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State of Wisconsin |
Release 24-02 |
Federal SSI law and regulations state that the SSI program can find a person to be presumptively disabled, and the person 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 person to be disabled.
Wisconsin's Medicaid program also allows a determination of presumptive disability.
Presumptive disability is a method for temporarily determining a disability for a person while a formal disability determination is being done by Disability Determination Bureau (DDB). Presumptive disability is determined either by DDB, or in some circumstances, the IM agency. 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 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 person unless there has been a change in the person’s condition.
When an applicant or 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 applicant or member may be certified as presumptively disabled by the IM agency. When the IM agency is making the presumptive disability decision, they should do so as quickly as possible. However, the normal 30-day application processing period applies (see Section 2.7 Application Processing Period).
In determining that the applicant is presumptively disabled, the IM agency will need a medical professional to attest in writing that:
| Note | If the attending physician attests under “Urgent Need for Medical Services” that the applicant has one or more medically determinable physical or mental impairments that cause severe functional limitations and/or inability to work, and that have lasted or can be expected to last for at least 12 months or are expected to result in death, and the applicant is otherwise eligible for Medicaid, the IM worker must certify presumptive disability even if the applicant does not have one of the specific listed impairments (see SECTION 5.9.2.1 Definition of Urgent Need). |
For purposes of presumptive disability determinations, 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 may be a licensed physician, physician’s assistant, nurse practitioner, licensed or registered nurse, psychologist, osteopath, podiatrist, optometrist, hospice coordinator, medical records custodian, or social worker. Some urgent need criteria specifically require a physician to make the attestation, which is noted where applicable.
If someone has an impairment but not an urgent need, the normal disability application process must be followed (see SECTION 5.3 DISABILITY APPLICATION).
To be considered to have an urgent need, a person must be in one of the following situations due to a physical or mental health condition:
| Note | If Box A in Section I – Urgent Need for Medical Services is checked on the Medicaid Presumptive Disability form (F-10130) and the form is signed by an attending physician, the worker must certify the presumptive disability if the applicant meets all other Medicaid program rules, even if the applicant does not have any of the specific impairments listed in SECTION 5.9.2.2 IMPAIRMENTS. |
When an urgent need for medical services has been identified, the IM agency can certify the person as presumptively disabled if they have one of the following impairments, as attested to in writing by a medical professional.
A medical professional must complete and sign the Medicaid Presumptive Disability (F-10130) form, 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, a copy of this form will be saved in the case file to document the Medicaid Presumptive Disability decision. If the applicant is otherwise eligible for EBD Medicaid, Medicaid eligibility will be certified (see Section 5.9.5 Eligibility).
Changes in Urgent Need Prior to Presumptive Disability Medicaid Certification
Sometimes a person’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 person 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 then 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 the IM agency is making the presumptive disability Medicaid eligibility determination/certification, the presumptive disability request must be denied, and the applicant must be notified that their request for a presumptive disability eligibility determination has been denied.
| Example 1 | Bob is 55 years old and has been hospitalized since February 1, after suffering his second stroke in the last four months. Bob applies for Medicaid on February 7. 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 (F-10130). The IM agency has requested verification of Bob’s non-exempt assets and completion of the Medicaid Disability Application (MADA) (F-10112). On February 14, Bob returns the completed MADA and asset verification information to his IM agency. He also indicates that he was released from the hospital on February 11 and is recuperating at home. On February 14, the IM agency 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 agency or DDB makes the presumptive disability determination, the Medicaid Disability Application (MADA) (F-10112) must be completed before the IM agency can certify the member based on a presumptive disability.
The following forms are required for the presumptive disability process:
Once a presumptive disability decision has been made, the IM agency must still follow the disability application process (see Section 5.3 Disability Application Process and Process Help, Section 9.4 Automated Medicaid Disability Determination). The Medicaid Disability Application (MADA) (F-10112) must be completed and sent to DDB along with the necessary copies of the Authorization to Disclose Information to Disability Determination Bureau (DDB) (F-14014).
DDB will process the disability application and make a final disability determination.
If the applicant has an urgent need but does not have one of the listed impairments, the IM agency must ask DDB to make a presumptive disability determination.
| Note |
If someone has an impairment but not an urgent need, the normal disability application process must be followed (see Section 5.3 Disability Application Process). |
All the forms listed in Section 5.9.2.3 are still required when DDB is making the presumptive disability determination (see Process Help, Section 9.4 Automated Medicaid Disability Determination for more information).
DDB will make a presumptive disability determination on these cases and communicate their determination to the local IM agency within three business days of receiving the request for presumptive disability and the Medicaid Disability Application (F-10112) (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, strokes, 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.
While a deceased person can be eligible for Medicaid in the months prior to their death, presumptive disability determinations are not allowed for persons who are deceased. Such requests for a final disability determination are processed through the regular disability process through DDB.
Medicaid coverage based on a presumptive disability determination begins on the date the person is found presumptively disabled by DDB or the IM worker. If the presumptive disability determination is made by the IM worker, Medicaid coverage should begin the date the complete Medicaid Presumptive Disability (F-10130) form is received by the IM agency, if all other eligibility requirements are met. The effective date should not be delayed based on the date the IM worker takes action to confirm the case.
| Example 1 | 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 and requests that a medical professional complete and sign the Medicaid Presumptive Disability (F-10130) form to attest to the urgent need and impairment. Jane’s physician completes and returns the form to the IM agency on July 12. The IM worker processes the verification on July 14. Jane is found presumptively disabled and eligible for Medicaid effective July 12. |
| Example 2 | 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 (F-10130) form 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 (F-10110) form 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
Eligibility cannot be granted 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, eligibility 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. The applicant does not need to submit a new application or signature.
When backdating eligibility after DDB has made a formal disability determination, the member could qualify for Medicaid by meeting a three-month deductible even if they 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 apply. The member can be certified for Medicaid for that period on the first day they meet the deductible during that three-month period.
If 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)”
If a member is determined ineligible for non-medical reasons, eligibility based on a presumptive disability may be terminated with timely notice without waiting for DDB's final disability decision. In such a case, the IM agency will notify DDB immediately that a medical determination is no longer needed.
If DDB denies a disability application, their decision reverses a presumptive disability decision made by the IM agency or by DDB. Medicaid eligibility is terminated 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 person made misstatements or omissions of fact at the time of the presumptive disability determination.
This page last updated in Release Number: 23-04
Release Date: 12/18/2023
Effective Date: 12/18/2023
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