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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
Calculate premiums using only the member's income. Calculate a premium if the member's monthly Premium Gross Income exceeds 100 percent of the FPL (see Section 39.5 Federal Poverty Level Table) for a group of one.
To calculate monthly premium amount:
The result is the member’s monthly premium amount.
| Note: | 503, DAC, widow or widower disregards allowed in eligibility determinations cannot be allowed in premium calculations. |
| Example 1: | Shannon applies for MAPP. Her Premium Gross income is under 100 percent of the FPL. She has no premium. |
| Example 2: | Michael applies for MAPP. His Premium Gross income is 105 percent of the FPL. Even though his impairment-related work expenses and medical/remedial expenses decrease his Premium Net Income to $0, Michael will still have a $25 monthly MAPP premium. |
| Example 3: |
Susan is a MAPP member whose Premium Gross income is 206 percent of the FPL. When her allowable deductions are taken in the premium calculation, her Countable Net Income is $1,750. Her monthly MAPP premium will be calculated as shown below: $2,200 Premium Gross Income − $300 monthly IRWE deduction − $150 monthly medical/remedial deduction -------------- $1,750 Countable Net Income − $1,063.33 (100% of the FPL) -------------- $686.67 Premium Net Income $686.67 Premium Net Income X 0.03 (3%) -------------- $20.60 +$25 Base Premium Amount -------------- $45.60 (round down to nearest whole dollar) Susan’s monthly MAPP premium is $45. |
If the member deposits income (earned or unearned) in an amount that exceeds 50 percent of the member's gross earnings into an Independence Account, the member will be penalized using the following formula. At renewal or re-application for MAPP, look back 12 months and:
| Example 4: | Brenda deposited $1,200 more than 50 percent of her actual annual gross earned income in her Independence Account. If Brenda’s income exceeds 100 percent of the FPL (see Section 39.5 Federal Poverty Level Table) and she is responsible for a monthly premium, add the monthly assessment of $100 to her monthly premium for the next 12 months. If Brenda’s income is less than or equal to 100 percent of the FPL, do not impose a penalty. |
There are no free premium months. Before eligibility confirmation, the member must pay applicable premiums for the initial benefit month and for any backdated months for which the member is eligible and requests coverage. If determining eligibility in the month after application, the premium for the second month also must be paid before confirming eligibility.
| Example 5: | Eric applies for MAPP on January 29, but his application is not processed until February 11. The IM agency determines that he owes a $50 premium per month. Before eligibility is approved (confirmed), Eric must pay a $50 premium for January and a $50 premium for February. |
| Example 6: | Eric applies for MAPP on January 29. Eric is requesting MAPP for February but not January. CARES will not pend the case for February’s premium because you are processing it in January. Confirm the case. The Medicaid fiscal agent will pursue collection of the premium for February. |
CARES will send premium information to MMIS and the Medicaid Purchase Plan Premium Information/Payment (F-00332) is sent to the member with the verification checklist (VCL). The IM worker continues to be responsible for collecting the premium due for initial month(s) and any backdated months for which the member is eligible for and requests coverage and recording receipt of the premium payment in CARES. Refer to Process Help 25.1.6 Processing a MAPP Application Requiring a Premium.
When requested, the fiscal agent will provide members with instructions for choosing the payment method they want. Members can contact Member Services at 1-800-362-3002.
The payment methods are:
Provide members with the Medicaid Purchase Plan Premium Member/Employer Electronic Funds Transfer form (F-13023) and the Medicaid Purchase Plan Premium Employer Wage Withholding form (F-13024) to allow the member to choose a payment method other than direct payment. Since it takes some time to set up EFT and wage withholding, the member pays directly until the fiscal agent informs him or her otherwise.
Premiums may not be paid in advance.
The fiscal agent issues refunds if the premium was paid and is for a month in which one of the following situations occurs:
| Note: | When determining if a change was reported within 10 days of when the change occurred, the worker should use the reported date of change from the member. If the worker has information that makes the reported date of change questionable, the worker can request verification of the date of change. |
The member’s estate can receive a refund if he or she dies between adverse action and the beginning of the benefit month.
Ongoing premium payments are sent to the MAPP Premium Unit. Checks are made out to "Medicaid Purchase Plan.” MAPP premiums are due on the 10th of the benefit month regardless of which payment method is chosen. For members who have chosen "direct pay’ as their payment method, the fiscal agent sends the premium coupon on the 20th of the month before the benefit month. The payment must be received by the fiscal agent by the 10th of the benefit month. EFT occurs on the third business day of the benefit month.
Cases are treated differently depending on when the late payment is received. The following explains the policy based on those time differences. Members must pay the payment that closed them, but do not have to pay the following month right away to open, unless the late pay is made after the benefit month.
| Example 4: | If a member owed a premium for September and does not pay it until October, then he or she will need to pay both September and October. October eligibility will pend until the payment is received by the agency and recorded in CARES. |
The case will stay open for the benefit month even if no payment is received by the due date. It will close at the end of the benefit month if no payment is received by adverse action in the benefit month.
If a member pays between adverse action of the benefit month and the last day of the benefit month, he or she can reopen. Run eligibility with dates and confirm.
| Example 5: | Adverse action is September 16. Jim’s September premium was due September 10. Jim has not paid his September premium by September 16. He does pay on September 26. The case closed effective September 30. Run with dates to open for October. Then run without dates for November eligibility. |
If the member pays any time in the month after the benefit month, he or she can reopen. He or she must pay the premium that closed them. If they owe a premium for that following month, he or she must pay that premium before CARES will open MAPP. The member must pay the IM agency directly (not the fiscal agent). The IM worker can check with the fiscal agent to see if a premium has already been collected for that month.
