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SPECIAL MEDICAL CRITERIA

ISSUE DATE: 09/2016

MFIP:
This section describes special medical criteria outlined below that provide for banking months during the 1st 60 months, and extension after reaching the 60-month time limit. See 0011.30 (60-Month Lifetime Limit), 0011.33 (MFIP Hardship Extensions), 0011.33.09 (MFIP Ill/Incapacitated Extension Category), 0011.39 (Qualified Professionals), 0028.18 (Good Cause for Non-Compliance -- MFIP/DWP).

To qualify for the special medical criteria, the child or an adult in the household only needs to meet the criteria; he/she does not need to be receiving services.

In a 2-parent household with a child or an adult who meets the special medical criteria, only 1 parent is presumed to be prevented from obtaining or maintaining employment. If the family provides documentation from their health care provider that a 2nd parent is also needed in the home to care for the child or adult who meets the special medical criteria, the 2nd parent may be eligible for a hardship extension under the category for participants whose presence is needed in the home because of the illness or incapacity of another member of the assistance unit.

Participants must be evaluated for extension on or before the 60th month. The special medical criteria extension applies only when the caregiver has a child or an adult in the household who meet the criteria. When the caregiver receives similar services or has a serious and persistent mental illness, he/she may be extended in another category, such as the ill/incapacitated (lasting 30 days or more) category or the hard to employ/MI category.

SPECIAL MEDICAL CRITERIA CATEGORIES


Participants are considered to have a child or adult in the unit who meets special medical criteria in any of the following categories:

HOME CARE SERVICES
There is a child or an adult in the household who meets the disability or medical criteria for home care services. For the purpose of this determination, home care services means a medically necessary health service that is ordered by a physician and documented in a service plan that is reviewed by the physician at least once every 60 days for the provision of home health services, or private duty nursing, or at least once every 365 days for personal care. Participants may also request services directly from a Home Care Agency, which can contact the physician for the necessary documentation. Home care services are provided at the recipient’s residence that is a place other than a hospital or long term care facility.

HOME AND COMMUNITY-BASED WAIVER SERVICES
There is a child or an adult in the household who meets the disability or medical criteria for a home and community-based waiver services program. Also see the Minnesota Health Care Programs Eligibility Policy Manual for additional information. These are services not normally covered by MA which are covered under a waiver, including case management, homemaker services, adult day health treatment, habilitation, respite care, and day treatment for individuals with chronic mental illness. The provisions of this criterion apply to the following home and community-based waiver services programs:

Alternative Care Grant Program (ACG)
A state-funded program that targets people age 65 or older who are at risk of nursing facility level of care and whose personal financial resources would allow no more than a 6-month stay in a nursing facility. The service menu is the same as that available for people receiving services under the Elderly Waiver

Community Access for Disability Inclusion (CADI)
Targets people at risk of nursing facility level of care. They must meet ALL of the following:

-

Be under 65 at the time of assessment.

-

Be certified disabled by the Social Security Administration or the State Medical Review Team (SMRT).

-

Be eligible for Medical Assistance.

-

Be assessed by a Public Health Nurse or Social Worker as needing the level of medical services provided in a nursing facility.

Community Alternative Care (CAC)
Targets people at risk of long term or frequently recurring hospitalization (initially designed to serve medically fragile children). They must meet ALL of the following:

-

Be under 65 at the time of assessment.

-

Be certified disabled by the Social Security Administration or State Medical Review Team (SMRT).

-

Be eligible for Medical Assistance.

-

Have an interdisciplinary team assessment which determines he/she would require frequent or continued hospitalization without waiver services.

Traumatic Brain Injury Waiver (TBIW)
TBIW targets 2 groups of people:

1.

Those at risk of the level of care provided in a neurobehavioral hospital.

AND

2.

Those at risk of the level of care provided in a specialized nursing facility (designed for people who have cognitive and/or behavioral issues).

They must meet ALL of the following

-

Be under 65 at the time of screening.

-

Be certified disabled by the Social Security Administration or the State Medical Review Team (SMRT).

-

Be eligible for Medical Assistance.

Developmental Disabilities (DD) Waiver
Targets people who are determined to have DD and are at risk of the level of care provided in an Intermediate Care Facility for people with developmental disabilities (ICF/DD).

They must:

-

Have developmental disabilities as evidenced by substantial limitations in present functioning manifested by significantly sub-average intellectual functioning (generally, full scale IQ score of 70 or less) and commensurate demonstrated deficits of adaptive behavior. These conditions must be manifested before age 22.

OR

-

Require a 24 hour plan of care that involves a general need for a continuous program which includes aggressive, consistent implementation of specialized and generic training, treatment and services in the areas of adaptive daily living skills, household management, communication, social skills, community living and responsibility for health and safety.

OR

-

Be assessed as eligible on an age appropriate level by an intake worker or case manager.

Elderly Waiver (EW)
Targets people over the age of 65 who are in a nursing facility or at risk of placement in a nursing facility.

Each of the waivers serves both people moving from an institutional setting to the community and people who are determined to be "at risk of" the level of care provided in the respective institutional setting.

CADI, TBIW, and CAC recipients may remain on the waiver after age 65 if warranted by their needs and service plan.

