MAP 219598 (11/10/2025)
MAPP premium waiver cannot exceed 12 months for same hardship reason

Preliminary Recitals

Pursuant to a petition filed on August 13, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03, to review a decision by the Shawano County Department of Human Services regarding Medical Assistance (MA), a hearing was held on October 2, 2025, by telephone.

The issue for determination is whether Petitioner is entitled to an additional waiver of his MAPP premium.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Heather Ondik
Shawano County Department of Human Services
W7327 Anderson Avenue
Shawano, WI 54166-3105

ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a 75-year old resident of Shawano County who is enrolled in the Medical Assistance Purchase Plan Program (MAPP).
2. Petitioner requested a Temporary Waiver for his MAPP premiums on July 15, 2024 and identified the following temporary expenses: $250 per month towards a $3,500 bill for the repair of his truck engine and $100 per month to — for a bridge. He also listed his rent expense and his utility expenses. He provided a receipt showing that he made a $250 payment for his truck repair in June 2024 and a letter showing that he owed — $1,056.
3. The agency granted Petitioner’s request for a waiver of his MAPP premium from August 2024 through July 2025.
4. Via notice dated July 18, 2025, the agency informed Petitioner that his MAPP premium waiver had ended and that his monthly premium would be $41 as of August 1, 2025.
5. On July 30, 2025, and again on August 8, 2025, Petitioner requested a continuation of the waiver of his MAPP premiums and identified the following temporary expenses: “dental infection”, “dental reconstruction” “serious skin problems”, and “major truck engine rebuild.” He further referenced his rent, food, electric, and gas bills. He provided a receipt showing that he made a $100 payment for his truck repair on June 15, 2025.
6. The agency denied Petitioner’s July 30, 2025 and August 8, 2025 requests for a continuation of the temporary waiver of his MAPP premium because the financial difficulties he described in those requests were duplicative of those listed in his July 2024 request and because the maximum 12-month waiver time period has been exhausted.
7. Petitioner filed a request for fair hearing with the Division of Hearings and Appeals regarding the denial of his request for a continued MAPP premium waiver.

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. See id. at § 26.5.8. The rules that the agency must follow in evaluating whether to grant a requested temporary hardship waiver are, in relevant part, as follows:

There is no limit to how many temporary premium waivers may be requested, but the temporary premium waiver cannot exceed 12 months in duration for the same hardship reason …

A qualifying temporary hardship is an unexpected, unusual expense or situation related to the member’s health or ability to work, such as an injury or illness, or reduction of hours worked.

A temporary hardship may include, but is not limited to, the following, when the applicant or member:

• Has an unusual expense related to their health or ability to work. An unusual expense is an expense that is necessary for the ability of the individual to work or take care of their health that is not a regular, recurring, or planned expense. The expense cannot be anything that was used to establish eligibility or the premium amount for the individual, as these should be regular and recurring…
• Is experiencing temporary transportation issues, causing a decrease in the hours they can work. …

Situations that do not qualify for a temporary premium waiver include, but are not limited to:

• Expenses that are not related to an applicant or member’s health or ability to work.
• Inflation or other regular increase in price, such as groceries or gasoline.
• Regular, recurring expenses that can be budgeted for, like rent or utilities, that are not the result of an unexpected or unplanned change.

The agency’s representative testified at the hearing that the agency cannot grant Petitioner’s request to continue his MAPP premium waiver beyond the twelve month waiver already granted because the reasons he is asking for the continued waiver mirror the reasons he asked for the initial waiver. I reviewed the documentation offered by the agency and Petitioner and found that the agency’s assertion is largely true with one exception. Petitioner did not mention any dermatology bills or other bills related to his skin infection when he requested his waiver in July 2024. However, Petitioner did not provide a dollar amount or documentation of bills related to his skin infection to the agency with the waiver requests he filed in July 2025 and August 2025. Petitioner provided a copy of a $30 dermatology bill with his hearing request but no documentation regarding whether those costs are expected to continue. Petitioner’s rent, utility, and food expenses cannot be considered because they are regular, recurring expenses.

I do not doubt for one moment the sincerity of Petitioner’s testimony regarding his financial challenges. However, I do not have sufficient evidence upon which to grant his request. The agency has correctly applied the relevant policy which is quoted, in part, above for Petitioner’s reference. If Petitioner wishes to submit documentation of his dermatology-related expenses to the agency for further consideration, other medical bills (aside from his — dental bill), or other “unusual expenses related to his healthy or ability to work”, he may do so at any time. Neither this decision nor relevant policy prohibits the agency from considering additional requests in the future.

Conclusions of Law

There is insufficient evidence upon which to grant Petitioner’s request for a continued MAPP premium waiver at this time.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

[Request for a rehearing and appeal to court instructions omitted.]