State of Wisconsin Department of Health Services

Release 24-01 April 03, 2024

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5.3 Disability Application Process

5.3.1 Application Form

Give a MADAMedicaid — Disability Application Medicaid Disability Application form, F-10112 to each person applying for Medicaid Disability. The MADA must be completed by the Medicaid applicantA person who has submitted a request for coverage for whom no decision has been made regarding eligibility or his or her representative.

The applicant must send the following to the local/county/tribal human or social service agency:

1. The completed MADA Medicaid Disability Application form, F-10112. Applicants must list information about all of their medical problems and contact information for all medical providers that have treated them;
2. One copy of the Authorization to Disclose Information to Disability Determination Bureau (DDB) form, F-14014; and, if applicable,
3. The Medicaid/FoodShare Wisconsin Appoint, Change, or Remove an Authorized Representative form, F-10126.

5.3.1.1 Claims Filed on Behalf of Deceased Applicants

Even when the applicant is deceased DDB needs medical and other information upon which to base the disability decision. If available, the IMincome maintenance worker should send copies of the following to DDB, along with all other application materials:

1. Medical reports (if available from the person filing the Medicaid disability application on the decedent’s behalf.)
2. Death Certificate.
3. Medical releases Authorization to Disclose Information to Disability Determination Bureau (DDB) form, F-14014. If the claim was initiated prior to the applicant’s death and the applicant signed medical releases, those should be sent to DDB. If the applicant was able to sign the releases only with an "X” or other mark, two witness signatures are needed on the release form.
4. Documentation of guardianship or power of attorney should be included if medical releases are signed by a guardian or person with power of attorney.

The IM worker should complete the MADA form as thoroughly as possible, including:

1. Name, address, and phone number of next of kin, friend, or other person initiating the Medicaid application on the decedent’s behalf (Section I).
2. The date on which the applicant became unable to work (Section I, number 2).
3. Contact information for medical sources treating the applicant prior to and at time of death (Section III).

If Medicaid coverage is needed for less than three full months prior to application the IM worker should include a statement regarding the necessary coverage dates in Part VI of the MADA. For example, when the applicant died shortly after an accident or start of illness and coverage is needed only for brief medical care and/or burial expenses.  

5.3.2 Agency Form Processing

See Process Help Section 9.4 Automated Medicaid Disability Determination.

When completed MADA forms are received by the local agency, the IM worker must:

Determine if the applicant meets all other Medicaid eligibility requirements, with the exception of the disability determination and income. Do not send the MADA to DDB if the applicant does not meet all other Medicaid eligibility requirements aside from disability and income, with one exception:

If a non-qualifying immigrant would qualify for Emergency Services Medicaid only if he or she was disabled, send the MADA to DDB.

5.3.3 Release Form

Ask the applicant to sign a Confidential Information Release Authorization to Disclose Information to Disability Determination Bureau (DDB) form, F-14014. This is the only form DDB can accept. See Process Help Section 9.4 Automated Medicaid Disability Determination.

Applications for disability made by the applicant must include releases that are signed personally by the disabled applicant. Applications made on behalf of a disabled applicant must be accompanied by release forms signed by a legally appointed representative. A copy of the court order appointing a representative must be included with the application. An authorized representative’s signature on the release is not acceptable unless he or she has a court order.

5.3.4 Medical Report

If the applicant has copies of any medical records, school records, etc., include them with the application.

A medical report of disability does not need to be submitted with the application. DDB will obtain all of the medical reports necessary for the disability determination. However, if the applicant or the representative has already provided medical records/reports to the IM agency, this evidence must be scanned into the ECFElectronic Case File along with the completed MADA form.

DDB will contact the IM agency for applications that are not fully completed with names and addresses and work information. See Process Help Section 9.4.5 How to Resend an Application to DDB.

5.3.5 SSI Application Date

Occasionally a person applies for SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. and is determined ineligible for SSI payments. In these cases, determine Medicaid eligibility from the SSI application date, if it is earlier than the Medicaid application date.

An application for SSI is also an application for Medicaid.

He or she must still meet all Medicaid eligibility requirements. You must request the SSI application date by using the state on line query (SOLQ).

Use the SSI application date as the filing date if the memberA recipient of Medicaid; formerly referred to as a "client." contacts the IM agency within the calendar month following the month of the SSI denial. If the contact to the IM agency is later than the above, the filing date is the regular date he or she applied at the IM agency.

5.3.6 Routine SSI Medicaid Extension

An SSI Medicaid member is eligible for a redetermination of Medicaid eligibility and Medicare Savings Program (MSP) when SSI is terminated. Members that are eligible for Medicare should also be tested for the Medicare Savings Program unless the member requests not to be tested for the Medicare Savings Program. The person is allowed an extra month of SSI Medicaid eligibility and MSP to allow the IM agency to redetermine eligibility. The IM agency must fill the gap by ensuring continued Medicaid and MSP eligibility between the last date of SSI Medicaid and the date an eligibility determination for continuing Medicaid and MSP on another basis is completed (see Process Help Section 26.2 Routine SSI Medicaid Extension). Determining Medicaid and MSP eligibility should usually occur within the month after the person loses SSI.

When a person applies for SSI and is denied, there is no obligation to "fill gaps.” The exception to this is in Section 5.3.5 SSI Application Date.

There is no fill the gap provision for those who lose their SSI eligibility because of:

• Death
• Leaving Wisconsin
• Incarceration
• Fleeing drug felon

Reminder: For all cases (CARES and non-CARES), even if the member does not meet Medicaid eligibility requirements for the months between when he or she lost SSI and when you are re-determining eligibility, he or she is still eligible. Do not require the member to come into the office. Ineligibility starts, following timely notice, when he or she:

• Does not return the application (the fiscal agent takes care of this), or
• Fails to respond to an information request, or
• No longer meets eligibility requirements (as of when the review or application is done).

5.3.7 Other SSI Medicaid Extensions

Fill the gap between the loss of SSI Medicaid and an eligibility determination by the IM agency when:

1. Retroactive SSI approval and termination occurs. A person applies for SSI and is approved. The approval is retroactive and the SSI also is terminated retroactively.
2. Eligibility for Medicaid is not determined timely by the IM agency through no fault of the member.

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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