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.” In this case, the petitioner provided transportation for her disabled son as her MAPP-required work activity and was granted a premium waiver for car and home repairs, among other things. She then requested a second waiver, citing more recent vehicle problems. ALJ Teresa Perez concluded the petitioner was entitled to a second waiver because she needed an operating car to work and the needed car repairs were not the same expenses used to establish the first waiver.
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 October 22, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03, to review a decision by the Marathon County Department of Social Services regarding Medical Assistance (MA), a hearing was held on December 10, 2025, by telephone.
The issue for determination is whether Petitioner is entitled to a second 12-month waiver of her Medical Assistance Purchase Plan premiums.
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: Anthony Meier
Marathon County Department of Social Services
400 E. Thomas Street
Wausau, WI 54403
ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Oneida County who is enrolled in the Medical Assistance Purchase Plan Program (MAPP).
- Petitioner works for her son, —, who is disabled and unable to drive. She uses her 26-year old vehicle to transport him places as her MAPP-required work activity.
- Petitioner requested a Temporary Waiver for her MAPP premiums on July 30, 2024 and identified the following temporary expenses: car repairs, rent increase, credit card debt incurred due to basic needs and home repairs including but not limited to: a lawn mower, a storage shed, plumbing repairs in the bathroom and kitchen, a leaky roof, a porch repair, and tile for the kitchen.
- The agency granted Petitioner’s request for a waiver of her MAPP premium from August 2024 through July 2025.
- Via notice dated July 18, 2025, the agency informed Petitioner that her MAPP premium waiver had ended and that her monthly premium would be $31 as of August 1, 2025.
- On August 22, 2025, Petitioner requested a second waiver of her MAPP premiums and identified the following temporary expenses: credit card debt, including judgements entered to recover some of that debt; car repairs (specifically, new rims), food, repair of newly developed roof leak. Petitioner also needs to repair the heater in her car and to replace the fuel pump and alternator. These are issues with her car that have arisen more recently. If she does not have a car, she cannot complete her work activity.
- The agency denied Petitioner’s August 22, 2025 request for a continuation of the temporary waiver of her MAPP premium because she “did not verify that the circumstances are temporary or that there is a difficult situation.”
- 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 Eligibility 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.
Based on Petitioner’s credible testimony at hearing, I find that she is entitled to a second waiver of her MAPP premium because of the auto repairs that she currently requires and because she needs an operating car to continue working. The auto repairs identified in Finding of Fact No. 6 were not expenses used to establish the waiver of her premium last year.
Conclusions of Law
Petitioner’s request for a continued MAPP premium waiver may be granted pursuant to Department policy.
THEREFORE, it is
Ordered
That the matter is remanded to the agency to authorize Petitioner’s premium waiver request for the months August 2025 through July 2026. The agency must comply with this instruction within ten days of the date of this order.
[Request for a rehearing and appeal to court instructions omitted.]
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