When applying for MAPP, an applicant may be determined presumptively disabled. A presumptive disability decision stands until the DDB makes a final disability determination, at which point IM must send a manual notice. In this case, the petitioner was granted presumptive disability, but then the DDB denied disability in its final determination. IM, however, never sent proper notice of the termination. In fact, the petitioner received contradictory notices and was told to keep paying her MAPP premium. ALJ Brian Schneider concluded the lack of notice meant the petitioner’s MAPP benefits must be restored.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed December 12, 2025, under Wis. Stat., §49.45(5)(a), to review a decision by Brown County Human Services to discontinue Medical Assistance (MA), a hearing was held on January 29, 2026, by telephone.
The issue for determination is whether the agency correctly closed petitioner’s eligibility for the Medicaid Purchase Plan (MAPP).
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Kelly Bukowski
Brown County Human Services
111 N. Jefferson St.
Green Bay, WI 54301
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Brown County.
- Petitioner applied for MAPP in the spring, 2025, after BadgerCare Plus (BC+) ended due to income.
- The county agency received a presumptive disability finding from the Disability Determination Bureau (DDB) in late April, 2025, and it opened MAPP for petitioner effective May 1, 2025. A notice dated April 29, 2025 informed petitioner of the eligibility and that she had to pay a monthly MAPP premium of $88. Petitioner paid the premium by automatic withdrawal from her account. Automatic withdrawals occurred in both May and June, 2025.
- The DDB denied disability on June 20, 2025. It sent petitioner a notice dated June 24, 2025 detailing the denial, with instructions on how to request reconsideration. Petitioner did not request reconsideration.
- At that point presumptive disability ended, and MAPP eligibility closed at the end of June, 2025. Automatic MAPP premium withdrawals from petitioner’s account also ended.
- On July 9, 2025, the agency sent petitioner a notice telling her that she was eligible for MAPP in June, 2025, with an $88 premium. The notice did not mention any month beyond June.
- Nothing else happened on petitioner’s case until October, 2025. Petitioner paid MAPP premiums for July through October, 2025 by submitting a check directly to the county agency.
- On October 23, 2025, a Brown County worker noticed that MAPP had closed effective July 1, 2025. On November 10, the county worker informed petitioner by telephone that the DDB denied disability in June, 2025 and that petitioner did not have MAPP eligibility beyond June 30, 2025.
- On November 11, 2025, the agency sent petitioner a notice informing her that MAPP was denied for August, September, and October, 2025 because of a June, 2025 determination of no disability. Petitioner filed this appeal. The agency refunded the premiums that petitioner had paid for July through October.
Discussion
The MAPP program allows disabled individuals to work but to retain eligibility for MA. Wis. Stat., §49.472; MA Handbook, Appendix 26.1. If net income is below 250% of the federal poverty level, the person is eligible for the program. Wis. Admin. Code, §DHS 103.03(8)(b); Handbook, App. 26.4.2. If gross income is above 150% of the federal poverty level, the person is required to pay a monthly premium to receive MAPP benefits. Wis. Admin. Code, §DHS 103.087(1)(b); Handbook, App. 26.5.1.
When petitioner’s earned income rose above the BC+ limit, her only eligibility for MA would be through the MAPP program. When she applied, petitioner had not been found to be disabled. As noted during the hearing, a social security claim for disability was pending with the Social Security Administration in 2025; in September the social security claim was withdrawn at petitioner’s attorney’s advice. One of the confusing points of this appeal hearing was that Ms. Bukowski said the disability claim was withdrawn in June. That led me to look at petitioner’s history. What I found is detailed in Finding of Fact no. 4.
Petitioner applied for MAPP in late April. She was granted presumptive disability. Federal SSI law and regulations provide that the SSI and MA programs can find a person to be presumptively disabled, and the person will be treated as a person with a disability until a final disability determination can be completed. A presumptive disability decision stands until DDB makes its final disability determination. See MA Handbook, App. 5.9.1. The Handbook, App. 5.9.6.1, provides further:
If DDB returns a negative Presumptive Disability decision, the IM worker must send a manual notice of decision to the applicant. The notice must state:
“Your request for Medicaid is based upon your statement that you are disabled. The final decision on your disability has not yet been made, however we have determined that you cannot be considered presumptively disabled. This means that you cannot be certified as eligible for Medicaid as a person with a disability until a final disability decision has been made. You will be informed when the Disability Determination Bureau makes the final disability decision. (Wis. Stats. ss. 49.46 and 49.47)”…
If DDB denies a disability application, their decision reverses a presumptive disability decision made by the IM agency or by DDB. Medicaid eligibility is terminated following timely notice requirements…
Petitioner was granted presumptive disability. She was notified that she was eligible for MAPP. In June, the DDB determined that she was not disabled for MAPP purposes, a determination totally separate from the pending social security claim. At that point, the county agency should have sent petitioner the notice described above, telling her essentially that her MAPP eligibility would end. The county agency did not send that notice. In fact, it is evident from case comments that the county workers were unaware of the DDB denial. When petitioner called the county on June 25 to ask about contradictory notices, she was told to continue paying her MAPP premiums. In August, a worker noted that MAPP had closed June 30, and she re-ran eligibility, but the re-run failed.
The point is that petitioner’s MAPP ended June 30, 2025, and it should have ended that date. However, petitioner did not receive timely notice of MAPP ending. She did not receive any notice of MAPP ending until November. I thus conclude that petitioner’s MAPP eligibility should be restored for the months of July through November, 2025. Although the November 11, 2025 notice stated that she was ineligible for backdated months, it was sufficient to warn her that she would not be eligible in future months also.
That leads to the final twist. The MA Handbook, App. 22.6 provides:
If it is determined that a member’s benefits have been incorrectly denied or terminated, their Medicaid should be restored from the date of the incorrect denial or termination through the time period that they would have remained eligible.
If the member was incorrectly denied or terminated for BadgerCare Plus or MAPP with a premium obligation, the member should be allowed to pick the months in which they would like to receive benefits. All premiums owed for the months in which the member would like to receive benefits must be paid before the member is enrolled for those months.
If a member already paid for a Medicaid covered service, the member will need to contact their provider to bill Medicaid for services provided during that time. A Medicaid provider must refund the amount that Medicaid will reimburse for the service. The provider may choose to refund up to the full amount billed to the member, but that decision is entirely optional.
Petitioner can choose the months in which she will have eligibility restored and pay the premiums only for those months. Presumably those would be months in which she incurred medical expenses. Petitioner testified that she incurred pharmacy expenses, but it is unknown if she paid out-of-pocket or whether she owes money to the provider.
Finally, petitioner’s major concern is the future. Unfortunately, I cannot help her there. During the hearing, I suggested reapplying for MAPP disability again, but that was based on the belief that she withdrew her disability claim in the social security appeal. In fact, in June, 2025, the DDB specifically found petitioner to be not disabled on her MAPP claim. At this point her only option is to apply for Marketplace insurance. At her income level monthly premiums might not be unmanageable.
Conclusions of Law
- Although petitioner’s MAPP eligibility ended effective July 1, 2025, the agency failed to notify her of the discontinuance.
- Petitioner’s MAPP eligibility must be restored for the months of July through November, 2025.
THEREFORE, it is
Ordered
That the matter be remanded to the agency with instructions to contact petitioner to give her the option to pick which months she wants to have MAPP eligibility and to pay premiums for and to restore MAPP eligibility for the period July 1 through November 30, 2025, based on petitioner’s choice. The agency shall take these actions within 10 days of this decision.
[Request for a rehearing and appeal to court instructions omitted.]
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