[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR436.541]



[Page 197-198]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 436_ELIGIBILITY IN GUAM, PUERTO RICO, AND THE VIRGIN ISLANDS--

 

       Subpart F_Categorical Requirements for Medicaid Eligibility

 

Sec.  436.541  Determination of disability.



    (a) Basic requirements. (1) At a minimum, the agency must use the 

review team, information, and evidence requirements specified in 

paragraph (b) through (d) of this section in making a determination of 

disability.

    (2) If the requirements or determining disability under the State's 

APTD or AABD program are more restrictive than the minimum requirements 

specified in this section, the agency must use the requirements applied 

under the APTD or AABD program.

    (b) The agency must obtain a medical report and a social history for 

individuals applying for Medicaid on the basis of disability. The 

medical report must include a diagnosis based on medical evidence. The 

social history must contain enough information to enable the agency to 

determine disability.

    (c) A physician and social worker, qualified by professional 

training and experience, must review the medical report and social 

history and determine on behalf of the agency whether the individual 

meets the definition of



[[Page 198]]



disability. The physician must determine whether and when reexaminations 

will be necessary for periodic redeterminations of eligibility as 

required under Sec.  435.916 of this subchapter.

    (d) In subsequently determining disability, the physician and social 

worker must review reexamination reports and the social history and 

determine whether the individual continues to meet the definition. 

Disability is considered to continue until this determination is made.



[54 FR 50762, Dec. 11, 1989]