Disability Determinations in TAFDC and EAEDC

Disability Determinations in TAFDC AND EAEDC

The June CRC Info Session featured guest speakers, Ambika Panday and Rebecca Plummer, attorneys from Greater Boston Legal Services, Welfare Law Unit. The presentation gave an overview of the Massachusetts Disability Determination process relating to the TAFDC and EAEDC programs.

TAFDC and EAEDC Basics

Both TAFDC and EAEDC are cash assistance programs issued by the Department of Transitional Assistance (DTA). TAFDC is available to certain low-income households with dependent children and EAEDC is available primarily to elderly or disabled adults or their caretakers.

Some similarities and differences between the TAFDC and EAEDC disability programs follow.

Similarities:

The disability determination process is the same for both the EAEDC and TAFDC programs.

Applicants for EAEDC and TAFDC disability exemptions have to complete the same Disability Supplement Form

DES (UMass Medical School’s Disability Evaluation Service) makes the disability determinations for both TAFDC and EAEDC.

DES uses virtually identical disability criteria for both EAEDC and TAFDC (except for a difference in the duration requirement).

Differences:

To qualify for EAEDC disability status, the disability must be expected to last at least 60 days versus TAFDC, in which a disability only needs to be expected to last at least 30 days.

To be eligible for EAEDC based on a disability, a person has to have an EAEDC Medical Report completed by his or her doctor versus the TAFDC program, which does not have a Medical Report requirement.

For more information about the TAFDC and EAEDC programs please see: http://healthcare.partners.org/ss/ssframebottom/staffresources/New%20Site/Basic%20Needs/BN_PB-CA_TAFDC-EAEDC.html OR www.mghsocialwork.org > Staff Access > Basic Needs > Cash Assistance > TAFDC/EAEDC

When does DTA evaluate applicants’ or recipients’ disabilities?

EAEDC: Those who are applying for EAEDC on the basis of disability must go through a disability screening review. Their disability status will also be subject to periodic reevaluation.

TAFDC: In contrast, the TAFDC program, was designed to assist families with dependent children and does not require disability for eligibility. However, parents/caretakers are subject to work requirements and benefit time-limits (24 months out of a 5 year period). There are exemptions from these requirements for those with disabilities- which is where the disability review process comes into play.

TAFDC Disability Exemption from the Work Requirement & Time Limit

A TAFDC applicant or recipient may be entitled to a disability exemption if he or she has a physical, emotional, or cognitive impairment that lasts at least 30 days and substantially reduces his or her ability to support him/herself. An individual must meet the DTA medical standards for disability according to the DTA regulations, which can be read at: 106 CMR 203.540 (for TAFDC) and 106 CMR 320.210 (for EAEDC). If the University of Massachusetts Medical School, Disability Evaluation Services (DES), determines the applicant/recipient is disabled, she is exempt from the two-year time limit and the TAFDC work requirement. The work requirement specifics vary but usually consist of documenting 20-30 hours a week of work, community service, or structured job search. An additional benefit from exemption- those with exempt status receive a monthly TAFDC grant that is 2.75% higher than a non-exempt grant.

Other ways to qualify:

Those who have been approved for or receive SSI or SSDI benefits are considered disabled for TAFDC purposes. TAFDC applicants do not need to go through the DTA disability review nor do they need to fill out a separate medical report or disability supplement, instead applicants must show the Social Security Administration approval letter.

Any person who has been approved for MassHealth Standard on the basis of being disabled is automatically qualified as disabled for the TAFDC program. The disability will be deemed “current” as long as the approved duration of the disability has not expired. DTA is supposed to check with the Division of Medical Assistance (DMA) directly, therefore, eliminating a separate disability review by DTA.

Advocacy Tip – While under a disability exemption, recipients may participate in Education and Training programs and even work, but they are not required to participate.

Note: Another exemption is available to caregivers who are unable to meet the TAFDC work requirement due to the disability and related care needs of the child. The Caregiver Exemption does not require a disability evaluation by DTA, instead applicants must fill out the “Verification of Caring for Disabled” form (with the help of the disabled person’s medical provider).

The Disability Determination Process

1. Applying for TAFDC Disability Exemptions or EAEDC Benefits:

To apply for TAFDC Disability Exemptions or EAEDC benefits, individuals must complete the Disability Supplement form, which asks the recipient to list all of his or her impairments (physical, psychological, and cognitive) and how the impairments interfere with his or her ability to work. The supplement also requires a complete list of medical providers and others who may be able to provide information about why the applicant is unable to work.

EAEDC applicants must also submit a doctor-signed Medical Report form that is based upon an examination conducted within 30 days of completing the report. The forms are available in both English and Spanish; however, if requested, DTA or DES must provide translator assistance in any language, this can either be directly or through AT & T telephone translation services.

ADVOCACY TIP – The disability Supplement (and the Medical Report Form for EAEDC) must be received by DTA within 30 days of the date of application for the TAFDC disability exemption or EAEDC benefits. If the forms are not received within the allotted time, applicants must start the application process over.

2. Submitting a Disability Supplement:

The Disability Supplement form must be returned to the caseworker at DTA. DTA then forwards the original form to the University of Massachusetts Medical School, Disability Evaluation Services (DES).

Advocacy Tip - The original form must first go to DTA, not to DES. If the deadline is approaching, the form can be submitted by fax with a promise that the original will be mailed right away.

3. Will DES accept information about an applicant’s disability after the disability application is submitted?

Yes, any additional medical, social service, vocational information that is provided by the claimant or on his/her behalf can be submitted as a supplement to the already pending disability application. The supplemental information can be given to the DTA worker with a letter requesting that it be forwarded to DES as part of the disability claim OR the supplemental information can be faxed directly to DES. To ensure that the fax reaches the appropriate person at DES, first call DES Medical Records at 1-800-888-3420 and ask which nurse/evaluator has the claim. The information should then be faxed to the evaluator’s attention at 1-508-721-7292. You will need the applicants/recipient’s Social Security number when talking to the DES, as claims are organized by SSN.

