Form Mc 221 La - Disability Determination And Transmittal (Page 2 of 2) in pdf

Due to the fact that items 5, 6, and 8 are frequently misunderstood, the following explanations are given:

Item 5:

Date applied: For a new Medi-Cal applicant, enter the date that the SAWS 1 was signed. For a continuing case,

enter the date that the disability was first reported to the county.

Item 6:

List retro month(s): List all months for which applicant requests coverage during the retroactive period (not more

than three months prior to any application date).

Item 8:

Check all boxes that apply.

Initial Referral: Check this box to request first-time evaluation for disability or blindness. This is used for all initial referrals.

Redetermination: Check box if a beneficiary was previously determined to be disabled, was discontinued for a reason other

than cessation of disability, AND (1) the last DDSD determination occurred 12 or more months in the past, OR (2) whose

reexamination date is due/past due or unknown. Attach a copy of the prior MC 221.

Reevaluation: Check box if the county disagrees with DDSD’s determination and is sending the case back for another review

within 90 days of DDSD’s decision. Reason for the disagreement must be explained in item 10. Attach a copy of the prior

MC 221.

Pickle-Blind: Potentially blind individuals who are discontinued from SSI for any reason must be screened under the Pickle

program (DHS 7020). Blindness evaluations for former SSI recipients for a determination under the Pickle Amendment to the

Social Security Act may be necessary even if the individual has reached age 65 or has already been determined to be disabled.

This is because blind individuals are entitled to a higher SSI payment level than disabled or aged persons.

Reexamination: Check box if a reexam date is due/past due or if an evaluation of a beneficiary’s disability is needed to

determine if medical improvement has occurred. Attach a copy of the prior MC 221.

IHSS: In Home Supportive Services. Check box if a disability evaluation is needed for an IHSS applicant.

SGA IHSS: Check box if an applicant’s SSI benefits have been discontinued due to SGA and the applicant is in need of IHSS.

In these DDSD evaluations, DDSD must confirm that the applicant’s SSI benefit was discontinued due to SGA and prove that

the impairment(s) for which SSI was allowed has not improved.

SGA Disabled: Substantial Gainful Activity (SGA). Check box if an applicant was an SSI disabled recipient, became ineligible

for SSI because of SGA (gainful employment), and still has the medical impairment which was the basis of the SSI disability

determination.

CAPI (Cash Assistance Program for Immigrants): This program provides cash assistance to aged, blind and disabled legal

immigrants who meet the SSI immigration status requirements effective August 21, 1996, and all other current SSI eligibility

requirements. If not aged (65 years of age or older), then disability/blindness must be established on an individual before CAPI

payments can be made.

Resubmitted Packet: Check box if the original packet was received by DDSD and subsequently returned to the county for

needed information, i.e., Z56 (no determination) or Z55 (county return for packet deficiency, upon resubmitting to DDSD, county

should attach a copy of the SPB 105 letter which DDSD previously attached to the returned packet). The county will furnish the

needed information and return the packet to DDSD as a Resubmitted Packet. Attach a copy of the prior MC 221.

Retro-Onset:

Check box only if the beneficiary was previously determined to be disabled and the case is being resubmitted

to evaluate for an earlier onset date. (Onset cannot be granted more than three months prior to application.) Attach a copy of

the prior MC 221 to the packet. For new referrals, DO NOT check this box; simply indicate the requested onset in item 6.

Limited Referral: Appropriate under the following circumstances: (1) A reevaluation packet is sent back within 30 days of

DDSD decision and no new treating source alleged; (2) an earlier onset is needed after DDSD approved case (no new treating

sources are alleged during earlier onset period) and it is within 12 months of application; (3) client discontinued from SSI due to

excess income/resource and not receiving Title II disability benefits; (4) application is made on behalf of deceased client and

death certificate is included; or (5) county unable to verify SSI benefits and only verification for SSI benefits for IHSS is

requested.

MC 221 LA (2/14)

Form Mc 221 La - Disability Determination And Transmittal Page 2

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