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Wisconsin Department of Health and Family Services |
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Wisconsin Department of Health and Family Services |
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 detemination of presumptive disability.
Presumptive Disability ( PD ) is a method for authorizing emergency MA coverage prior to a formal disability determination by DDB. Presumptive disability is determined either by the DDB, or in some circumstances, by the IM worker. The regular disability application process (3.6.2) must still be completed for persons with a presumptive disability. A presumptive disability decision stands until the DDB makes its final disability determination.
When a client 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 client may be certified as presumptively disabled by the IM worker.
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 (3.6.8.1.1) for medical services,
and
The individual has one of a certain set of impairments (3.6.8.1.2).
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.)
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; or
The applicant will be admitted to a hospital or other medical institution without immediate health care treatment; or
The applicant is in need of long-term care and the nursing home will not admit the applicant until Medicaid benefits are in effect; or
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.
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Example: An individual with schizophrenia who will need to be hospitalized if he or she does not take prescribed medication has an ‘urgent need’ if such medication is not available without Medicaid coverage. |
When an urgent need for medical services has been identified, the IM worker can certify the client as presumptively disabled if the client 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 mental deficiency 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 mental deficiency 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: ‘Mental deficiency’ means mental retardation. 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 mental retardation.
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 client 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.
A medical professional must complete and sign the Medicaid Presumptive Disability form (HCF 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 3.6.8.4)
Once a presumptive disability decision has been made, the IM worker must still follow the disability application process (3.6.2). The Medicaid Disability Application form (HCF 10112, formerly DES 3071) must be completed and sent to the DDB along with the necessary copies of the Confidential Information Release Authorization form (HCF 14014).
Note: Whether the IM worker makes the PD determination or DDB makes the PD determination, the Medicaid Disability Application (HCF 10112) must be completed "before" the IM worker certifies the client for PD.
The DDB will then 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 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
(HCF 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 (3.6.2).
Document the urgent need by placing the
Medicaid Presumptive Disability form (HCF
10130) in the case file.
Complete, with assistance from the applicant as necessary, the following three forms:
Send via fax (608-266-8297) each of the three forms listed above to DDB for both a presumptive and final disability determination. The FAX number is also on the request form (HCF 10125).
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 HCF 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.
While a deceased person can be eligible for Medicaid in the months prior to his/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.
PD-MA coverage begins on the date on which the presumptive disability finding is made by DDB or the IM worker.
Because CARES usually certifies MA from the beginning of the month, you must do a manual HCF 10110 (Formerly DES 3070) to apply the correct begin date.
The HCF 10110 may be returned by:
Mail: EDS
P.O. Box 7636
Madison, WI 53707
E-mail: eds_3070@dhfs.state.wi.us
Fax: (608) 221-8815
Do not grant retroactive eligibility 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.
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)”
If a recipient is determined ineligible for non-medical reasons,
you may terminate PD 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.
If the DDB denies a disability application their decision reverses a
PD decision made by the IM worker or by DDB. Terminate
Medicaid eligibility following timely notice requirements. (IMM, Ch. I).
Medicaid
eligibility based on a PD 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: 05-03
Release Date:08/29/05
Effective Date: 08/29/05
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