9 CCR 2503-5-3.541 - DISABILITY REQUIREMENTS
A. To
qualify for AND-SO, the client must meet both the non-financial and financial
eligibility requirements and have a total disability as defined in Section
3.540.1 and pursuant to Sections
26-2-103(14)(a)
and 26-2-111(4)(a),
C.R.S.
1. To meet the total disability
requirement for AND-SO, the client shall be certified by a medical professional
as defined by Section 3.541.1.
2.
The client must have a physical or mental impairment that is disabling as
identified by the SSA in the Listing Of Impairments and consistent with Federal
Regulations found at 20 CFR, Appendix 1 to Subpart p of Part 404 (September 24,
2019), which are herein incorporated by reference. This rule does not contain
any later amendments or editions. These regulations are available at no cost at
https://www.ecfr.gov/. These
regulations are also available for public inspection and copying at the
Colorado Department of Human Services, Director of the Employment and Benefits
Division, 1575 Sherman Street, Denver, Colorado, 80203, or at any State
publications library during regular business hours.
3. The total disability must be expected to
last six (6) months or longer.
B. To determine the client's disability the
county department shall review and document medical data.
1. The county department shall review State
prescribed medical certification form(s) and/or any Medicaid disability
determination; and,
2. The county
department shall weigh more heavily a disability determination completed
through a Medicaid disability determination process than a medical
certification form completed by a medical provider.
C. The county department shall review all
documentation collected to determine if the client is eligible for
AND-SO.
3.541.1
MEDICAL
CERTIFICATION FORM
A. Medical
certification shall be completed on the State Department's prescribed medical
certification form.
1. The county department
shall provide the form to the client or the medical provider at the time of
application or interview and prior to the re-examination due date. The client
shall arrange for the medical exam with an appropriate medical provider of his
or her choosing.
a. It is the county
department's responsibility to provide the medical form to the client or the
client's provider of choice within ten (10) calendar days of
application.
b. If the client fails
to submit the required medical examination within thirty (30) calendar days
following the interview, the client has failed to comply with the requirements
for eligibility and the client's participation in the program will be denied or
discontinued following the policies outlined in Section 3.554.
c. If the client requests a second opinion,
the subsequent medical examination shall be at the client's expense.
d. If the county department requests a second
opinion, the subsequent medical examination shall be at the county department's
expense.
e. The county department
shall review the medical certification form for completeness and to determine
whether the information submitted is in conflict with other medical data,
records, documentation, and information and/or observations received from the
client, family, friends, professionals, community members, or the county
department. The county department shall:
1)
Ensure any incomplete forms are returned to the provider to be completed;
and,
2) Consult and verify with the
provider any questionable or contradictory information.
2. The medical certification shall
be completed and signed by a medical provider as defined in Section 3.540.
a. The client shall be allowed to choose a
medical provider licensed in a bordering state when the nearest Colorado
provider is more than one hour from the client's home.
b. The medical certification must be dated no
earlier than ninety (90) days before the application or
recertification.
3. The
medical certification form shall contain the disability limitations, including
the length and scope of the disability, if any; and,
4. The medical re-examination date shall be
based upon the date of the application or redetermination and the length of the
disability, as documented by the medical provider, but shall not exceed twelve
(12) months. However, if the client has been determined disabled by the State
disability review contractor, the medical re-examination date shall be
established by the review contractor.
B. The medical examination determining the
client's disability and completion of the medical certification form shall be
completed by a medical provider that accepts Medicaid whenever possible when
the client is receiving Medicaid. If the client's primary medical provider does
not accept Medicaid or the client is not receiving Medicaid, the county
department shall authorize payment for examinations for AND-SO medical
certification examinations.
1. Fees and costs
shall be reimbursed to the county department using the 80% State share, 20%
county share reimbursement methodology described in Section
26-1-122(3)(B),
C.R.S.
2. The county department
shall set the provider fee and shall make such payments in a timely
manner.
3. Providers shall accept
fees for services as negotiated as payment in full. No client shall be assessed
any additional or supplementary fee.
4. Providers may be excluded from completing
medical certification examinations if there is adequate documentation that the
provider:
a. Is not completing a thorough
examination on which to base his or her decision; or,
b. Falsified a medical certification
form.
C. A
determination of medical eligibility shall be completed by each medical
re-examination date. The county department shall be allowed to request the
client submit a medical re-examination at the time of financial redetermination
or when the county has information that the client's medical condition may have
changed.
1. Prior to the medical
re-examination due date, the county department shall send a new medical
certification form to the client.
2. If the client fails to submit the required
medical re-examination by the redetermination due date, the county department
shall terminate assistance following the policies outlined in Section
3.554.
