Changes to mental impairment listings

Social Security has substantially changed the mental impairment listings effective January 17, 2017.  The revisions add three new listed impairments: neurodevelopmental disorders (includes learning disabilities) (new Listing 12.11), eating disorders (new listing 12.13), and trauma- and stressor-related disorders (including PTSD) (new listing 12.15).  The revisions also substantially rewrite the listing for Intellectual Disability (listing 12.05).  Revisions to the children’s listings mirror changes to the adult listings.

The revisions change the “B” criteria.  The new “B” criteria are: Understand, Remember or Apply Information; Interact with Others; Concentrate, Persist or Maintain Pace and Adapt or Manage Oneself.  The revisions add multiple factors to consider for each of the new “B” criteria.

The revisions also require considering homelessness as a factor in difficulty to produce medical evidence.

Revised Medical Criteria for Evaluating Mental Disorders, 81 Fed. Reg. 66138 (September 26, 2016).

Posted in SSI

Member Handbook Requirements for Medi-Cal Dental Plans

CMS’s new Managed Care Final Rule stipulates new requirements for enrollee handbooks effective July 1, 2017.  DHCS issued a Dental All Plan Letter to provide clarification and guidance of these rules.

Current DHCS contracts require plan communications to be written at a sixth grade reading level.  Under the new federal rule, dental managed care plans (DMCs) are to use the state-developed manual.  Manuals must be provided within a reasonable time after receiving notice of enrollment, and the content of the manual must allow the member to understand how to effectively use the dental plan.  The letter describes the content requirements.

DHCS Dental APL 17-002 (May 24, 2017)

Changes to Social Security hearings process

Social Security has finalized new regulations that change its hearing process.  These are important changes because they change the deadlines and time frames for Social Security hearings.  Three key changes in the process are:

  1. Social Security will now give at least 75 days notice of the hearing date.
  1. Claimants and claimant’s representatives must now submit evidence, hearing briefs and objections to issues at least five business days prior to the hearing. For evidence that the Claimant has not yet received, the Claimant or claimant’s representative must inform about that evidence.  Exceptions to the five business day rule include disability that prevents the Claimant from submitting evidence and “other unusual, unexpected or unavoidable circumstances” which expressly includes actively and diligently seeking evidence but the evidence was not received 5 business days before the hearing.
  1. When seeking Appeals Council review, any new evidence must be submitted to the Appeal Council with the Request for Review. The Appeals Council will only consider new evidence under limited circumstances, including disability that prevents the Claimant from submitting evidence and “other unusual, unexpected or unavoidable circumstances” which expressly includes actively and diligently seeking evidence but the evidence was not received 5 business days before the hearing.

Ensuring Program Uniformity at the Hearing and Appeals Council Levels of the Administrative Review Process, 81 Fed. Reg. 90987 (December 16, 2016).

 

Posted in SSI

MAGI Eligibility for DDS Waiver Participants

Participants in the HCBS-DD (Developmentally Disabled) Waiver can be eligible under any of the MAGI eligibility programs, including the Targeted Low-Income Children’s Program (TLICP) without a change to their aid codes.

The HCBS-DD Waiver allows Regional Center patients who would either be assigned a share of cost or be ineligible for Medi-Cal due to deemed income or assets of parents, spouses or others to qualify on their own income and assets.

DHCS ACWDL 17-15 (May 18, 2017).

Guidance on Continuity of Care for MER Denials

DHCS issued a new letter to non-COHS health plans reminding MCPs to treat denied medical exemption requests (MERs) as an automatic request for continuity of care with an existing FFS or nonparticipating health plan provider.  MCPs must make every effort to ensure that the beneficiary is allowed to continue to receive ongoing medical care through his or her FFS or nonparticipating health plan provider(s).

MCPs must process these requests within 5 working days from receipt of request.  DHCS is also urging MCPs to allow non-contracted providers to continue a beneficiary’s treatment plan for other services that are not contracted.  MCPs can provide more than the statutory 12-month continuity of care period if they so choose.

DHCS APL 17-007 (May 11, 2017)