GIS 11 MA/017: Medical Report for MBI-WPD Medical Improvement Group Continuing Disability Review (DOH-5029)

To: Local District Commissioners, Medicaid Directors

From: Judith Arnold, Director Division of Coverage and Enrollment

Subject: Medical Report for MBI-WPD Medical Improvement Group Continuing Disability Review (DOH-5029)

Effective Date: Immediately

Contact Person: Local District Support Unit - Upstate (518) 474-8887, New York City (212) 417-4500

The purpose of this General Information System (GIS) message is to inform local departments of social services (LDSS) that a new form is available for use in gathering medical information for a Continuing Disability Review (CDR) for an individual in the Medicaid Buy-In program for Working People with Disabilities (MBI-WPD) Medical Improvement (MI) Group. The new form, the "Medical Report for MBI-WPD MI CDR" (DOH-5029), has been added to the DOH Forms Library and may be accessed through CentraPort.

Individuals assigned to the MBI-WPD MI group by the State Disability Review Team (SDRT) no longer meet the criteria for disability for the MBI-WPD basic group but continue to have a severe, medically determinable impairment that has been stabilized by care, services and/or supports, the loss of which could result in the individual's inability to continue to function at his/her current level. An MI approval is given a group II end date, which must be tracked by the district. Three to four months prior to the end date, the district gathers medical information for a CDR, as is done for a group II disability case. Historically, this meant sending a cover letter, the 25-page LDSS-486T and a signed "Release of Medical Information" form to all of the recipient's current treating physicians.

The new DOH-5029 form was developed to streamline the CDR process for the MI group by providing a single-form CDR submission for a MBI-WPD MI CDR only. This was possible because the MI group is not subject to the Social Security Administration's requirements for determining disability. One DOH-5029 form, completed in its entirety, and signed and dated by an acceptable medical source, will supply the SDRT with the information needed to determine whether the individual's MI approval may continue. The term, "completed in its entirety," means that the treating physician has completed Part A of the form by filling in all current diagnoses, Part B of the form and Parts C and D if indicated (see the instructions on the form). The DOH-5029 form must be signed and dated by an acceptable medical source. To see a list of acceptable medical sources, please refer to the New York State (NYS) "Medicaid Disability Manual," Policy page 7. The new form eliminates the need for the LDSS-486T and supporting documentation such as hospital records, office notes and treatment records.

The DOH-5029 form is only to be used for a CDR for the MBI-WPD MI group. A cover letter and signed consent for release of medical information should accompany the form. Instructions for completion are on the form. When the form is returned to the district by the medical source, the completed, signed DOH-5029 form, with the previous disability records are submitted to the SDRT. A LDSS-654 transmittal sheet must be included with the submission. Upon receipt of the CDR packet, the SDRT will complete the "Disability Review Team Certificate" (LDSS-639), assigning the continued approval, if appropriate, with a new group II end date.

If an acceptable medical source does not complete the DOH-5029 form in its entirety and sign and date the form, the district should follow the instructions in the NYS "Medicaid Disability Manual" for gathering medical information for the CDR. Districts may accept pages 1 and 2 of the LDSS-486T, "Medical Report for Determination of Disability," signed and dated by the physician, in addition to available office notes, treatment records, lab results, etc.

It is hoped that this new form will be well received by treating physicians and other medical sources to effectively eliminate the large quantity of documentation currently involved in a MI CDR. It remains to be seen whether physicians will choose to complete the form or whether they will send photocopied office notes, lab results and treatment records instead. Feedback from districts regarding this new form and process is appreciated. Please send comments to Peggy Williams at