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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
26.3.1 MAPP Nonfinancial Requirements Introduction
26.3.3.2 Contractual Employment
26.3.4 Work Requirement Exemption
26.3.5 Health and Employment Counseling Program (HEC)
26.3.5.3 HEC Participation Changes
26.3.6 Health Insurance Premium Payment (HIPP)
Clients must meet all of the following:
Meet general MA non-financial requirements (4.1 Who is Nonfinancially Eligible for Medicaid),
Be at least 18-years-old, (there is no maximum age limit).
Be determined disabled, presumptively disabled, or MAPP disabled by the Disability Determination Bureau ( DDB ) (5.2 Determination of Disability and 5.10 MAPP), regardless of age, and
Be working in a paid position or participating in a Health and Employment Counseling (HEC ) program (26.3.4 Work Requirement Exemption) .
Note: Individuals who are receiving MA through SSI's 1619 (b) program are non financially eligible for MAPP. Those persons who are SSI eligible under 1619 (b) can be on SSI Medicaid and MAPP at the same time. These individuals are not receiving an SSI cash benefit because they are working, but they meet certain specific SSI requirements that allow them to keep their categorical eligibility for Medicaid. Because this group is the most likely to move from SSI Medicaid to MAPP, DHS has decided to allow them to be eligible for both at the same time.
DDB must certify disability (5.10 MAPP). There is no requirement that a member be a current or former SSI or SSDI beneficiary to qualify for MAPP. Earned income is not used as evidence in MAPP disability determinations.
If a member does not have a disability determination from SSA , a federal agency which administers the SSI, OASDI , and Medicare programs, complete the disability application process outlined in 5.3 Disability Application Process. The rest of the MAPP application must be completed at this time and MAPP eligibility pending only for the disability before the MADA will be sent to DDB through the automated process. (See the Process Help Chapter 12 Automated Medicaid Disability Determination)
Follow the rules in section 5.7 Redetermination on when to review disability determination.
Note: A current MAPP member who loses SSDI because he or she exceeds the Substantial Gainful Activity level remains MAPP eligible until a MAPP disability determination is done by DDB. If DDB determines the individual is not disabled using the MAPP criteria, the MAPP eligibility will terminate with adverse action notice for the reason "not MAPP disabled."
To meet the work requirement, a member must engage in a work activity at least once per month, or be enrolled in a Health and Employment Counseling (HEC) program (See 26.3.4 Work Requirement Exemption). Consider a member to be working whenever he or she receives something of value as compensation for his or her work activity.
This includes wages or in-kind payments. The exceptions are loans, gifts, awards, prizes, and reimbursement for expenses.
If a member engages in a self-employment activity that generates some compensation, at least once in the calendar month, the individual is employed for purposes of MAPP.
A member does not need to realize a profit from self-employment for it to be defined as work.
If an individual is under contractual employment for the entire year, he or she is employed for the purposes of determining MAPP eligibility for the entire year. Do not consider members employed for any months in which they do not have a contractual employment agreement.
A member has until the last day of the next calendar month to become employed again. Do not take action to terminate eligibility until one full calendar month has passed since employment ended.
If a member has signed up with a temporary service agency and is not actually working, he or she is not working for purposes of MAPP. If a member is engaged in work activity for which compensation will be received, at least once in a calendar month, he or she is employed for the purposes of determining MAPP eligibility in that calendar month.
If there is a serious illness or hospitalization that causes the member to be unable to work, the work requirement can be suspended for up to six months. He or she can continue to be MAPP eligible. The member must contact the IM agency to request the exemption. Have the member complete the Medicaid Purchase Plan (MAPP) Work Requirement Exemption (F-10127). This provision is not available unless he or she:
Has been enrolled in MAPP for six months and has paid any applicable premiums prior to the request of an exemption.
Is expected to return to work in the next six months.
Provides an expected date of recovery.
Provides the reason that an exemption is needed (i.e., illness or hospitalization).
