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State of Wisconsin |
Release 26-02 |
The law defines disability for Medicaid as: "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." See Section 39.4.7 SSI Reference Values for the current SGA limits.
One exception to this is that a MAPP disability determination does not involve the SGA test. See Section 26.1 MAPP Introduction for the MAPP disability definition.
Disability and blindness determinations for most EBD Medicaid programs are made by the DDB. The IM agency should submit an application for a disability determination even if the applicant/member has already applied for SSI or SSDI (see Section 5.3 Disability Application Process), except for children applying for home and community-based waivers. An application for a disability determination should only be submitted for these children at the parent's request.
Note that for some long-term care programs, eligibility is based on level of care determinations rather than on a disability determination. For example, there is no disability determination required for children to be eligible for home and community-based waivers. The appropriate level-of-care determination as established by the functional screen is used as an indicator of the child’s need for services. This is also true for some adults. See Section 28.1 Adult Home and Community-Based Waivers Long-term Care Introduction and Chapter 37 Home and Community-Based Services: The Children's Long-Term Support Waiver Program.
An EBD Medicaid applicant or member whose SSDI or any other disability-related Old Age, Survivors and Disability Insurance (OASDI or Title II) benefits stopped because he or she began receiving SSRE is considered to have met the disability requirement for all types of EBD Medicaid, including MAPP. A disability re-determination is not required. The member is not required to provide verification of the disability unless the worker is not able to use data exchanges or other information from SSA to confirm that the individual received disability payments immediately prior to receiving SSRE.
| Example 1 | Ed is an EBD Medicaid member who was determined disabled ten years ago and has been receiving SSDI since that time. Upon turning 63, his SSDI payments change to SSRE payments. The IM worker can see this change by querying SOLQ-I. By policy, Ed is considered disabled and will not be required to provide any further verification or go through a re-determination. |
| Example 2 | Nancy was determined disabled fifteen years ago and began receiving SSDI. Two years ago, her SSDI payments converted to SSRE payments. Nancy came into the agency this year to apply for MAPP. Although she was previously unknown to CARES, the IM worker was able to research her payments through SOLQ-I and see that prior to receiving her SSRE payment, she was receiving SSDI. Nancy is considered disabled and is not required to provide any further disability verification. |
| Example 3 | Fred was determined disabled twenty years ago. His SSDI payments recently converted to SSRE. Fred moved to Wisconsin and applied for MAPP. The worker was unable to find evidence of this conversion through SOLQ-I. Fred provided a statement from his “My Social Security” account that shows his SSDI payment stopped and SSRE payments began. This verification is sufficient to consider Fred disabled. He does not need to provide any further verification or go through a re-determination. |
Katie Beckett Medicaid (KBM) is a full-benefit Medicaid program for children with disabilities who have complex health care needs and live at home (see Chapter 29.1 Katie Beckett Medicaid). KBM workers determine eligibility for KBM. Eligibility for KBM requires a disability determination that is completed by the Bureau of Clinical Policy and Pharmacy (BCPP) rather than the Disability Determination Bureau (DDB). BCPP uses the same criteria as the Social Security Administration (SSA) and the DDB.
When a member loses eligibility for KBM for any reason other than a medical cessation of disability, the member’s KBM disability determination meets the disability requirement for all categories of EBD Medicaid as long as the member submits requested information timely. The member’s submission of information is timely if a health care application is submitted to IM within three months of when their KBM coverage ended. When an application is received, if the former KBM member otherwise meets all financial and non-financial requirements, they will be enrolled in an EBD Medicaid program first and then asked to submit the Medicaid-Disability Application, F-10112 (MADA), and an Authorization to Disclose Information to Disability Determination Bureau (DDB), F-14014 (ADDD). As long as all required information is provided timely and they are otherwise eligible, the former KBM member will continue to be considered to meet the disability requirement for all Medicaid programs until there is a decision on their DDB disability application. The member’s eligibility will be redetermined once there is a final decision on their DDB disability application.
