What is this form?
This is a
form that assesses eligibility for medical assistance benefits on the basis of
medical conditions. It is NOT a commercial insurance disability form, and it is
NOT an evaluation for Social Security disability.
Who can complete this form?
The Department of Public Welfare recently changed their rule on this. Now, the form can be filled out by a licensed physician
or psychologist or a medical professional under the physician's supervision and authority, such as a registered nurse, physician assistant or certified nurse practioner.
Why does my patient need me to complete this form?
If the County Assistance Office has given your patient this form, they are not eligible for medical assistance in any other category. Depending on what you say, they may be eligible for medical assistance
because of a temporary or permanent disability.
Does DPW have a definition of disability that I must
use?
DPW does not have a specific definition of disability under its rules.
If, in your opinion as a practitioner, you believe that a person is unable to
work because of one or more medical conditions, that is sufficient. A person can
be disabled by a combination of conditions which together make it unlikely that
they would have the organizational, physical, and mental skills needed to
perform daily work. The DPW definition is your judgment and is substantially
different than the Social Security Administration definition of disability,
which is a much more difficult standard.
If I am unsure about how long a person may be disabled,
what do I indicate?
The time period has important implications for the
applicant. If you indicate less than 12 months, and give a date, and the person
is granted medical assistance on the basis of this information, the medical
assistance will automatically terminate on that date. For less than 12 months,
the applicant must go to the County Assistance Office for a face-to-face
interview , can only have between$174 and $215/month in income for a single
person household and 3) can only have $250 in long term savings/resources.
If the condition is chronic and I put down temporarily
disabled 12 months or more, what happens?
If you are unsure but believe it
may be around 12 months, checking off 12 months or more is beneficial to the
patient. The patient’s income and savings allowances will be higher – a monthly
household income of $736/month and and savings of $2000. The applicant can mail
in the application and does not need an in-person interview.
The applicant also will be referred to the Disability Advocacy Project and may be helped to apply for SSI/SSDI (Social Security Income/Social Security Disability Income).
What is the difference, on the
EAF form, between temporarily disabled for 12 months or more, and permanently
disabled?
This needs to be answered to the best of your medical ability. It
is understood that the medical future is not predictable. Most of the time the
benefits available to the applicant will be similar whichever you answer.
Does DPW ever question physician
decisions or submit these forms to physician reviewers for appeal?
DPW’s
policy is to accept the judgment of the physician completing the form.
What if I believe that the
patient is employable?
If you believe that there is no medical condition, or combination of conditions, which keeps someone from being able to work, and you check "employable" then the person will not be found eligible for medical assistance under the temporarily/permanently disabled category. If this is true, perform an assessment to see if they need
