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State of Wisconsin |
Release 24-02 |
Effective August 1, 2024, MAPP applicants and members with gross monthly income over 100% of the FPL will be charged a premium.
Applicants with a filing date on or after August 1, 2024, with gross monthly income over 100% of the FPL must pay an initial premium to become eligible for MAPP.
Medicaid Purchase Plan (MAPP) premiums are calculated using only the member's income. A premium is calculated if the member's monthly Premium Gross Income exceeds 100% of the Federal Poverty Level (FPL) (see Section 39.5 Federal Poverty Level Table) for a group of one.
Tribal members are not exempt from paying MAPP premiums (unlike BadgerCare Plus premiums). Federal statutes for MAPP supersede other parts of the law that exempt tribal members from premiums and copayments for services.
Eighteen-year-old MAPP members are not required to pay a premium.
To calculate monthly premium amount:
The result is the member’s monthly premium amount.
| Note | 503, Disabled Adult Child (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% of the FPL. She has no premium. |
| Example 2 | Michael applies for MAPP. His Premium Gross income is 105% 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 175% 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 − $1,255 (100% of the FPL) -------------- $495 Premium Net Income X 0.03 (3%) -------------- $14.85 +$25 Base Premium Amount -------------- $39.85 (round down to nearest whole dollar) Susan’s monthly MAPP premium is $39. |
If the member's total deposits into an Independent Account exceed 50% of the member's gross earnings, 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% of her actual annual gross earned income in her Independence Account. If Brenda’s income exceeds 100% 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% of the FPL, do not impose a penalty. |
There are no free premium months. Before enrolling in MAPP, the applicant must pay applicable premiums for the initial benefit month and for any requested backdated months for which they are eligible and are charged a premium. Premiums must be paid up to the current month, so if eligibility is not determined until the month after application, the premium for the current month also must be paid before they can be enrolled in MAPP.
| Example 5 | Eric applies for MAPP on January 29, but his application is not processed until February 11. Eric was determined eligible for MAPP effective January 1 with a monthly premium of $50. Eric must pay a $50 premium for January and a $50 premium for February to open for MAPP. |
| Example 6 | Eric applies for MAPP on January 29. Eric is requesting MAPP for February but not January. Eric is determined eligible for MAPP effective February 1. Eric does not have to pay February's premium before MAPP opens because it is for a future month. Eric will be enrolled in MAPP and be sent a premium statement to pay February's premium by the due date of February 10. |
It is possible that an applicant owes a premium for some but not all initial months at application because premiums were suspended (before August 2024) or their income was lower. For example, if the applicant requests backdated coverage, and their monthly premium gross income was under 100% FPL during the backdated months, but their monthly premium gross income is over 100% FPL in the application month, no premium is required for the backdated months, however, a premium is owed for application month. The premium for the application month (or the next month if the application is being processed after the application month) must be paid before the individual can enroll in MAPP. If the premium is not paid, eligibility can be granted for any months a premium was not required but will be denied for months a premium was not paid.
| Example 7 | Bernice applied for MAPP on March 10 and requested backdated eligibility for January and February. She had no income in January. She started a job in February, and her monthly premium gross income went over 100% FPL starting in March. On March 15, the worker determined that she met eligibility requirements effective January 1. Due to Bernice’s income, she is not charged a premium for January or February but owes a premium beginning in March. Bernice must pay the March premium before her eligibility can be confirmed. If Bernice does not pay March’s premium by the due date, she will only qualify for eligibility for the months of January and February. |
| Example 8 | Jessie applied for MAPP on August 5, 2024, with a two-month backdate request. She was determined eligible for MAPP effective June 1, 2024, with a monthly premium of $25. Jessie does not owe a premium for June or July 2024, as MAPP premiums were not in effect. However, Jessie must pay the August premium to open for MAPP benefits for the month of August and ongoing. If Jessie's August premium is not paid, she will be determined ineligible for MAPP for August and ongoing, but she will be eligible for MAPP without a premium from June 1, 2024, to July 31, 2024. |
The Medicaid Purchase Plan Premium Information/Payment (F-00332) is sent to the member with the verification checklist (VCL) notifying them of the premium amount due and where to submit the premium payment (see Process Help, Section 25.3 MAPP Premium Processing for Applications and Renewals).
An applicant could change or remove their request for backdated benefits if they are unable or do not want to pay the premiums.
| Example 9 | Vang applied for MAPP on October 8, with a two-month backdate request. He was determined eligible for MAPP effective August 1, with a monthly premium of $39. Vang must pay his monthly premium for August, September, and October to open for MAPP as of August 1. If Vang is unable to pay the premiums for all three benefit months at application, he can gain eligibility as of September 1 by paying the September and October premium, or as of October 1 by paying the October premium only. |
Initial premium payments required to gain MAPP eligibility must be paid by check or money order and are collected by the Income Maintenance (IM) agency. This includes initial premiums at application or re-request.
For ongoing premium payments, premium statements will be sent monthly. The statement will provide the amount due and how to pay the premium.
Members have several options to pay their ongoing monthly premiums, including:
Members are able to make one-time payments using a credit or debit card, or EFT from a checking or savings account, through the ACCESS website.