3.541.2
DENIAL AND DISCONTINUATION
RELATED TO DISABILITY
A. Following the
policies outlined in Section 3.554, the county department shall deny or
discontinue AND-SO assistance when:
1. There
was an error in the prior disability determination. The county department shall
gather more information on the discrepancies before taking a negative action on
the case; or,
2. There has been
improvement in the client's medical condition and the client is no longer
totally disabled, as defined in Section 3.540.1 . Improvement may be
demonstrated by:
a. Observations, symptoms,
or other findings which demonstrate positive changes in the client's medical
condition; or,
b. Observations,
symptoms, or other findings which demonstrate that the effect of the medical
impairment(s) on the client has decreased.
c. New medical evidence which shows that
while the client's underlying condition may not have changed, advances in
medical therapy or technology have reduced or eliminated the adverse effect of
the condition on the client; or,
d.
New or improved diagnostic techniques or other medical evaluations show that
the client's previously determined medical condition is not as serious as
previously indicated; or,
e. There
has been a change in prognosis; or,
f. The client has compensated or adjusted to
the medical condition which now enables the client to engage in SGA;
or,
g. The client's medical
condition is correctable and the client refuses, without good cause, to obtain
prescribed medical treatment to correct the condition. Good cause may include,
but is not limited to:
1) Treatment is
contrary to the established teachings of the client's religion, provided the
client can establish he or she observes his or her religion; or,
2) Surgery has previously been performed with
unsuccessful results and the same surgery is again being recommended for the
same impairment; or,
3) The
treatment because of its magnitude (e.g., open heart surgery or organ
transplant that has less than a 50% chance of improving the client's condition)
or unusual nature (e.g., experimental procedures) is very risky; or,
4) The cost of treatment is prohibitive or
cannot be obtained; or,
3. There has been improvement in the client's
residual functional capacity and the client is not totally disabled, as defined
in Section 3.540.1 . Improvement may be demonstrated by:
a. Observations, symptoms, or other findings
which demonstrate positive changes in the client's residual functional
capacity; or,
b. Observations,
symptoms, or other findings which demonstrate that the effect of the social
factors impacting residual functional capacity on the client has decreased;
or,
c. New evidence shows that
while the client's underlying condition may not have changed, the client's
vocational abilities and/or residual functional capacity has so improved that
the client is able to engage in SGA; or,
d. Vocational opportunities for which the
client has competence have become available in the community; or,
e. The client has compensated or adjusted to
the social factors impacting residual functional capacity and the client is
able to engage in SGA; or,
f.
Residual functional capacity is not a barrier to employment in some type of
employment that exists in the community.
B. If the county department has documented
evidence that a client is working and receiving earnings exceeding the AND-SO
grant standard after applicable disregards as an employee, engaged in
self-employment, or donating services or work hours without pay as defined in
Section 3.520.784, the county department shall deny or discontinue the client
from AND-SO grant payments following the policies outlined in Section
3.554.
3.541.3
DISABILITY DUE TO SUBSTANCE ABUSE
For the purpose of AND-SO, when the client's primary diagnosis is alcoholism or controlled substance addiction, the following criteria shall apply pursuant to Section 26-2-111(4)(E), C.R.S.:
A. The client shall only be
eligible for twelve (12) cumulative months in a lifetime when substance abuse
is identified on the medical certification form.
B. The client shall agree to treatment for
addiction to be eligible for AND-SO. Upon consent, the county department shall
refer the client to an assessment/treatment agency licensed by the State
Department's Office of Behavioral Health.
C. The client shall agree to a defined
treatment program by the licensed agency.
D. If the client fails to comply with
treatment, the following steps shall be followed:
1. The treatment center shall contact the
county department within twenty-four (24) hours of the client's termination
from treatment; and,
2. The county
department shall discontinue the client's AND-SO assistance immediately upon
termination from treatment effective the following month with timely notice
provided.
E. The client
shall submit to random testing by the licensed agency to ensure the client
remains free of alcohol or controlled substance(s).
F. Any time a client tests positive for
alcohol or controlled substance(s), the client shall be warned by the treatment
center in writing. A copy of the written warnings shall be placed in the
client's file and noted as either mailed or hand delivered. If a client tests
positive for alcohol or controlled substance(s) twice in any three-month
period, the county department shall be notified and the client shall be
terminated from AND-SO immediately effective the following month with timely
notice provided.
G. The initial
partial month is not counted toward the twelve-month maximum allowed. However,
if a client is discontinued and subsequently reapplies and is approved, partial
months after re-approval will count as a full month toward the twelve-month
maximum allowed.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.