If the Social Security Administration makes a finding of no disability for an SSI or SSDI application within 12 months of a state Medicaid application, that finding is generally binding on the state. In this case, the petitioner appealed a denial of a Medicaid application but had been determined not disabled by Social Security within the past 12 months (and was in the process of appealing that denial as well). ALJ Nicole Bjork concluded she lacked jurisdiction to reconsider the merits of the disability determination.
Preliminary Recitals
Pursuant to a petition filed on September 17, 2020, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Racine County Department of Human Services regarding MDD, a hearing was held on December 22, 2020, by telephone.
The issue for determination is whether Petitioner is disabled for purposes of medical assistance disability.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By:
Racine County Department of Human Services
1717 Taylor Ave
Racine, WI 53403-2497
ADMINISTRATIVE LAW JUDGE:
Nicole Bjork
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Racine County.
- Petitioner applied for disability through the state MA program.
- By letter dated January 13, 2020, the Disability Determination Bureau (DDB) found that Petitioner was not disabled for state disability MA. Petitioner sought reconsideration on March 5, 2020 but the DDB affirmed its determination on or about September 16, 2020. The file was then forwarded to the Division of Hearings and Appeals to schedule a hearing for Petitioner. That hearing is the subject of this decision.
- In 2019, Petitioner also applied for federal Social Security Supplemental Security Income (SSI – Title 16). That application was processed separately through the Social Security Administration.
- The Social Security Administration determined Petitioner was not eligible for SSI on December 5, 2019. Petitioner is currently appealing that federal decision.
- Petitioner does not allege any new medical impairment other than the impairments considered in the Social Security decision.
Discussion
The standards for state MA disability and federal SSDI and SSI disability benefits are the same, a finding of no disability for SSDI/SSI purposes made within 12 months of the MA application is binding on a state MA agency. Exceptions may occur only if certain conditions exist such as allegations of a different disabling condition or changes in the previously considered conditions which have been presented to the Social Security Administration. None of those exceptions apply here. See 42 C.F.R. § 435.541(a); see also U.S. Department of Health and Human Services commentary, 54 Fed. Reg. 236 (1989).
Because Petitioner has been denied SSDI/SSI following a finding of no disability by the federal Social Security Administration within one year of her application for state MA disability, I must conclude I do not have jurisdiction to consider the merits of Petitioner’s disability appeal. Therefore, it must be determined Petitioner is not eligible for state MA disability at this time.
Petitioner filed a federal appeal. Should Petitioner prevail at her federal hearing and is found disabled, she would qualify as disabled for state MA.
Conclusions of Law
That Petitioner is not disabled as that term is used for state disability MA purposes pursuant to Wis. Stat. §49.47(4).
THEREFORE, it is
Ordered
That the petition for review herein be and the same is hereby dismissed.
[Request for a rehearing and appeal to court instructions omitted.]