|
State of Wisconsin |
Release 24-01 |
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 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. |
It is possible that an applicant owes a premium for some but not all initial months at application. For example, they request backdated coverage, and their income was under 100% FPL during the backdated months, but their income is over 100% FPL in the application month, so no premium is required for the backdated months, but 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 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. |
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 25.1.6 Processing a MAPP Application Requiring a Premium).
Initial premium payments must be paid by check or money order and are collected by the IM agency.
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.
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. 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 their premium between adverse action of the benefit month and the last day of the benefit month, they can reopen without a break in coverage.
| 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. Jim will be eligible as of October without a break in service. |
If the member pays their premium any time in the month after the benefit month, they can reopen. They must pay the premium that closed them. If they owe a premium for that following month, they must pay that premium before CARES will open MAPP. The member must pay the IM agency directly (not the fiscal agent).
When the payment(s) is received, benefits will be reopened back to the first of the benefit month and there will be no gap in coverage.
| 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. If Jim pays his premium arrears in October, his benefits will reopen as of October. 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, an RRP will be applied (see Section 26.6 MAPP Restrictive Re-enrollment Period (rrp)), 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, the RRP will be lifted, and benefits will be reinstated.
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 by check, and the payment is rejected for insufficient funds. An RRP will be applied, unless there is good cause (anything that is beyond the member’s control), and the member's benefits will end. The RRP begins with the first month after closure.
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 and an RRP will not be imposed (see 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: 24-01
Release Date: 04/03/2024
Effective Date: 02/01/2024
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