2) You must accept and follow through on required medical treatment and referrals to other agencies and services, including applying for SSI, unless you have ((a convincing reason)) good cause for not doing so. Examples of good cause are found in WAC 388-448-0140.

(3) ((If your basic claim of incapacity is alcoholism or drug dependency, we refer you for evaluation under the alcoholism and drug addiction treatment and support act (ADATSA).

(4))) We may require you to undergo alcohol or drug treatment before ((re-evaluating)) reviewing your eligibility for GAU.

(((5))) (4) You may request a fair hearing if you disagree with the treatment or referral requirements we set for you (see WAC 388-458-0040). ((If you request a fair hearing we will not reduce or stop your benefits as a result of your refusal to follow the requirement until the fair hearing is decided.))

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, 388-448-0130, filed 8/2/00, effective 9/1/00.]


AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0140   Good cause for refusing medical treatment or other agency referrals.   We may determine that you have good cause for refusing required treatment or referrals to other agencies. We may require you to provide ((documentation)) proof to support your good cause claim. Valid reasons for refusing treatment and other agency referrals include, but are not limited to, the following:

(1) Valid reasons for refusing treatment referrals:

(a) You are so fearful of the treatment that your fear could interfere with the treatment or reduce its benefits;

(b) Treatment could cause further limitations or loss of a function or an organ and you are not willing to take that risk;

(c) You practice an organized religion that prohibits treatment; or

(d) Treatment is not available without cost to you.

(2) Valid reasons for refusing treatment or other agency referrals:

(a) ((You)) We did not ((have)) give you enough information ((on)) about the requirement;

(b) You did not receive written notice of the requirement;

(((b))) (c) The requirement was made in error;

(((c))) (d) You are temporarily unable to participate because of documented interference, or

(((d))) (e) Your medical condition or limitations are consistent with the definition of necessary supplemental accommodation (NSA), WAC ((388-200-1300)), 388-472-0020 and your condition or limitations contributed to your refusal, per WAC 388-472-0050.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 00-16-113, 388-448-0140, filed 8/2/00, effective 9/1/00.]


AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0180   How and when we redetermine your eligibility if ((it is evident you meet federal disability criteria for SSI)) we decide you are eligible for GAX.   When we decide you are eligible for GAX, we may extend your incapacity period up to thirty-six months from the date of the last ((date of)) incapacity ((determination)) decision without requesting additional medical documentation ((when it is evident that you meet federal disability criteria for Supplemental Security Income (SSI) eligibility)).

(1) If you remain on GAX at the end of the thirty-six-month period, we determine your eligibility ((at the end of the thirty-six-month period,)) using current medical evidence.

(2) If ((you applied)) your application for SSI((, were)) is denied, and the denial ((was)) is upheld by an SSI/SSA administrative ((appeal)) hearing before the end of the thirty-six-month incapacity period, we change your program eligibility from GAX to GAU and adjust the incapacity ((period)) review date to be sixty days after the ((SSI denial)) administrative hearing date.

[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.]


AMENDATORY SECTION(Amending WSR 00-16-113, filed 8/2/00, effective 9/1/00)

WAC 388-448-0200   Eligibility for general assistance unemployable pending SSI eligibility.   If we approve you ((are applying for SSI and we determine you may become eligible for SSI, we approve you for GAU benefits. The assistance is)) for GAX, benefits are authorized through the month SSI payments begin if you:

(1) Apply for SSI ((and)), 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.

[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.]

Washington State Code Reviser's Office