Advocacy Tip - It is prudent to call DES a few days after submitting supplemental information to confirm that the correct person at DES received the information.

4. How does DES Review Disability Claims?

First, DES develops a medical record by contacting all treating sources that were listed within the Disability Supplement to request any written information regarding the applicant; this includes progress notes, lab reports, test results, and consultations. A multi-step consideration process is the used to determine disability. This process includes use of the medical standards as set forth in the state regulations at 106 CMR 203.540 (for TAFDC) and 106 CMR 320.210 (for EAEDC). The review also includes an assessment of an applicant’s individual and combination of impairments, functional abilities, vocational abilities, and work history.

Next, if there is not enough information within the applicant’s records to determine disability status, DES schedules a Consultative Exam (CE). It is essential that the applicant attend the Consultative Exam, otherwise the applicant will be automatically denied. If the applicant needs to reschedule a CE, or misses a CE with good cause (i.e., reasons related to disability, child illness, break-down of transportation, day care or interpreter services) the patient should call DES, not the doctor’s office, and keep a record of the phone call. If the applicant anticipates that they will need transportation or interpreter services, they must call DES as early as possible in advance of the CE to request such assistance.

Advocacy Tips – DES will generally grant ONE rescheduling without hassle, but subsequent rescheduling requires more advocacy and the applicant should contact legal services for assistance.

5. The Decision

DES reports the disability claim decision —whether the applicant was found disabled and the duration of the disability (the duration of disability determines when a case will next need to be reviewed by DES) – to both DTA and the applicant. DTA then sends a separate notice to the applicant explaining how this will affect the applicant’s benefits.

6. While a Disability Application is pending

During the Disability Determination Process an applicant may be exempt from the work requirement and time limit as set by the TAFDC regulations. To qualify for this exemption pending disability determination, the applicant cannot have had any disability exemption denials within the last five years. If this is the case, then the applicant will receive “presumptive” exemption status while DES is reviewing the claim.

If the applicant is not considered eligible for presumptive exemption status, to be exempt during the disability determination process, he or she must have a doctor, psychologist, or psychiatrist sign a Good Cause Medical Statement to verify that his or her disability will last for at least 30 days. Submitting a Good Cause Medical Statement will protect the applicant from the TAFDC work requirement during the period when the disability claim is pending.

EAEDC applicants are eligible to receive benefits while the disability evaluation is still pending, as long as the medical report and disability supplement are issued to DTA within 30 days of the date of application for benefits. Benefits are issued retroactively to the date of application. If the applicant is found not disabled, benefits paid while a disability application was pending DO NOT have to be paid back.

For TAFDC recipients who file a disability exemption, they would need to repay the 2.5% grant increase if they are found not disabled.

How Advocates in Health Settings Can Help

Speakers Ambika Panday and Rebecca Plummer put together a series of tips specifically for advocates in a healthcare setting who are working with disability applicants.

1. Include All Relevant Information

When listing impairments on the disability supplement include all relevant symptoms to give a fuller picture of the impact on daily function.

Additionally asking the patient whether or not they have ever seen a therapist or psychiatrist, and what issues were discussed may help to focus on how the impairments affect daily life tasks and/or the ability to work.

Last, it may be helpful to ask the patient if he or she has ever been diagnosed or prescribed medication to treat any impairment.

2. How can you help develop your patient’s disability claim?

Assistance with gathering the patient’s most recent medical records, test results, and diagnoses can be extremely helpful in expediting the disability claim process.

It can be extremely beneficial to directly contact the patient’s medical provider(s) requesting a letter on behalf of the patient. In speaking with the provider it is best to direct him or her to the medical listings 106 CMR 203.540 (for TAFDC) and 106 CMR 320.210 (for EAEDC) and ask that the diagnosis, symptoms, and functional limitations be explicitly detailed along with their expected duration. To expedite the process you may want to offer to draft the letter based on a conversation with the doctor, then have the doctor edit and sign it on his or her letterhead.

Last, you can write your own letter on behalf of the patient stating your assessment of the patient’s inability to work, which can be attached to the Disability Supplement or faxed after the application to the claim evaluator at DES (See Step 3 in the Disability Determination Process).

3. What are some challenges you may face when talking to your patients about their impairments?

Patients may be embarrassed to discuss their impairment (especially mental health and cognitive impairments).

Patients may not like to be labeled “disabled” as they may associate it with being “crazy” or “lazy”.

Patients may not connect their symptoms to a pertinent impairment.

Patients may be afraid if they say they are disabled, it will appear that they can’t care for their kids adequately.

Patients may mistakenly believe they cannot pursue an education or training program if the Department of Transitional Assistance finds them disabled.

4. What are some ways to work with the providers in this process?

Explain to providers that they do NOT need to determine whether the patient is “disabled”. DES makes this decision.

It may also be helpful to remind providers that the patient is applying for or trying to maintain subsistence benefits; the sooner they submit the disability application, the better off they and their family will be. The typical monthly grants for TAFDC are $478-491 for a family of 2 (in 2008) or for EAEDC $303 or less for an individual who shares expenses.

SEALS/MGH Collaboration (Program Closed)

If a patient encounters problems navigating the disability determination process, Social Service staff may fax a referral to the SEALS Program at 617-371-1222 (attention: Welfare Law Unit). Although the SEALS program cannot guarantee representation to all clients, they are happy to provide advice or strategies.

-Thanks again to Ambika Panday and Rebecca Plummer for their presentation and help with this article.

06/08