Has had no more than two exemptions (maximum of six months each) to the work requirement in a three-year time period. The two exemptions cannot be consecutive.
Based on criteria outlined above, the IM agency will approve or deny the request. If a work exemption request is denied, the member has appeal rights in accordance with the Medicaid program.
In the sixth month of an exemption, mail to the member a notice indicating the date the Medical Work Exemption will end as well as steps the member may take to continue MAPP eligibility.
Health and Employment Counseling Program (HEC) is a program certified by the Department of Health and Family Services (DHS) to arrange services that help a member reach his or her employment goals. HEC participation can occur for up to nine months with a three-month extension, for a total of 12 months. After six months a member can re-enroll in HEC to meet the eligibility criteria for MAPP, as long as they have not already participated two times within a five-year period. HEC participation is limited to twice within a five-year period, and there must be six months between any two HEC participation periods.
Clients who are not working can meet the MAPP work requirement if participating in a HEC program. If an applicant is not currently working and wants to meet with a HEC screener, pend the case for up to 30 days beyond the application processing period. For an ongoing case, pend the case for up to 30 days after the change is reported or eligibility review is completed. This allows time for the screener to determine if the person qualifies for HEC.
If a determination has not been provided by the HEC screener within the thirty days, deny the case. The member is responsible for reporting HEC participation to the IM agency. The IM agency is not responsible for tracking HEC participation.
Employment Initiatives Section
HEC Manager
Room 418
1 W. Wilson St
Madison, WI 53708
Fax: 608-223-7755
Phone: 866-278-6440
If the plan is not approved, the member will be informed he or she has not been approved and of his or her right to file a fair hearing.
The DHS MAPP Unit will send an approval letter to the member. In order to receive MAPP, the member is responsible for providing the IM worker with a copy of the approval letter.
Income Maintenance worker should give the form along with a MAPP factsheet (P-10071) to any MAPP applicant who is not yet employed. The applicant can complete the application on their own or with the assistance of the HEC Manager. IM workers are not expected to assist with filling out or submitting the form to the HEC Manager.
A participant can extend a HEC period by contacting HEC to request an extension.
If the HEC period is ending prior to the member meeting his or her employment plan goals, but the goals can be met within the three months after the regular HEC period will end, the DHS MAPP Unit can extend the HEC participation for three months.
The HEC counselor/screener monitors the participation of the member as he or she pursues the goals described in his or her MAPP Employment Plan. Whenever a member notifies the IM agency that he or she has stopped participating in the HEC program, the eligibility will be terminated with an adverse action notice.
Whenever a HEC participant notifies the IM agency that he or she is now employed, information about the employment will be needed and eligibility redetermined.
See 9.4 Health Insurance Premium Payment for information about Health Insurance Premium Payment (HIPP) and cooperation requirements.
There are no spousal impoverishment protections for MAPP. An institutionalized member who was determined ineligible for Medicaid using the Medicaid Institutions tests can qualify for Medicaid through MAPP. However, because only the member’s assets count in determining MAPP eligibility, do not apply the spousal impoverishment provisions for assets. Similarly, because there is no post-eligibility treatment of income and instead calculate a premium using only the member’s income, there is no community spouse income allocation or family member maintenance allowance for MAPP.
Clients in an institution may qualify for MAPP if they fail institutional Medicaid. If the member’s income exceeds 150% of the FPL (39.5 FPL Table), he or she is responsible to pay a monthly premium instead of a patient liability or cost share (27.7 ILTC Cost of Care Calculation) and (27.7.4 Partial Months).
MAPP is a full-benefit Medicaid subprogram for community waiver participation (21.2 Full Benefit Medicaid). If the member’s monthly income exceeds 150% of the FPL (39.5 FPL Table), he or she is responsible to pay a monthly premium instead of a cost share.
This page last updated in Release Number: 15-01
Release Date: 06/10/2015
Effective Date: 06/10/2015
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030