SEVERE EMOTIONAL DISTURBANCE (SED)
There is a child or children in the household who meet the following definition of “severe emotional disturbance” as determined by a qualified professional such that he/she:

-

Has been admitted within the last 3 years or is at risk of being admitted to inpatient or residential treatment.

OR

-

Is a Minnesota resident receiving inpatient treatment or residential treatment for the emotional disturbance through the interstate compact.

OR

-

Has been determined by a mental health professional to have psychosis or clinical depression, to be at risk of harming self or others, or to have psychopathological symptoms that resulted from physical or sexual abuse or psychic trauma within the past year.

OR

-

Has significantly impaired home, school, or community functioning for at least 1 year or for a period that a mental health professional documents as presenting substantial risk of lasting at least a year.

SERIOUS AND PERSISTENT MENTAL ILLNESS (SPMI)
There is an adult or adults who meet the definition of “serious and persistent mental illness” as determined by a qualified professional such that he/she:

-

Has undergone 2 or more episodes of inpatient care for a mental illness within the preceding 24 months.

OR

-

Continuously experienced a psychiatric hospitalization or residential treatment exceeding 6 months' duration within the preceding 12 months.

OR

-

Has been treated by a crisis team 2 or more times within the preceding 24 months.

OR

-

Has a diagnosis of schizophrenia, bipolar disorder, major depression, or borderline personality disorder which significantly impairs functioning; and a mental health professional documents that he/she is reasonably likely to have future episodes requiring inpatient or residential treatment unless ongoing case management or community support services are provided.

OR

-

Has been court-committed as a mentally ill person in the past 3 years or has had the commitment stayed or continued.

OR

-

Meets any of the criteria above but the specified time period has expired.

OR

-

Was diagnosed with severe emotional disturbance as a child and who a mental health professional has documented in the past 3 years is reasonably likely to have future episodes requiring inpatient or residential treatment unless ongoing case management or community support services are provided.


BANKED MONTHS


If a participant who has accrued time beginning 1-1-98 while exempt from Employment Services under the special medical criteria exemption reaches the time limit and is no longer eligible for the special medical criteria extension, the participant must use the banked months before applying for a different type of extension. A caregiver may accrue months back to 1-1-98 if someone in the household met special medical criteria. Review caregivers who might be retroactively eligible for this exemption so that accrued months can be allowed correctly. See BANKED MONTHS in 0002.05 (Glossary: Assistance Standard...). Participants are subject to regular Employment Services requirements and pre 60 month sanction policies while using banked months. If there is information known to the county or employment services provider that the participant may meet one of the other Family Stabilization Services (FSS) eligibility criteria then FSS sanction provisions must be followed prior to imposing a sanction. See Employment Services Manual Appendix H (FSS Sanction Guidance). After the banked months have been exhausted, evaluate the caregiver to see if there is eligibility for an extension under another extension category.

MAXIS is unable to differentiate between extensions for the purpose of drawing on the banked months. Therefore, to ensure the system pulls the banked months before the participant is extended under a different category, code the STAT/TIME panel “Extension” field “NO” (no extension identified) when the participant no longer qualifies for the special medical criteria extension, even if the participant meets the criteria for a different type of extension.

Banked months are accrued based on the special medical criteria of an adult or child in the household, NOT based on a caregiver’s own special medical criteria. If a caregiver meets any of the special medical criteria on his or her own, he/she may be extended under the ill/incapacitated category, for example, but would not accrue banked months.

As long as someone in the household meets the special medical criteria he/she will accrue months to be used after reaching the 60-month time limit and no longer be eligible for a special medical criteria extension. Participating in Employment Services or working does not affect the participant’s eligibility for banked months or an extension.

Some participants who have been exempt from Employment Services (ES) because they were needed in the home due to the illness or incapacity of another assistance unit member, a relative who lived in the same household, or foster child may be able to accrue time back to 1-1-98 if they met the special medical criteria for an ES exemption during that same period.

No later than the time of the face-to-face interview, explain to any participant with a code of “8” (member is required at home to care for an ill or incapacitated family member) on the “ES Status” field of the STAT/EMPS panel that time can be accrued if he/she can document that the special medical criteria were met for 1 or more months beginning January 1998. If an ES exemption for a person needed in the home was not approved for the participant but it can be documented that he/she should have been exempt, this policy may also be applied. The participant can authorize the county agency to help document the special medical criteria during this period. To track these cases, enter a CASE/NOTE when you discover months that a participant met the special medical criteria exemption between January 1998 and June 2000. The CASE/NOTE should include the months accruing time under the special medical criteria exemption (mm/yy to mm/yy), the household member who met special medical criteria, and the type of documentation provided.

Also see TEMP Manual TE13.041 (Special Medical Criteria – MAXIS Coding Tips).


DWP:

If at any time during the DWP application process or during the 4-month DWP eligibility period, the agency determines that a participant is unlikely to benefit from DWP, convert the participant to MFIP. Participants who are determined by a qualified professional to be needed in the home to care for a child or an adult meeting the Special Medical Criteria are considered to be unlikely to benefit from DWP. See 0008.06.24 (DWP Conversion or Referral to MFIP).


SNAP, MSA, GA, GRH:

No provisions.

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