When the payment(s) is received, record the payment in CARES and run eligibility for the benefit month and confirm. Then run eligibility for the following month and confirm.
| Example 6: | Adverse action is September 16. Jim has not paid his September premium by September 16. He pays on October 26. His case closed for October. Jim must pay both the premiums for September and October since they were in arrears before he will open. To reopen his case, run eligibility for October and confirm. Finally, run eligibility for November and confirm. (The November premium is not due until November 10 and does not have to be paid in advance.) |
If the member pays in the second month after the benefit month, it is a non-payment (see 26.5.6 Non-Payment below).
If a MAPP member does not pay the monthly premium by adverse action in the benefit month, apply an RRP (see Section 26.6 Restrictive Re-enrollment Period, unless there is good cause (see Section 26.6.2 Good Cause). The RRP begins with the first month of closure. If a late payment is received by the end of the month after the benefit month, lift the RRP.
You will be notified with a 056 Run SFED/SFEX alert in CARES if a MAPP member pays the monthly premium through EFT or direct payment by check, and the payment is rejected for insufficient funds. Apply an RRP, unless there is good cause (anything that is beyond the member’s control), and close the case. The RRP begins with the first month after closure. Determine if an overpayment exists and process the overpayment.
If a MAPP member chooses to de-request MAPP coverage, or opt out, anytime prior to the beginning of the next benefit month, close the case in CARES for the next possible month and do not impose an RRP. Refer to Process Help 25.1.9 Opting Out.
A MAPP applicant’s decision to opt out does not affect other family members' eligibility for Medicaid or Medicaid-related programs.
MAPP applicants and members who experience a temporary hardship that makes them unable to pay their premium can apply for a temporary premium waiver. 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. Applicants and members may request the premium waiver for a backdated period of up to three months, but the premium waiver cannot exceed 12 months. If a temporary premium waiver is approved for months where a premium has already been paid, those premiums must be refunded.
To request a temporary premium waiver, MAPP applicants and members will use the Request for a Temporary Waiver of Your Medicaid Purchase Plan Premium Because of a Difficult Situation (F-02603) form. The applicant or member must describe the short-term hardship and state when it began (up to three months in the past) and its expected duration.
Note that temporary premium waiver periods can begin no earlier than August 1, 2020.
A temporary hardship may include, but is not limited to, the following:
IM workers will be required to review temporary premium waiver requests and approve or deny them within 30 calendar days after receipt of the request.
In determining whether there is hardship, the IM worker may only consider circumstances that are documented. Hardship must be verified (see Section 20.1 Verification). Proof includes, but is not limited to, the following:
Verification must be received by the due date (or the extended due date if additional time is requested) in order to process an application for a temporary waiver of premium. If verification is not received by the due date or extended due date, the request must be denied. This denial does not prevent the applicant or member from submitting another request for the same time period and being approved once verification has been received, as long as the request does not include a backdate of longer than three months prior to the month the request is received.
| Example 7: | On November 1, John requested a temporary waiver of premium starting August 1, but he did not provide the requested verification, so the request was denied. On December 1, John submits a new request for a temporary waiver of premium with the appropriate verification. The earliest that the waiver could be approved is September 1. |
If the request for temporary waiver of premium is denied, the waiver applicant will be notified. The waiver applicant has the right to appeal the decision through a written request to the Division of Appeals (DHA). The waiver applicant has 45 calendar days from the date of the notice issuance to file the appeal.
If the request is approved, the premium waiver period will begin on one of the following:
| Note: | When processing temporary premium waiver requests received before October 2020, IM workers should remember that the premium waiver period can begin no earlier than August 1, 2020, even if the hardship began before August 1. |
| Example 8: | Susie requests a temporary waiver of premium on March 31. If approved, the premium waiver period could start as early as December 1 and as late as April 1, depending on the request and the verification. |
The member’s premium will be waived for the duration approved by the agency (up to 12 months). Temporary premium waivers that have been granted for a shorter duration than 12 months can be extended at the member’s request for up to the full 12-month limit for a given hardship reason.
| Example 9: | Mae is a MAPP member who uses a car to get to work. Her vehicle requires an expensive fix by a mechanic. She requests a three month temporary premium waiver to help her redirect the funds toward the repairs on the car. The request is approved. When the repairs are completed, they were twice what she was quoted. She requests a three month extension of her temporary premium waiver in order to redirect those funds to the remaining repair bill. That request is approved. |
| Example 10: | Stan is a MAPP member. He is experiencing health concerns that impact his ability to work the number of hours he typically works. While the IM worker has adjusted his premium due to the decrease in income, his doctor tells him it could be nine months before he will be back to normal work hours. He requests a temporary premium waiver and is approved. At month eight of his premium waiver, Stan’s doctors inform him that they cannot approve an increase in his hours for another six months. Stan requests an extension to his temporary premium waiver. Because he has an approved nine month waiver and the maximum time a waiver can be granted for the same hardship reason is 12 months, the IM worker can only approve an additional three months to extend the waiver. |
This page last updated in Release Number: 21-02
Release Date: 08/30/2021
Effective Date: 08/30/2021
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