5.9 Presumptive Disability

5.9.1 Presumptive Disability Introduction

Federal SSI law and regulations state that the SSI program can find an individual to be presumptively disabled and will be treated as a person with a disability until a final disability determination can be completed. To be treated as presumptively disabled by SSI means that the applicant’s benefits can begin before SSA, or its contracted agency, has formally determined the individual to be disabled.

Wisconsin's Medicaid program also allows a determination of presumptive disability.

Presumptive Disability (PD) is a method for temporarily determining a disability for an individual while a formal disability determination is being done by DDB . Presumptive disability is determined either by the DDB, or in some circumstances, by the IM worker. The regular disability application process (see Section 5.3 Disability Application Process) must still be completed for persons with a presumptive disability. A presumptive disability decision stands until the DDB makes its final disability determination.

When the regular disability determination is denied by DDB, a new presumptive disability determination cannot be made for that individual unless there has been a change in the person’s condition.

5.9.2 PD Determined By the IM Workers

When a member has an urgent need for medical services attested to in writing by a medical professional, and is likely to be found disabled by DDB because of an apparent impairment, the member may be certified as presumptively disabled by the IM worker. When the IM worker is making the PD decision, they should do so as quickly as possible. However, the normal 30 day application processing requirements (see Section 2.7.1 Time Frames Introduction) are still applicable even for PD determinations.

In determining that the applicant is presumptively disabled, the IM worker will need a "medical professional” to attest in writing that:

The individual’s circumstances constitutes an urgent need (see Section 5.9.2.1 Definition of Urgent Need) for medical services
The individual has one of a certain set of impairments (see Section 5.9.2.2 Impairments)

A "medical professional” is defined as any health care provider or health care worker who is familiar with the applicant and is qualified to confirm the presence of an 'urgent need’ and the presence of one of the impairments. (A medical professional is a licensed physician, physician’s assistant, nurse practitioner, licensed or registered nurse, psychologist, osteopath, podiatrist, optometrist, hospice coordinator, medical records custodian, or social worker.)

5.9.2.1 Definition of Urgent Need

A person must be in one of the following situations to be considered to have an urgent need:

The applicant is a patient in a hospital or other medical institution.
The applicant will be admitted to a hospital or other medical institution without immediate health care treatment.
The applicant is in need of long-term care and the nursing home will not admit the applicant until Medicaid benefits are in effect.
The applicant is unable to return home from a nursing home unless in-home service or equipment is available and this cannot be obtained without Medicaid benefits.

Note: In addition to health conditions of a physical nature, the above criteria may also apply to an urgent need resulting from an individual’s serious and persistent mental illness.

Example 1: An individual with schizophrenia who will need to be hospitalized if he or she does not take prescribed medication has an 1; urgent need’ if such medication is not available without Medicaid coverage.

5.9.2.2 Impairments

When an urgent need for medical services has been identified, the IM worker can certify the member as presumptively disabled if the member has one of the following readily apparent impairments, as attested to in writing by a medical professional:

Amputation of a leg at the hip
Allegation of total deafness
Allegation of total blindness
Allegation of bed confinement or immobility without a wheelchair, walker, or crutches due to a condition that’s expected to last 12 months or longer
Allegation of a stroke (cerebral vascular accident) more than three months in the past and continued marked difficulty in walking or using a hand or arm
Allegation of cerebral palsy, muscular dystrophy or muscle atrophy and marked difficulty in walking (e.g., use of braces), speaking, or coordination of the hands or arms
Allegation of Down’s syndrome
Allegation of severe intellectual disorder made by another individual filing on behalf of a claimant who is at least seven years of age. For example, a mother filing for benefits for her child states that the child attends (or attended) a special school, or special classes in school, because of an intellectual disability or is unable to attend any type of school (or if beyond school age, was unable to attend), and requires care and supervision of routine daily activities

Note: "Intellectual disorder" means an intellectual disability. This category pertains to individuals whose dependence upon others for meeting personal care needs (e.g., hygiene) and in doing other routine disability activities (e.g., fastening a seat belt) grossly exceeds age appropriate dependence as a result of an intellectual disability.
A physician or knowledgeable hospice official (hospice coordinator, staff nurse, social worker or medical records custodian) confirms an individual is receiving hospice services because of a terminal condition, including but not limited to terminal cancer
Allegation of spinal cord injury producing inability to ambulate without the use of a walker or bilateral hand-held devices for more than two weeks, with confirmation of such status from an appropriate medical professional
End stage renal dialysis confirmed by a medical professional
The applicant’s attending physician states the applicant will be unable to work or return to normal functioning for at least 12 months or the condition will result in death within the next 12 months
The member has a positive diagnosis of HIV with other serious health conditions and will be unable to work or return to normal functioning for at least 12 months or the condition will result in death within the next 12 months

