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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
Clients must meet all of the following:
Meet general MA non-financial requirements (1.1.2),
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 ) (3.6.9), and
Be working in a paid position or participating
in a Health and Employment Counseling ( HEC ) program (5.12.3.4).
DDB must certify disability (3.6.9). There is no requirement that a client 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 client does not have a disability determination from SSA, refer the client to the DDB for a disability determination. Send a Medicaid Purchase Plan Transmittal of Medicaid Disability Application ( HCF 10120 ) to identify a client who has applied for MAPP and needs a disability determination. The rest of the MAPP application may be completed at this time, however, a client cannot be eligible for MAPP until the disability determination has been made. Pend the case in CARES while you are waiting for a MAPP disability determination from DDB.
Follow the rules in section 3.6.6 on when to review disability determination.
To meet the work requirement, a client must engage in a work activity at least once per month, or be enrolled in a Health and Employment Counseling ( HEC ) program (5.12.3.4). Consider a client to be working whenever s/he receives something of value as compensation for his/her work activity.
This includes wages or in-kind payments. The exceptions are loans, gifts, awards, prizes, and reimbursement for expenses.
If a client 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 client 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, s/he is employed for the purposes of determining MAPP eligibility for the entire year. Do not consider clients employed for any months in which they do not have a contractual employment agreement.
A client 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 client has signed up with a temporary service agency and is not actually working, s/he is not working for purposes of MAPP. If a client is engaged in work activity for which compensation will be received, at least once in a calendar month, s/he is employed for the purposes of determining MAPP eligibility in that calendar month.
If there is a serious illness or hospitalization that causes the client to be unable to work, the work requirement can be suspended for up to six months. S/he can continue to be MAPP eligible. The client must contact the ESA to request the exemption. Have the client complete the Medicaid Purchase Plan (MAPP) Work Requirement Exemption (HCF 10127). This provision is not available unless s/he:
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.
Based on criteria outlined above, the ESA will approve or deny the request. If a work exemption request is denied, the client has appeal rights in accordance with the MA program.
In the sixth month of an exemption, mail to the recipient a notice indicating the date the Medical Work Exemption will end as well as steps the client may take to continue MAPP eligibility.
Health and Employment Counseling Program ( HEC ) is a program certified by the Department of Health and Family Services ( DHFS ) to arrange services that help a client reach his/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 client 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 client is responsible for reporting HEC participation to the ESA. The ESA is not responsible for tracking HEC participation.
Give the client a blank MAPP Employment Plan form, a HEC consumer guide, and the list of HEC screeners in your area. The client needs to complete the Employment Plan and give it to the screener.
The screener and client meet to set employment goals. The screener approves or disapproves the Employment Plan and then sends it to the Department of Health and Family Services ( DHFS ) MAPP Unit, where a final approval/disapproval decision is made within ten working days. Their address is:
Pathways to Independence
Room 1150
1 W. Wilson St
Madison, WI 53701
If the plan is not approved, the client should be informed by the HEC counselor that s/he has appeal rights and has the right to file a fair hearing.
The DHFS MAPP Unit sends an approval letter to the client and the screener.
In order to receive MAPP, the client is responsible for providing ESS
with a copy of the approval letter.
See 5.12.10. HEC Regional Screeners for a listing.
A participant can extend a HEC period by contacting HEC to request an extension.
If the HEC period is ending prior to the client meeting his/her employment plan goals, but the goals can be met within the three months after the regular HEC period will end, the DHFS MAPP Unit can extend the HEC participation for three months.
The HEC counselor/screener monitors the participation of the client as s/he pursues the goals described in his/her MAPP Employment Plan. Whenever a client notifies you that s/he has stopped participating in the HEC program, terminate eligibility with adverse action notice.
Whenever a HEC participant notifies you that s/he is now employed, gather information about the employment and redetermine eligibility.
See 6.3.7 for information about Health Insurance Premium Payment ( HIPP ) and cooperation requirements.
There are no spousal impoverishment protections for MAPP. An institutionalized client who was determined ineligible for MA using the MA Institutions tests can qualify for MA through MAPP. However, because we only count the client’s assets in determining MAPP eligibility, we do not apply the spousal impoverishment provisions for assets. Similarly, because we do not have a post-eligibility treatment of income and instead calculate a premium using only the client’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 MA. If the client’s income exceeds 150% of the FPL (8.1.6), s/he is responsible to pay a monthly premium instead of a patient liability or cost share (5.8.7) and (5.8.7.3).
MAPP is a full-benefit MA subprogram for community waiver participation (7.1.2). If the client’s monthly income exceeds 150% of the FPL (8.1.6), s/he is responsible to pay a monthly premium instead of a cost share.
MAPP clients are eligible for enrollment into specific Special Managed Care Programs ( SMCP ).
This page last updated in Release Number : 04-03
Release Date: 08/02/04
Effective Date: 08/02/04