Presumptive Disability in Medicaid and SSI
February 27, 2003
People with disabilities often get Medicaid when they qualify for SSI. Ordinarily, it can take many days for Social Security to determine that someone meets disability standards for SSI and Medicaid. Establishing "presumptive disability" is a faster way of qualifying.
Presumptive disability is addressed in Social Security regulations. The Social Security Administration uses the same medical criteria to make both Social Security Disability and SSI Disability determinations. However, only in the SSI program (and not in SSDI), people may be able to get immediate cash benefits if the Bureau of Disability Determinations presumes that they are disabled while a more formal determination of their disability is under consideration. Regulations provide a list of conditions that allow for a decision of presumptive eligibility without any medical evidence. The list is at 20 CFR Section 416.934:
The Social Security Administration may make findings of presumptive disability and presumptive blindness in specific impairment categories without obtaining any medical evidence. These specific impairment categories are as follow:
(a) Amputation of a leg at the hip;
(b) Allegation of total deafness;
(c) Allegation of total blindness;
(d) Allegation of bed confinement or immobility without a wheelchair, walker, or crutches, due to a longstanding condition, excluding recent accident and recent surgery;
(e) Allegation of a stroke (cerebral vascular accident) more than 3 months in the past and continued marked difficulty in walking or using a hand or arm;
(f) Allegation of cerebral palsy, muscular dystrophy or muscle atrophy and marked difficulty in walking (e.g., use of braces), speaking, or coordination of the hands or arms.
(g) Allegation of Down's syndrome ;
(h) Allegation of severe mental deficiency made by another individual filing on behalf of a claimant who is at least 7 years of age. For example, a mother filing for benefits for her child states that the child attends (or attended) a special school, or special classes in school, because of mental deficiency or is unable to attend any type of school (or if beyond school age, was unable to attend), and requires care and supervision of routine daily activities; and
(i) Allegation of amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease).
For disability determinations generally, a publication entitled Disability Evaluation Under Social Security, known as the "blue book," explains the criteria on which Social Security bases disability determinations.
Another presumptive disability process results in access only to Medicaid but not to cash. This process may be used when people are not applying for SSI but need Medicaid quickly, which is often the case for children with disabilities. The same criteria are used to determine presumptive disability, but determination processes may vary among states. Under federal law, all states must have some process to determine disability for Medicaid purposes when someone is applying only for Medicaid and not for SSI, and some process for presumptive eligibility determinations. States have differing arrangements about what agency or unit performs these disability determinations. For example, in Montana, the county initiates the process and an independent contractor, rather than the Social Security Bureau of Disability Determinations, determines disability.
Even if someone will qualify for SSI eventually, applying for Medicaid separately and asking for a Medicaid determination of disability is important if the person has current or recent medical expenses since the person may qualify for retroactive Medicaid coverage.
This fact sheet was initially prepared as part of a February 27, 2003 Health Assistance Partnership (HAP) conference call. The speakers included Michele Thibodeau, Bureau of Disability Determination, Social Security Administration, Montana, and Bonnie Adee, Mental Health Ombudsman, Montana.