Non-Grant Medical Assistance (NGMA) overview
Purpose: To describe the procedures to obtain a determination of disability or blindness that enables adults not receiving other assistance to be related to Medicaid on the basis of disability or blindness.
- Aged: Age 65 or older.
- Blind: A corrected central visual acuity of 20/200 or a 20 degree field of vision limitation.
- Disability: the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
- Disability Determination Services (DDS):The state entity that uses federal criteria to determine disability or blindness under an agreement with the Social Security Administration.
- Apple Health for Workers with Disabilities (HWD): An Apple Health program that enables many people with disabilities to work and keep their health care.
- Non Grant Medical Assistance (NGMA): The process through which the department makes a disability determination for individuals who are not receiving Title II cash benefits based on disability.
- Substantial Gainful Activity (SGA): A person who is earning more than a certain monthly amount (net of impairment-related work expenses) is ordinarily considered to be engaging in SGA.
- On receipt of request for a Medicaid decision:
- Review the referral and Equal Access Services information and arrange for a telephone interview with the applicant or their representative if necessary.
- Confirm the applicant is claiming blindness or disability. If the claim does not appear to meet SSI criteria, explains this to the applicant or representative and suggest the application be withdrawn. Obtain a withdrawal request if the applicant or representative agrees. Explain the following points about the determination process:
- DDS makes the determination of blindness or disability.
- The standard of promptness date is 60 days, but additional time may be required.
- The individual has a right to request a hearing if they disagree with the decision and it will be the responsibility of DDS to defend the decision.
- The individual is required to pay a monthly premium if earning more than the current SGA amount and eligible for coverage only under the HWD program.
- Review of Financial Information:
- If the applicant is not working, and the applicant’s countable resources meet the following resource standards, complete a NGMA decision referral. The applicant is not eligible for HWD, if not working, but may be eligible for coverage under another Medicaid program. If the individual is under age 65 and not eligible for Medicare, coverage might also be available under the new adult group based on the MAGI methodology. See Health care for adults in the Apple Health eligibility manual.
- If the applicant is under age 65, working, and their income is over SGA standard or their resources exceed the standard described in 2.(a) above, forward the application, using the contact information listed below WAC 182-511-1150 Health care for workers with disabilities (HWD) -- Disability requirements in the HWD chapter.
- Send the following forms to the applicant for completion and signature.
Medical Disability Report and Decision, DSHS 14-144A.
Medical Information Release Form SSA 827.
- Initiate a NGMA referral to DDS through the Barcode NGMA application. Each referral contains the following:
- Transmittal Summary, DSHS 14-144.
- Medical Disability Report and Decision, DSHS 14-144A.
- Medical Information Release Form SSA 827.
- Request retroactive approval if applicant had a medical need in any of the three months before the month of application and meets financial eligibility for each of the retroactive months.
- Medical Records. DDDS support staff or adjudicators obtain medical records directly from DMS for initial applications and reconsiderations. DO NOT SEND PAPER MEDICAL RECORDS.
Note: The Administrative Hearing Coordinator is still required to send a paper copy of an Administrative Hearings packet to the DDS adjudicator.
- Previous NGMA Packet. If the individual is reapplying or requesting continued NGMA benefits:
- Initiate a redetermination referral to DDS through the Barcode NGMA application.
- Document all actions in ACES.
- Pend the application until a decision is received from DDS. Document the reason for delays beyond 60 days from the date of application in ACES.
- When DDS returns the disability determination form 14-144:
- If the individual meets the disability criteria, open medical care in the appropriate category, based on income and resources per WAC 182-508-0001.
- Enter the end date and the determination date on the DEM2 ACES screen, and send a request for a redetermination to DDS at least 30 days prior to the review end date.
- If the reexam has been waived by DDS, no end date is required.
- If the applicant does not meet the disability criteria, consider the applicant for all other medical programs, or allow the individual to provide new medical information to be forwarded to DDS for reconsideration.
- See Administrative Hearing chapter (Chapter 182-526 WAC) for hearing and reconsideration procedures. For additional information, see Special procedures for Non-Grant Medical Assistance (NGMA) hearings and Special Procedures on Non-Grant Medical Assistance and Health Care Authority hearings.