To be eligible for MAPP, an individual must (1) be a disabled adult, (2) meet all nonfinancial Medicaid requirements, (3) satisfy the MAPP work requirement, unless exempt, and (4) pay any required premium payments, unless exempt. In this case, the petitioner questioned why she needed to comply with premium payment and work requirements, even though she is disabled. She had been granted a temporary waiver of the premium requirement that expired. ALJ Wendy Smith concluded the petitioner was subject to the premium payment and work requirements.
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 on December 31, 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 January 29, 2025, by telephone. This matter was originally categorized as an MQB case type and recategorized as a MAP case type following the hearing to better address the issues. The hearing in this matter also addressed a companion appeal (FOO-216503). A separate decision will be issued for that appeal.
The issue for determination is whether Petitioner should be required to satisfy the premium payment and work requirements for the Medicaid Purchase Plan program.
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: Melissa Mortensen
Racine County Department of Human Services
1717 Taylor Ave
Racine, WI 53403-2497
ADMINISTRATIVE LAW JUDGE:
Wendy I. Smith
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Racine County who has been enrolled in the Medicaid Purchase Plan (MAPP) program beginning in October 2022.
- Petitioner requested a Temporary Waiver for her MAPP premiums on or about September 4, 2024, which was granted for the months of September, October, and November 2024.
- Sometime in December 2024, Petitioner requested another Temporary Waiver. The agency processed her request on January 3, 2025, and denied the request for failure to adequately explain the need for a waiver.
- Petitioner now appeals to the Division of Hearings and Appeals to contest having to comply with the MAPP premium and work requirements as she is disabled.
Discussion
The Medicaid Assistance Purchase Plan (MAPP) program allows disabled individuals who are working or who want to work to remain Medicaid eligible, even if employed, as the program has higher income limits than other Medicaid programs. Wis. Stat. § 49.472; Wisconsin Medicaid Eligibility Handbook (Medicaid Handbook) § 26.1. To be eligible for MAPP, an individual must (1) be a disabled adult, (2) meet all nonfinancial Medicaid requirements, (3) satisfy the MAPP work requirement, unless exempt, and (4) pay any required premium payments, unless exempt. Wis. Stat. § 49.472; Medicaid Handbook § 26.3.1. During the COVID-19 pandemic, the Wisconsin Department of Health Services (DHS) changed the MAPP program rules to temporarily eliminate the MAPP work and premium payment requirements. However, beginning in January 2024, DHS reinstated the MAPP work requirement. In August 2024, the Department reinstated the premium payment requirement.
Payment of a monthly premium is a condition of eligibility for MAPP. If a premium payment is not made, a notice will be sent to the enrollee and MAPP will close for non-payment of a premium at the end of the unpaid premium month. Medicaid Handbook § 26.5.6. If an applicant or member cannot afford the monthly premium, they may request a temporary hardship waiver using the agency’s standard form. See id. at § 26.5.8.
The MAPP work requirement can be satisfied by engaging in a work activity at least once per month, such as through employment, self-employment, or in-kind payments. Id. at § 26.3.3. If serious mental or physical illness or hospitalization causes the enrollee to be temporarily unable to work, the work requirement can be suspended for up to six months upon making a waiver request. Id. at §26.3.4.
In this case, Petitioner expressed concern about having to pay MAPP premiums and satisfy the work requirements and questioned why she needed to comply with these requirements, especially since she is disabled. The MAPP program is designed for disabled people. The program has higher income limits to allow disabled people to have full-benefit coverage while also working or receiving higher income from other sources. The agency’s representative testified at the hearing that Petitioner sought a temporary premium waiver in September 2024 and was granted a waiver for the months of September, October, and November 2024. Petitioner sought another waiver in December 2024 which was, according to the agency’s representative, denied in January 2025 because Petitioner did not provide an explanation as to why the temporary waiver was needed. Petitioner claimed that she previously supplied documentation showing unpredictable alimony payments and this should have been sufficient.
Based on the record, I have no evidence that Petitioner should not be subject to the general MAPP work and premium requirements. As Petitioner’s September premium waiver request was granted, there is no negative action for me to review.
As for the December premium waiver request, neither the Division of Hearings and Appeals nor the agency was advised prior to the hearing that Petitioner was challenging a waiver denial apparently made in January 2025, after she had already filed her appeal request. The December waiver request was not entered into the record. A notice of denial for the December waiver request was not entered into the record. I do not have sufficient evidence in the record to find that the agency erred in denying the December waiver request.
Petitioner asked why she was only considered for the MAPP program, instead of another MA program based on her disability. The agency’s representative testified that Petitioner has never been considered, or denied, for an alternative full-benefit MA program, but she could apply for the Elderly, Blind, and Disabled Medicaid program or Deductible Medicaid and await an eligibility determination. As the agency has not had an opportunity to either grant or deny Petitioner enrollment in a non-MAPP MA program, the Division of Hearings and Appeals does not yet have jurisdiction to hear an eligibility appeal on that matter.
Conclusions of Law
As an enrollee in the MAPP program, Petitioner is subject to the premium payment and work requirements, unless she is granted a waiver from those requirements.
THEREFORE, it is
Ordered
That Petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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