If the health care application is submitted more than three months after KBM coverage ends, or if the required MADA and ADDD forms and all requested information and verification are not submitted timely, the KBM disability determination will no longer satisfy the disability requirement for other Medicaid programs. The member will need a DDB disability determination to enroll or maintain their enrollment in an EBD Medicaid program or they may qualify for a health care program that does not require a disability determination, such as BadgerCare Plus.
| Example 4 | Carmen is 2 years old and enrolled in KBM through the end of May of this year. In February, Carmen is hospitalized and remains hospitalized in April. Despite her hospitalization for over 30 days, Carmen remains in KBM because she is still within her 12 months of continuous coverage. In late April, Carmen’s parents complete a KBM renewal. Due to her hospitalization, she is no longer eligible for KBM after her continuous coverage ends. She receives a letter informing her that her KBM enrollment will end on May 31. The letter states that if she submits a health care application to the IM agency within 30 days of the letter’s date, her KBM coverage will be extended until it is determined whether she is eligible for another Medicaid program. On May 5, Carmen’s parents submit a health care application to the IM agency. On May 10, the IM agency processes Carmen’s application and determines that she is eligible for Institutional Medicaid, and she is enrolled as of June 1. Carmen is sent a letter requesting that she submit the MADA and ADDD forms within 20 days. On May 20, Carmen’s parents submit the completed MADA and ADDD forms. Carmen’s Katie Beckett disability determination meets the EBD Medicaid disability requirement while she waits for a decision on her DDB application. Carmen’s disability application is later approved by the DDB, and her Institutional Medicaid continues with a May renewal date. |
| Example 5 | Tim is 15 years old and enrolled in KBM through the end of September. In July, it is determined that he no longer requires an institutional level of care, but he remains enrolled in KBM because he is still within his 12 months of continuous coverage. In August, Tim’s parents complete a KBM renewal. Because he does not meet the institutional level of care requirement, he is no longer eligible for KBM after his continuous coverage period ends. Tim receives a letter informing him that his KBM enrollment will end on September 30. The letter states that if he submits a health care application to the IM agency within 30 days of the letter’s date, his KBM coverage will be extended until it is determined whether he is eligible for another Medicaid program. In mid-September, Tim receives a notice informing him that his KBM enrollment will end on September 30. Tim’s KBM enrollment ends on September 30 because he did not submit his health care application by the 30-day deadline, so his KBM coverage is not extended. On December 10, Tim’s parents submit a health care application to the IM agency requesting a two-month backdate. On December 15, the application is processed, and Tim is determined non-financially and financially eligible for SSI-Related Medicaid. Tim is enrolled in SSI-Related Medicaid as of December 1 with a backdate to October 1. On December 15, Tim is sent a letter requesting that the MADA and ADDD forms be completed and returned within 20 days. Tim’s parents submit the MADA and ADDD forms on December 30. Because Tim’s application was received within three months of the KBM end date and he submitted the MADA and ADDD forms timely, the KBM disability determination meets the disability criteria for all EBD Medicaid programs while he waits for a decision on his DDB application. Tim’s disability application is later approved by the DDB, and his Medicaid continues with a November renewal date. |
| Example 6 | Sam is enrolled in KBM. Sam turns 19 on August 20. Six months prior to her birthday, Sam receives a letter informing her that her enrollment in KBM will end August 31 due to turning 19. On August 1, Sam submits a health care application, MADA, and ADDD to the IM agency. At adverse action in August, Sam receives a notice informing her that her KBM enrollment will end as of August 31. On August 20, Sam’s application is processed, and she is determined non-financially and financially eligible for Medicaid Purchase Plan (MAPP). Sam’s KBM disability determination meets the disability requirement for MAPP while she waits for a decision on her DDB application. Sam is enrolled in MAPP beginning September 1. Her disability application is later approved by the DDB, and her Medicaid continues with an August renewal date. |
| Example 7 | Daniel is 5 years old and enrolled in KBM through the end of June. In January, it is determined that he no longer requires an institutional level of care, but he remains enrolled in KBM because he is still within his 12 months of continuous coverage. In May, Daniel’s parents complete a KBM renewal. Because he does not meet the institutional level of care requirement, he is no longer eligible for KBM after his continuous coverage period ends. Daniel receives a letter informing him that his KBM enrollment will end on June 30. The letter states that if he submits a health care application to the IM agency within 30 days of the letter’s date, his KBM coverage will be extended until it is determined whether he is eligible for another Medicaid program. On June 2, Daniel’s parents submit a health care application to the IM agency. On June 10, Daniel is determined eligible for SSI-Related Medicaid. Daniel is enrolled in SSI-Related Medicaid with a start date of July 1. Daniel is sent a letter requesting that the MADA and ADDD forms be completed and returned within 20 days. On June 25, Daniel’s parents submit his MADA and ADDD forms. Daniel’s disability application is denied by the DDB on September 1. Since Daniel no longer meets the disability requirement for EBD Medicaid programs, he is no longer eligible for SSI-Related Medicaid. If he is ineligible for any other Medicaid program, he will remain in SSI-Related Medicaid until the end of his continuous coverage period on June 30. |
This page last updated in Release Number: 26-01
Release Date: 02/13/2026
Effective Date: 02/13/2026
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030