5.9.2.3 Presumptive Disability Certification Process

A medical professional must complete and sign the Medicaid Presumptive Disability form, F-10130 attesting to both the urgent need and the impairment, before an IM worker may certify the applicant as presumptively disabled. The worker should not require any additional documentation from the medical professional beyond the Medicaid Presumptive Disability form. Once completed, place a copy of this form in the case file to document the Medicaid Presumptive Disability decision. If the applicant is otherwise eligible for EBD Medicaid, certify Medicaid eligibility (see Section 5.9.5 Eligibility).

Changes in Urgent Need Prior to Presumptive Disability Medicaid Certification

Sometimes, an individual’s medical condition improves between the date of the presumptive disability Medicaid application and the date of the presumptive disability Medicaid certification. This improvement results in the individual no longer meeting the urgent need criteria at the time of the presumptive disability Medicaid eligibility determination. The most common example of this situation is that of a person who is hospitalized on the date of the presumptive disability Medicaid application, but released from the hospital prior to being certified by the IM worker for presumptive disability Medicaid eligibility. Under these circumstances, if the presumptive disability applicant no longer has an urgent need as of the date that you are making the presumptive disability Medicaid eligibility determination/certification, the presumptive disability request must be denied. Follow the procedures described in Section 5.9.6.1 DDB Returns a Negative Presumptive Disability Decision when notifying the applicant that their request for a presumptive disability eligibility determination has been denied.

Example 2: Bob is 55 years old and has been hospitalized since February 01, 2008 after suffering his second stroke in the last 4 months. Bob applies for Medicaid on February 07, 2008. His physician attests in writing that Bob has an urgent need (he is hospitalized), and that he has one of the impairments listed on the Medicaid Presumptive Disability form (F-10130). The IM worker has requested verification of Bob’s non exempt assets and completion of the Medicaid Disability Application (MADA), F-10112. On February 14, 2008 Bob returns the completed MADA and asset verification information to his IM worker. He also indicates that he was released from the hospital on February 11, 2008 and is recuperating at home. On February 14, 2008, the IM worker has all the necessary information to make a presumptive disability Medicaid eligibility determination. Since Bob no longer has an urgent need on that date, his request for presumptive disability Medicaid must be denied.

Regardless of whether the IM worker makes the presumptive disability determination or DDB makes the presumptive disability determination, the Medicaid Disability Application (MADA) (F-10112) must be completed before the IM worker certifies the member for presumptive disability.

The following forms are required for the presumptive disability process:

Once a presumptive disability decision has been made, the IM worker must still follow the disability application process (see Section 5.3 Disability Application Process and Process Help Chapter 12 Automated Medicaid Disability Determination). The Medicaid Disability Application (MADA) (F-10112) must be completed and sent to the DDB along with the necessary copies of the Authorization to Disclose Information to Disability Determination Bureau (DDB) (F-14014).

The DDB will then process the disability application and make a final disability determination.

5.9.3 Presumptive Disability Determined By DDB

If the applicant has an urgent need, but does not have one of the listed impairments, the IM worker must request DDB to make a presumptive disability determination. The IM worker must take the following actions once a medical professional has attested in writing, with the Medicaid Presumptive Disability form (F-10130), that there is an urgent need for medical services.

Note: If someone has an impairment, but not an urgent need, follow the normal disability application process (see Section 5.3 Disability Application Process).

Document the urgent need by placing the Medicaid Presumptive Disability form (F-10130) in the case file.

Complete, with assistance from the applicant as necessary, the following two forms:

a. The MADA form (F-10112, formerly DES 3071).

b. Release to Disability Determination Bureau form, F-14014.

See Process Help Chapter 12 Automated Medicaid Disability Determination for submissions of the forms, if necessary. This process is now automated. However, if the automated process isn't working, send via fax (608-266-8297) each of the three forms listed above to DDB for both a presumptive and final disability determination.

DDB will make a presumptive disability finding on these cases and communicate their finding to the local IM agency within three business days of receiving the request for presumptive disability and the F-10112 form (not including the day the fax was received).

Federal Regulations generally require the evaluation of certain disabilities after a three month period of recovery from the original injury or medical event (major head injuries, stokes, heart attacks, etc.) It may not be possible to establish disability, either on a presumptive or final basis during that period. However, all applications should be submitted and a complete medical review will be made.