For recurring EFT payments, members must submit a complete Medicaid Purchase Plan Premium Member/Employer Electronic Funds Transfer form (F-13023). To have premiums taken out of a paycheck, the Medicaid Purchase Plan Premium Employer Wage Withholding form (F-13024) must be submitted by an employer. Members must submit payments through one of the other methods until they get confirmation that their recurring EFT or wage withholding request has been processed. Once enrolled in EFT payments, monthly premium statements will no longer be sent.
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 can be paid through any of the methods listed in Section 26.5.3.1 Payment Methods. Ongoing premium payments paid by check 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. The fiscal agent sends the premium statement around the 20th of the month before the benefit month. The payment is due on the 10th of the benefit month. EFT occurs on the third business day of the benefit month. Members enrolled in EFT do not get premium statements mailed to them each month.
If a late payment is received and processed after the 10th of the month but before the end of the month, MAPP will be reinstated, and a premium statement will be sent for the following month's premium.
| Example 1: | Donald has been open for MAPP since March 2023. In early July 2024, Donald is notified that his gross monthly income is over 100% of the FPL, and he will owe a monthly premium of $56 starting August 2024. Donald receives a premium statement in mid-July for his premium due August 10, 2024. Donald does not pay his premium by the due date. On August adverse action, Donald's MAPP eligibility closes for non-payment of premium effective September 1, 2024. If Donald pays his premium before August 31, he can remain open for MAPP. |
Payments received and processed in the month after the premium was due and eligibility ended will be applied to the current month to allow the member to regain MAPP eligibility, as long as the payment covers the current month's premium in full.
| Example 2: | Miles has been open for MAPP since June 2024. In early July, Miles is notified that his gross monthly income is over 100% of the FPL, and he will owe a monthly premium of $60 starting August 2024. He receives a premium statement in mid-July for his premium due August 10, 2024. Miles does not pay his premium by the due date. On August adverse action, MAPP eligibility closes for non-payment of premium effective September 1, 2024. A check for $60 is received on September 5, 2024. This payment should be treated as a re-request for MAPP. Miles re-opens for MAPP effective September 1, 2024, and the $60 payment is applied to his September premium. |
Payments received more than a calendar month after the premium was due and eligibility ended will be refunded, unless the member has reapplied or re-requested MAPP (other health care benefits are open on the case), and the agency pended for the premium.
| Example 3: | Diego has been open for MAPP since August 2024. Diego’s gross monthly income is over 100% of the FPL, and he owes a monthly premium of $80. Diego did not pay his September premium by the due date. On September adverse action, MAPP eligibility closes for non-payment of premium effective October 1, 2024. A check for $80 is received by the fiscal agent on November 15, 2024, and it is refunded. There are no health care benefits open on Diego’s case, so he needs to reapply for MAPP. |
| Example 4: | Carol has been open for MAPP since September 2024. Carol’s gross monthly income is over 100% of the FPL and she owes a monthly premium of $55. Carol did not pay her October premium by the due date. On October adverse action, MAPP eligibility closes for non-payment of premium effective November 1, 2024. On December 5, 2024, Carol reapplies for MAPP. The IM consortium pends for her $55 December premium, which needs to be sent to the IM consortium. However, Carol mails her payment to the fiscal agent instead. The fiscal agent gets the payment on December 12, and sees that Carol has re-applied for MAPP and needs to pay her premium, so they notify IM of the payment via the late payment file. The IM consortium applies the payment and reopens Carol’s MAPP effective December 1,2024. |
Payment of a premium is a condition of eligibility for MAPP. If a premium payment is not made, a notice will be sent at adverse action and MAPP will close for non-payment of a premium at the end of the unpaid premium month. While MAPP members can lose coverage for non-payment of a premium, they are not subject to a restrictive re-enrollment period (RRP). A member whose MAPP eligibility closes due to non-payment of a premium can re-request MAPP. They do not have to pay the unpaid premium in order to reopen MAPP after the closure. However, they must pay any premiums owed for the month(s) in which MAPP reopens.
| Example 1: | Tatiana was determined eligible for MAPP in August with a monthly premium of $41. Tatiana does not pay her October premium, so her MAPP eligibility closes effective November 1. Tatiana re-requests MAPP on November 5. Because there is no RRP and Tatiana is re-requesting MAPP after the unpaid premium month has passed, she does not need to pay the October premium to regain eligibility. She only needs to pay an initial premium to gain eligibility for November. Tatiana pays the initial premium on November 6 and opens for MAPP as of November 1. Tatiana will receive a premium statement in mid-November for her premium due December 10. |
IM workers 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, and the payment is rejected for insufficient funds. If the premium is not paid by adverse action, the member's MAPP benefits will end.
Unless a temporary premium waiver is in place, members with gross monthly income over 100% of the FPL must pay their entire MAPP premium by the end of each month to maintain eligibility.
Partial payments made and processed before the last day of the month will be applied to the benefit month. If the remaining balance is not received and processed before the end of the benefit month, the MAPP member will lose eligibility due to non-payment of premium.
| Example 1: | Melinda was determined eligible for MAPP in September with a monthly premium of $51. Melinda pays her premiums in full until November, when she mails a check on November 1 for a partial payment of $25. On November adverse action, MAPP eligibility closes for non-payment of premium effective December 1. If she does not pay the remaining $26 before the end of the month, her MAPP eligibility will end November 30. |
If a MAPP member chooses to de-request MAPP coverage, or opt out, any time prior to the beginning of the next benefit month, MAPP eligibility will end the next possible month.
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: 24-02
Release Date: 08/22/2024
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