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State of Wisconsin |
Release 24-02 |
Members must:
| Note: |
People who are receiving Medicaid through SSI's 1619(b) program are nonfinancially eligible for MAPP. People who are SSI-eligible under 1619(b) can be on SSI Medicaid and MAPP at the same time. These people 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. SSI MA recipients have already had their assets verified by the Social Security Administration. Assets should not be re-verified for these individuals. 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. |
Disability is a non-financial eligibility requirement for MAPP, even for members who are age 65 and older. DDB must certify disability (see Section 5.10 Medicaid Purchase Plan Disability). 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 an applicant or member does not have a disability determination from DDB, complete the disability application process outlined in Section 5.3 Disability Application Process even if the applicant or member is age 65 or older (unless the applicant or member fits the policy on converting from SSDI to SSRE). The rest of the MAPP application must be completed at this time, and MAPP eligibility can only be pending for the disability determination before the MADA will be sent to DDB through the automated process (see Process Help Section 9.4 Automated Medicaid Disability Determination).
Applicants and Members Converting from SSDI to SSRE
An applicant or member whose SSDI or any other disability-related Old Age, Survivors and Disability Insurance (OASDI or Title II) benefits stopped because they began receiving SSRE is considered to have met the disability requirement for all types of EBD Medicaid, including MAPP. A disability re-determination is not required. The member is not required to provide verification of the disability unless the worker is not able to use data exchanges or other information from the Social Security Administration (SSA) to confirm that the individual received disability payments immediately prior to receiving SSRE.
Redeterminations
Follow the rules in Section 5.7 Redetermination on when to review disability determination.
Members Who Have Lost Their SSDI Due to Exceeding Substantial Gainful Activity
A current MAPP member who loses SSDI because they exceed 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."
| Note | An 18-year-old MAPP member who does not qualify for any other full-benefit health care category cannot lose MAPP during their continuous coverage period even if they are determined no longer disabled (see SECTION 1.2 CONTINUOUS COVERAGE FOR QUALIFYING CHILDREN). |
To meet the work requirement, a member must engage in a work activity at least once per month or be enrolled in an HEC program (see Section 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 (see Section 15.5.1 Income In-Kind). 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 a member 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. Eligibility cannot be terminated until one full calendar month has passed since employment ended.
| Example 1 | Kerrie reported on March 15 that her employment ended March 5. She has until April 30 to become employed again, and her eligibility cannot be terminated due to not having employment before then. |
| Note | An 18-year-old MAPP member who does not qualify for any other full-benefit health care category cannot lose MAPP during their continuous coverage period even if they are no longer meeting the work requirement (see SECTION 1.2 CONTINUOUS COVERAGE FOR QUALIFYING CHILDREN). |
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 serious mental or physical illness or hospitalization that causes the member to be temporarily unable to work or participate in the HEC program, the work requirement can be suspended for up to six months. The IM agency may grant up to two non-consecutive work requirement exemptions (up to six months each) within any three-year period. The member must contact the IM agency to request the exemption using the Medicaid Purchase Plan (MAPP) Work Requirement Exemption (F-10127) form.
The agency may grant a work requirement exemption if the MAPP member:
The MAPP member must continue to pay all applicable premiums during the work requirement exemption period.
DHS may also grant a temporary waiver of the work requirement for good cause.
| Example 1 | A MAPP member who has already been granted two work requirement exemptions by the IM agency within the last three years has a car accident and will be unable to work for three months. The agency cannot grant a third exemption but can refer the request to DHS for consideration. |
If a work exemption request is denied, the member has appeal rights in accordance with the Medicaid program.
In the last month of an exemption, the agency must send a notice to the member indicating the date the work requirement exemption will end and any steps the member must take to continue MAPP eligibility.
Health and Employment Counseling (HEC) is a pre-employment program for MAPP members who are not employed but are looking for work. HEC participation is one way to meet the MAPP work requirement.
Applicants and members who are interested in HEC can call 866-278-6440 to learn more about the program.
HEC participation can occur for up to nine months with a three-month extension, for a total of 12 months. After six months, members 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.
Applicants or members wishing to enroll in HEC are required to complete the HEC Application (F-00004) and send it to the address listed on the application.
The HEC Coordinator will make a final approval or disapproval decision within 10 working days. If the application is not approved, the member will be informed that he or she has not been approved and that he or she has the right to file a fair hearing. If the application is approved, the HEC Coordinator will send the member an approval letter and send a copy to the CDPU/MDPU. IM workers should give the Health and Employment Counseling (HEC) Application along with the Medicaid Purchase Plan Fact Sheet (P-10071) to any MAPP applicant who requests HEC. The applicant can complete the application on his or her own or with the assistance of the HEC Coordinator or an advocate. IM workers are not expected to assist with filling out or submitting the form to the HEC Coordinator.
A participant can apply to extend an 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 HEC Coordinator can extend the HEC participation for three months.
Whenever a member notifies the IM agency that they have stopped participating in the HEC program and are not meeting the work requirement in another way, MAPP eligibility will be terminated with an adverse action notice.
When a HEC participant notifies the IM agency that they are now employed, information about the employment will be needed and eligibility will need to be redetermined.
| Note | An 18-year-old MAPP member who does not qualify for any other full-benefit health care category cannot lose MAPP during their continuous coverage period even if they are determined no longer meeting the work requirement (see SECTION 1.2 CONTINUOUS COVERAGE FOR QUALIFYING CHILDREN). |
See Section 9.4 Health Insurance Premium Payment for information about 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.
Members in an institution may qualify for MAPP if they do not qualify for institutional Medicaid. If the member’s monthly premium gross income exceeds 100% FPL for a group of one (see Section 39.5 Federal Poverty Level Table), they are responsible to pay a monthly premium instead of a patient liability or cost share (see Section 27.7 Cost of Care Calculation and Section 27.7.3 Partial Months).
MAPP is a full-benefit Medicaid subprogram for community waiver participation (see Section 21.2 Full-Benefit Medicaid). If the member’s monthly premium gross income exceeds 100% of the FPL for a group of one (see Section 39.5 Federal Poverty Level Table), they are responsible to pay a monthly MAPP premium instead of a cost share.
This page last updated in Release Number: 24-02
Release Date: 08/22/2024
Effective Date: 08/22/2024
Section 26.3.8 and Section 26.3.9 Effective Date: 08/01/2024
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