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Title 8: Medicaid Page 77 Iowa Department of Health and Human Services Employees’ Manual Chapter C: Nonfinancial Eligibility Nonfinancial Non-MAGI-Related Eligibility Revised May 22, 2026 When the Department Determines Disability

Mr. J, age 50, applies for Medicaid on the basis that he is disabled. Mr. J’s countable resources are over $2,000, he is single, he has no dependent children, and he is not employed. The worker determines that Mr. J may be eligible only for the Medically Needy coverage group based upon disability. Mr. J provides proof that he has applied for SSDI and that disability was denied by the SSA four months earlier. The worker initiates a disability determination because the Department cannot rely on an SSA denial of disability for Medically Needy applicants. The following sections give further instructions on:  Determining substantial gainful activity for an employee  Determining substantial gainful activity for a self-employed person  Submitting medical evidence to DDS Substantial Gainful Activity for an Employee Legal reference: 20 CFR 416.974, Program Operations Manual System POMS 10505.020, 441 IAC 75 (Rules in Process) The first test of disability determination is evaluation of “substantial gainful activity” (SGA). SGA means the performance of “significant” physical or mental activities in work for substantial pay or profit.  “Significant physical or mental activities” are useful in a job or business and have economic value. Self-care, household tasks, unpaid training, therapy, school attendance, clubs, and social programs are not considered SGA.  Work may pay either in cash or in kind.  The current earnings threshold for determining “substantial” activity is $1,690. A person who is engaged in SGA despite physical or mental limitations is not disabled (unless the person would qualify under MEPD). Comment: There is no SGA if the person’s former job made many job accommodations or the person became more incapacitated and cannot find another similar job. Loss of work detrimental to health does not result in SGA. There may be SGA if the person worked for longer than six months despite the impairment, lost the job, and applied for Medicaid in the same month. If there is reasonable doubt, do not consider the person engaged in SGA.