Payment of a monthly premium is a condition of eligibility for MAPP, though a member may ask for a temporary hardship waiver that cannot exceed 12 months “for the same hardship reason.” Regular, recurring expenses that are not the result of an unexpected change, like rent or utilities, are not valid hardship reasons. In this case, the petitioner was granted a temporary hardship waiver for a rent increase, “mandatory bills,” food, utilities, a class, and a car payment. Her request for an extension based on the cost of monthly necessities (food, utilities, gas, veterinary and other expenses for her emotional support companions, car payment, car and renter’s insurance, rent, loan payments, and cell phone) was denied. ALJ Teresa Perez concluded the denial was correct.
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 September 11, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03, to review a decision by the Dodge County Human Services regarding Medical Assistance (MA), a hearing was held on December 17, 2025, by telephone. The hearing was rescheduled twice–once to accommodate Petitioner’s work schedule and once to allow the parties to file exhibits to support their respective cases.
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: Chandler Zweig
Dodge County Human Services
199 Cty Rd DF
Juneau, WI 53039
ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is resident of Dane County who is enrolled in the Medical Assistance Purchase Plan Program (MAPP).
- Petitioner requested a Temporary Waiver for her MAPP premiums on July 19, 2024 and identified the following expenses: rent increase, “mandatory bills”, food, utilities, a class, a rent increase, and a car payment.
- The agency granted Petitioner’s request for a waiver of his MAPP premium from August 2024 through July 2025.
- On August 12, 2025, Petitioner requested a continuation of the waiver of her MAPP premiums, explained that her income is not sufficient to meet her monthly necessities, and that she has taken out high interest loans to help cover those necessities. She identified the following specific expenses: food, utilities, gas, veterinary and other expenses for her emotional support companions, car payment, car and renter’s insurance, rent, loan payments, and cell phone.
- On August 13, 2025, the agency denied Petitioner’s August 2025 request for a continuation of the waiver of her MAPP premium because the financial difficulties she described in those requests are not temporary, because both requests described a similar hardship (e.g., overall typical living expenses exceeding income), and because only one 12-month waiver period can be granted for the same hardship reason.
- Petitioner filed a request for fair hearing with the Division of Hearings and Appeals regarding the denial of her 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.
Petitioner offered sincere, credible testimony regarding her ongoing financial struggles. She also provided documentation of many of her expenses. Petitioner explained that she does not spend money on “extras.” The agency’s representative testified at the hearing that the agency cannot grant Petitioner’s request to continue her MAPP premium waiver beyond the twelve month waiver already granted because the reasons she is asking for the continued waiver mirror the reasons she asked for the initial waiver. Moreover, the relevant policy now prohibits granting waivers for regular, recurring expenses or for expenses not related to a person’s health or ability to work.
I do not doubt for one moment the sincerity of Petitioner’s testimony regarding her financial challenges. However, I do not have sufficient evidence upon which to grant her request. The agency has correctly applied the relevant policy, which is quoted, in part, above for Petitioner’s reference. If Petitioner incurs an unexpected expense in the future that is related to her health or ability to work, she may file a new request at that time.
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.]
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