MDD 219938 (10/23/2025)
Petitioner with subsantial gainful activity was disabled under MAPP

Preliminary Recitals

Pursuant to a petition filed September 11, 2025, under Wis. Stat., §49.45(5), to review a decision by the Disability Determination Bureau regarding Medical Assistance (MA), a hearing was held on October 22, 2025, by telephone.

The issue for determination is whether petitioner is disabled under “regular” MA rules.

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: No Appearance

ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a 35-year-old resident of La Crosse County.
2. Petitioner has been considered to be disabled since suffering a traumatic brain injury. He recently has been eligible for MA under the Medicaid Purchase Plan (MAPP) because he had both social security and work income.
3. Petitioner reported a new job in 2022. The income from the job caused him to be over the social security substantial gainful activity figure, resulting in him losing disability status for social security.
4. A new disability application was filed for MA purposes. Disability was allowed for MAPP but denied for regular MA purposes. Reconsideration was requested but was denied, and the file was sent to the Division of Hearings and Appeals to schedule a hearing.
5. Petitioner remains eligible for MAPP and his home health care IRIS program.

Discussion

The MAPP program allows disabled individuals to work but to retain eligibility for MA. Wis. Stat., §49.472; MA Handbook, Appendix 26.1. It has higher income and asset limits than regular MA.

To be eligible for a community waiver program such as IRIS, a person must be a frail elder or have a physical or developmental disability. Wis. Admin. Code §DHS 10.32(1)(c). To qualify as disabled, the person must meet the definition of that term as it is used for Supplemental Security Income (SSI) purposes. Wis. Stat. §49.47(4)(a)4. Federal regulations automatically find that anyone engaging in substantial gainful activity is not disabled. However, Wisconsin has an exemption from the federal government that allows those who are disabled but wish to work to receive medical assistance through the MAPP program. Wis. Stat. §49.472; MA Handbook, Appendix, §5.12.1.

The applicable SSI disability standards are found in the Code of Federal Regulations, Title 20, Part 416, Subpart I, and by reference Appendices 1 and 2, Subpart P, Part 404. Specifically, to be disabled means to be unable to engage in any substantial gainful activity because of a medically determinable physical or mental condition which will, or has, lasted at least twelve months. To determine if this definition is met, the applicant’s current employment status, the severity of his medical condition, and his ability to return to vocationally relevant past work or to adapt to new forms of employment are evaluated in that sequence. 20 C.F.R. s. 416.905 and s. 416.920.

The SSI regulations typically require a five-step process. First, if the person is working at a job that is considered to be substantial gainful employment, he is found to be not disabled without further review. However, the MAPP program eliminates that step. Wis. Stat., §49.472(3)(c) provides as one criterion for MAPP eligibility that an individual “would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under 42 USC 1396d (q)(2)(B) and (D).” In other words, he can be considered to be disabled by excluding evidence that his income would be above the substantial gainful activity line.

In petitioner’s case, when his new job put his income over the substantial gainful activity line, he lost his status as disabled for social security and traditional MA. However, he was found to meet the disability status for MAPP, and thus he did not lose either MA or IRIS eligibility. There was confusion between the notices telling him that he was not disabled while at the same time his MA disability status remained in place on the state system.

I will dismiss this appeal because the Disability Bureau correctly determined that petitioner no longer meets the disability definition for regular MA. The dismissal has no ill effect on petitioner, however, because he remains disabled and MA-eligible under MAPP program rules.

Conclusions of Law

Although petitioner remains in disability status under MAPP rules, the agency correctly determined that he is not disabled under regular MA rules because his income is considered to be substantial gainful activity.

THEREFORE, it is

Ordered

That the petition for review is hereby dismissed.