MDD 214689 (10/21/2024)
Federal disability determination is binding on state

Preliminary Recitals

Pursuant to a petition filed on August 22, 2024, 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 Medical Assistance (MA), a hearing was held on October 3, 2024, by telephone.

The issue for determination is whether petitioner is eligible for state disability MA.

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: no appearance
Racine County Department of Human Services
1717 Taylor Ave
Racine, WI 53403-2497

ADMINISTRATIVE LAW JUDGE:
Kelly Cochrane
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Racine County.
2. On or about September 22, 2023, petitioner applied for disability through the state MA program.
3. By letter dated May 31, 2024, the Disability Determination Bureau (DDB) found that petitioner was not disabled for state disability MA. Petitioner sought reconsideration, but the DDB affirmed its determination on or about August 19, 2024. 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.
4. Prior to or concurrently with the state disability MA application, petitioner also applied for federal Supplemental Security Income (SSI – Title 16) and Social Security Disability Insurance (SSDI – Title 2). That application was processed separately through the Social Security Administration.
5. The Social Security Administration initially determined petitioner was not eligible for SSI/SSDI on June 9, 2023, and a reconsideration of petitioner’s case resulted in a second denial by the Social Security Administration on April 26, 2024.
6. The petitioner does not allege any new medical impairment other than the impairments considered in the Social Security decision.

Discussion

To be eligible for state MA disability benefits, a person between the ages of 18 and 65 must be blind or totally and permanently disabled. A disability determination is based upon the conclusion that the individual is:

Unable to engage in any substantial, gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

20 C.F.R. § 416.905

“Substantial, gainful activity” is defined in 2024 as earning $1,550, or more, through some type of employment. See https://www.ssa.gov/oact/cola/sga.html.

In addition, Wis. Stat. § 49.47(4)(a)4, declares that a state finding of total and permanent disability for MA purposes must be in accordance with federal SSDI/SSI standards. The federal regulations provide that a finding of no disability for SSDI/SSI purposes, made within 12 months of an application for state MA, is binding on the state MA agency because the standards for federal and state disability are the same. 42 C.F.R. § 435.541(c).

SSI is a federal welfare program also operated by the Social Security Administration for low-income people whom it determines are disabled. An individual need not have paid into the Social Security program to obtain these benefits, but there are asset and income limits. SSDI is a federal insurance program operated by the Social Security Administration for workers whom it determines are disabled. In order to receive SSDI benefits, an individual must have had earnings from which Social Security deductions were taken in at least 20 quarters (3-month periods) during the last ten years.

As the standards for state MA disability and federal SSDI/SSI 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. Unfortunately for petitioner, 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). The information provided at hearing is not different from what was provided to the Social Security Administration.

Because petitioner has been denied SSDI/SSI following a finding of no disability by the federal Social Security Administration within one year of the 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 has appealed the federal decision separately to the Social Security Administration (SSA) for a hearing before a federal administrative law judge. Should petitioner prevail at the federal level and is found disabled, he would qualify nonfinancially as disabled for state MA.

I add, assuming petitioner finds this decision unfair, that it is the long-standing position of the Division of Hearings & Appeals that the Division’s hearing examiners lack the authority to render a decision on equitable arguments. See, Wisconsin Socialist Workers 1976 Campaign Committee v. McCann, 433 F. Supp. 540, 545 (E.D. Wis. 1977). This office must limit its review to the law as set forth in statutes, federal regulations, and administrative code provisions.

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.]