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Purchase Plan (MAPP). Sam’s KBM disability determination meets the disability requirement for MAPP while she waits for a decision on her DDB application. Sam is enrolled in MAPP beginning September 1. Her disability application is later approved by the DDB, and her Medicaid continues with an August renewal date. Example 7 Daniel is 5 years old and enrolled in KBM through the end of June. In January, it is determined that he no longer requires an institutional level of care, but he remains enrolled in KBM because he is still within his 12 months of continuous coverage. In May, Daniel’s parents complete a KBM renewal. Because he does not meet the institutional level of care requirement, he is no longer eligible for KBM after his continuous coverage period ends. Daniel receives a letter informing him that his KBM enrollment will end on June 30. The letter states that if he submits a health care application to the IM agency within 30 days of the letter’s date, his KBM coverage will be extended until it is determined whether he is eligible for another Medicaid program. On June 2, Daniel’s parents submit a health care application to the IM agency. On June 10, Daniel is determined eligible for SSI-Related Medicaid. Daniel is enrolled in SSI-Related Medicaid with a start date of July 1. Daniel is sent a letter requesting that the MADA and ADDD forms be completed and returned within 20 days. On June 25, Daniel’s parents submit his MADA and ADDD forms. Daniel’s disability application is denied by the DDB on September 1. Since Daniel no longer meets the disability requirement for EBD Medicaid programs, he is no longer eligible for SSI-Related Medicaid. If he is ineligible for any other Medicaid program, he will remain in SSI-Related Medicaid until the end of his continuous coverage period on June 30. This page last updated in Release Number: 26-01 Release Date: 02/13/2026 Effective Date: 02/13/2026 5.3 Disability Application Process 5.3.1 Application Form Give a MADA Medicaid Disability Application form, F-10112 to each person applying for Medicaid Disability. The MADA must be completed by the Medicaid applicant or his or her representative. The applicant must send the following to the local/county/tribal human or social service agency: 1. The completed MADA Medicaid Disability Application form, F-10112. Applicants must list information about all of their medical problems and contact information for all medical providers that have treated them; 2. One copy of the Authorization to Disclose Information to Disability Determination Bureau (DDB) form, F-14014; and, if applicable, 3. The Medicaid/FoodShare Wisconsin Appoint, Change, or Remove an Authorized Representative form, F-10126. 5.3.1.1 Claims Filed on Behalf of Deceased Applicants Even when the applicant is deceased DDB needs medical and other information upon which to base the disability decision. If available, the IM worker should send copies of the following to DDB, along with all other application materials: 1. Medical reports (if available from the person filing the Medicaid disability application on the decedent’s behalf.) 2. Death Certificate. 3. Medical releases Authorization to Disclose Information to Disability Determination Bureau (DDB) form, F-14014. If the claim was initiated prior to the applicant’s death and the applicant signed