340:10-10-2. Physical or mental incapacity of the natural or adoptive parent
(a) Scope and applicability.The physical or mental incapacity of a natural or adoptive parent exists when one parent has a physical or mental illness or impairment that substantially reduces or eliminates the parent's ability to support or care for his or her child(ren).To be considered incapacitated, the parent's illness or impairment must be expected to last for at least a 30-calendar day period.The physical or mental incapacity must be supported by competent medical and social evidence.
(1)Both parents may be included in the assistance unit when either parent is incapacitated regardless of whether the parent who is not incapacitated is employed or the incapacitated parent's usual function as a homemaker or wage earner.
(2) The reduction of the ability to provide support to an eligible child is not the same as the inability to perform work.A parent may be working or capable of work but still be incapacitated for the purposes of establishing eligibility for Temporary Assistance for Needy Families (TANF).The criterion is the reduced ability of the parent to provide support or care, not the parent's employability.
(b) Determination of substantial reduction or elimination of ability to provide support or care.The factors in (1) - (8) of this subsection are considered evidence of a substantial reduction or elimination of a parent's ability to provide support or care.One factor by itself does not automatically determine that a parent is incapacitated.These factors are indicators to the Oklahoma Health Care Authority, Level of Care Evaluation Unit (LOCEU) of the various ways a physical or mental impairment affects a parent's ability and the extent that such ability is affected.Any factor considered must exist as a result of the parent's physical or mental impairment and must be supported by specific medical information or social facts. • 1Factors include the:
(1) parent's inability to perform any type of gainful employment;
(2) parent's ability to provide care for the child(ren) is substantially impaired without help from others; • 2
(3) parent qualifies for placement in a job that is rehabilitative or therapeutic, or for work in a sheltered workshop that is not considered to be a competitive full-time job;
(4) number of hours the parent is able to work is substantially reduced;
(5) wages the parent is able to earn are substantially reduced;
(6) parent is unable to work in his or her customary occupation, but is able to work at employment that he or she is equipped by education, training, and experience to perform, but that pays substantially less than his or her customary employment;
(7) parent is incapable of accomplishing as much on the job as an unimpaired worker and is or would be paid on a reduced basis even though able to work full- time; or
(8) employer's refusal to hire the parent due to of the nature of the parent's physical or mental impairment.This includes behavioral disorders and disabling conditions.
(c) Determination of incapacity at the time of application.When deprivation at application for TANF is based on the incapacity of a parent who receives Social Security Administration (SSA) disability benefits, Supplemental Security Income (SSI) due to disability or blindness, or State Supplemental Payment (SSP) for the blind or disabled, the determination of disability or blindness that established SSA, SSI, or SSP eligibility establishes incapacity for TANF. • 3When disability or blindness was not predetermined by the previous criteria, a referral is sent to LOCEU to make an incapacity decision for TANF eligibility.
(1) The worker obtains medical information from the client or, with the client's permission, from the relevant health professional and sends the medicalinformation and a completed Form 08MA022E, Medical Social Summary, to LOCEU for use in determining incapacity.The medical information must be less than 90-calendar days old in order for LOCEU to make an incapacity decision, per OAC 317:35-5-4(2)(C). • 4
(2) When existing medical information cannot be obtained without cost to the client, payment may be authorized for existing medical information or one general physical examination by a medical or osteopathic physician of the parent's choice.The physician cannot be in an intern, residency, or fellowship program of the medical facility, or in the full-time employment of the Veterans Administration, Public Health Service, or other agency.Refer to OAC 317:35-3-2 for information regarding transportation and subsistence assistance. • 5
(3) Form 08MA022E, completed with the client, along with medical documentation provides sufficient medical and social information to enable LOCEU staff to make a prompt and proper decision.Upon receipt of the medical documentation and Form 08MA022E, a medical review team within LOCEU is responsible for:
(A) making an incapacity decision; • 6
(B) setting the incapacity eligibility effective date;
(C) requesting additional medical and social information when it is necessary for a decision;
(D) setting the date when a re-examination and medical social summary is needed or stating no further medical social summary is needed; • 7 and
(E) recommending a training plan, when advisable. • 8
(d) Incapacity not established.LOCEU determines if incapacity is established based on the medical and social information provided.When incapacity cannot be established, LOCEU describes the specific factors relied on to make the decision. • 9 The worker denies the application or closes the TANF benefit as incapacity was not established.
(e) Incapacity determination at renewal or other specified times after certification. • 10 When the parent's initial incapacity was based on an SSA determination of blindness or disability or by LOCEU the steps outlined in (1) - (6) of this subsection are followed.When SSA or LOCEU no longer consider the parent incapacitated, the worker closes the TANF benefit.
(1) No further incapacity determination is required when the parent continues to receive SSI based on disability or blindness or SSA disability benefits.
(2) When the parent stops receiving SSA or SSI because SSA determines the parent no longer meets the disability or blindness definition and the parent states he or she is still incapacitated, an incapacity decision must be made by LOCEU.Form 08MA022E is completed and submitted to LOCEU for a determination of continuing incapacity for TANF, per (c) of this Section.
(3) When SSA discontinues disability benefits or SSI benefits for a reason other than failure to meet the definition of disability or blindness and the assistance unit meets all other conditions of TANF eligibility, continuing incapacity is determined by LOCEU per (c) of this Section.