5.9.4 Deceased Applicants

While a deceased person can be eligible for Medicaid in the months prior to his or her death, presumptive disability determinations are not allowed for individuals that are deceased. Process such requests for a final disability determination through the disability process through DDB.

5.9.5 Eligibility

Medicaid coverage based on a presumptive disability determination begins on the date the individual is found presumptively disabled, as indicated by DDB or the receipt of written attestation from a medical profession. If the presumptive disability determination is made by the IM worker, Medicaid coverage should begin the date the complete Medicaid Presumptive Disability form (F-10130) was received by the agency, as long as all other eligibility requirements are met. The effective date should not be delayed based on the date the worker takes action to confirm the case.

Example 3: Jane contacted her IM agency and applied for Medicaid on July 3. She reported being in urgent need of medical services due to muscular dystrophy. The IM worker determines that Jane would be eligible based on presumptive disability, but requests that a medical professional complete and sign the Medicaid Presumptive Disability form (F-10130) to attest to the urgent need and impairment. Jane’s physician completes and returns the form to the IM agency on July 12. A worker processes the verification on July 14. Jane is found presumptively disabled and eligible for Medicaid effective July 12.

Example 4: Bob is Jack’s son and authorized representative. Bob applied for Medicaid on behalf of his father by telephone on June 20. He reported to the IM worker that Jack had a stroke six weeks ago and is in urgent need of medical services. The IM worker determines that Jack may be eligible based on presumptive disability, but requests that a medical professional complete and sign the Medicaid Presumptive Disability form (F-10130) to attest to the urgent need and impairment. Bob also needs to verify Jack’s assets. The completed Medicaid Presumptive Disability form, attesting to the impairment and urgent need, is received by the IM agency on July 2, and verification of Jack’s checking account is received July 12. The IM worker processes the verification on July 15. The worker determines that Jack is presumptively disabled and eligible for Medicaid effective July 2.

Because CARES usually certifies Medicaid from the beginning of the month, the IM worker must manually complete a Medicaid/BadgerCare Plus Eligibility Certification form, F-10110 to apply the correct begin date. The form can be returned by fax to 608-221-8815 or by mail to the following address:

ForwardHealth

Eligibility Unit

P.O. Box 7636

Madison, WI 53707

Do not grant eligibility prior to the date the presumptive disability was determined until DDB makes a formal disability determination, (when the case folder is returned to the IM agency). Once DDB does the final determination, the case may be backdated up to three months prior to the month of application but no earlier than the date of disability onset, provided all other eligibility requirements are met.

When backdating eligibility after DDB has made the formal disability determination, the member could qualify for Medicaid by meeting a three-month deductible even if he or she had excess income in the three-month backdate period. This is an exception to the normal six month Medicaid deductible requirements. The deductible amount for this three-month deductible period will be the total excess income for those same three months. All other deductible rules will apply and the individual can be certified for Medicaid for that period on the first day they meet the deductible during that three month period.

5.9.6 Disability Application Denials

5.9.6.1 DDB Returns a Negative Presumptive Disability Decision

If the DDB returns a negative Presumptive Disability decision, the IM worker must send a manual notice of decision to the applicant. The notice must state:

"Your request for Medicaid is based upon your statement that you are disabled. The final decision on your disability has not yet been made, however we have determined that you cannot be considered presumptively disabled. This means that you cannot be certified as eligible for Medicaid as a person with a disability until a final disability decision has been made. You will be informed when the Disability Determination Bureau makes the final disability decision. (Wis. Stats. ss. 49.46 and 49.47)”

5.9.6.2 Member Ineligible for Non-Medical Reasons

If a member is determined ineligible for non-medical reasons, you may terminate presumptive disability with timely notice without waiting for DDB's final disability decision. In such a case, notify DDB immediately at, (608) 266-1565, that a medical determination is no longer needed.

5.9.6.3 DDB Reverses Presumptive Disability Decision Made by DDB or by the IM Worker

If the DDB denies a disability application their decision reverses a presumptive disability decision made by the IM worker or by DDB. Terminate Medicaid eligibility following timely notice requirements. Medicaid eligibility based on a presumptive disability decision does not continue during the period a person is appealing DDB's decision that they are not disabled.

Benefits received while the disability decision was pending are not subject to recovery, unless the individual made misstatements or omissions of fact at the time of the presumptive disability determination.

This page last updated in Release Number: 18-02

Release Date: 8/10/2018

Effective Date: 8/10/2018