(4) When the parent continues to receive SSP on the basis of an LOCEU decision, no further determination of incapacity is made as long as the parent continues to be eligible for SSP because of disability or blindness.
(5) When LOCEU determines the person no longer meets the definition of disability or blindness but the assistance unit meets all other conditions of TANF eligibility, the worker requests that LOCEU determine incapacity, per (c) of this Section.
(6) When LOCEU staff determined initial incapacity and includes a date when a new Form 08MA022E is due, the worker completes Form 08MA022E with the client and begins gathering new medical information per (c) of this Section the month before a new incapacity decision is due. • 11
(f) Incapacity determination at reapplication.An incapacity determination is not needed at reapplication when TANF was previously denied or closed for reasons other than incapacity, the:
(1) parent's incapacity was established prior to denial or closure, and the incapacity approval date extends beyond the reapplication date; or • 12
(2) parent receives SSP or SSI benefits based on disability or blindness or SSA disability benefits. • 13
1.(a) The medical information includes:
(1) a medical diagnosis of the parent's current medical condition;
(2) an explanation of how the medical diagnosis affects the parent's ability to perform his or her usual and customary job skills; and
(3) a prognosis for the parent's future medical condition.
(b) The worker sends all pertinent supporting documents necessary to substantiate or explain the medical diagnosis and medical summary and Form 08MA022E, Medical Social Summary, to the Oklahoma Health Care Authority (OHCA), Level of Care Evaluation Unit (LOCEU) by:
(1) email to LOCEU@okhca.org;
(2) interagency mail with a cover sheet addressed to OHCA: LOCEU;
(3) mail to Oklahoma Health Care Authority LOCEU, 4345 N. Lincoln Boulevard, Oklahoma City, Oklahoma 73105; or
(4) fax to 405-530-3312 or 405-530-3272.
(c) Refer to the "How to Complete the Medical Social Summary (08MA022E)" article in Quest for help in completing Form 08MA022E.
(d) The MDL and MDI screens in the information management system (IMS) normally show receipt of the information within a week of submission.
(1) When a submission date does not display on the MDI screen within 10-calendar days, the worker phones OHCA LOCEU for additional information at 405-522-7663.
(2) Refer to the "Medical Eligibility and Data Tracking System (MEDATS" article on Quest for information regarding how to use the MDL and MDI transactions.
2.Child care includes feeding, cleaning, and supervision of the child(ren).
3.The worker verifies the receipt of Social Security or Supplemental Security Income (SSI) by seeing the award letter or check.Refer to Oklahoma Administrative Code (OAC) 340:65-3-4 for Beneficiary and Earnings Data Exchange System (BENDEX) or Supplemental Data Exchange (SDX) data exchange screens when the award letter or check is not available.The worker documents the verification provided in Family Assistance/Client Services (FACS) case notes.
4.When the worker requests existing medical information from a doctor, hospital, or other medical provider, he or she attaches a signed Form 13HI003E, Authorization to Disclose Medical Records, to the request letter.When a hospital charges for this service or certification is delayed because of the failure of a hospital to furnish records, Form 08MA022E must contain this information.
5.The worker authorizes an examination by use of Form 08MA016E, Authorization for Examination and Billing and attaches Form 08MA080E, Report of Physician's Examination, and Form HCFA-1500, Health Insurance Claim Form.Refer to OAC 317:35-3-2for information regarding transportation and subsistence payments.Refer toOAC 317:35-5-4(2)(C) for additional information regarding incapacity determination procedures.
6.When LOCEU staff needs additional information or makes a decision, it appears on the MDL and MDI screens.The worker must check these screens at least once per week for updates.Refer to the "Medical Eligibility and Data Tracking System (MEDATS)" article on Quest for information regarding how to read the MDL and MDI screens.
7.(a) When the 'Review' field on the MDI transaction shows a date when the next medical social summary is due, the worker enters this date in the 'Medical Evaluation Date' field of the Medical General tab in the Eligibility Notebook of the Family Assistance/Client Services (FACS) system.
(b) Refer to the "Coding Incapacity for TANF" article in Quest for coding instructions.
8.When LOCEU considers the client medically feasible for services from the Oklahoma Department of Rehabilitation Services (DRS), the recommendation appears in the 'Comments' field of the MDI screen 'Comments' field.The worker gives the client Form 08MP013E, Referral for Services, to take to the local DRS office.A decision as to the feasibility of services is made by DRS.The services prescribed by DRS becomes a part of the parent's employability plan.
9.The worker checks the MDL transaction to determine LOCEU's incapacity decision.When LOCEU determines the client is not incapacitated, the MDI transaction shows a brief reason for denial in the 'Comments' field.The worker is responsible for explaining the reason incapacity was not determined and the parent's right to request a fair hearing.
10.When LOCEU determines the parent is incapacitated, the MDI screen specifies the date when incapacity must be re-determined or that further re-determination is not needed.
11.Case Worker Activity (CWA) Report 10, Medical Evaluation Due Next Month, appears on the worker's CWA Report the month before the next medical evaluation is due.This may or may not coincide with the TANF renewal date.
12.When the worker determines the applicant is eligible for TANF, refer to the "Coding Incapacity for TANF" article in Quest for incapacity coding instructions.
13.When none of the circumstances of this subsection exist, LOCEU must make a determination of incapacity.