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State of Wisconsin |
Release 25-04 |
MAPP members with gross monthly income over 100% of the FPL will be charged a premium.
MAPP applicants with gross monthly income over 100% of the FPL must pay an initial premium to enroll in 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 169% 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 − $1,304.17 (100% of the FPL) -------------- $445.83 Premium Net Income X 0.03 (3%) -------------- $13.37 +$25 Base Premium Amount -------------- $38.37 (round down to nearest whole dollar) Susan’s monthly MAPP premium is $38. |
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 their monthly premium gross income was less than 100% FPL for some of the months. 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 and a premium is owed for the 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 for which a premium was owed.
| 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. |
The Medicaid Purchase Plan Premium Information/Payment form (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 eligibility if they are unable or do not want to pay the premiums.
| Example 8 | 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. |
Ongoing premium payments can be paid through any of the methods listed in Section 26.5.4.1 Payment Methods. Premiums are due on the 10th of the benefit month regardless of which payment method is chosen.
Members enrolled in ACCESS AutoPay or Electronic Funds Transfer (EFT) or Wage Withholding are mailed a monthly automatic premium payment reminder letter. This letter is mailed around the 20th of the month before the benefit month. ACCESS AutoPay payments occur on the 3rd calendar day of the benefit month. EFT and Wage Withholding payments occur on the 3rd business day of the benefit month.
Members not enrolled in ACCESS AutoPay or EFT or Wage Withholding are mailed a premium statement. The fiscal agent sends the premium statement around the 20th of the month before the benefit month.
Initial premium payments required to gain MAPP eligibility can be paid:
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. Members can:
To ensure that premium payments are properly posted by the fiscal agent, individuals may no longer pay their initial or ongoing MAPP premiums to their local or tribal IM agency. If an individual brings a premium payment to the agency, the agency must assist them with paying online or mailing their premium payment. In-person premium payments will be processed by the agency only in very limited circumstances, when the following criteria are met:
To make recurring monthly payments via EFT, members must submit a completed Medicaid Purchase Plan Premium Member/Employer Electronic Funds Transfer form (F-13023).
To make recurring monthly payments via Wage Withholding, members must submit a completed Medicaid Purchase Plan Premium Member/Employer Electronic Funds Transfer form (F-13023) and the employer must submit the Medicaid Purchase Plan Premium Employer Wage Withholding form (F-13024).
Members who are awaiting enrollment in EFT or Wage Withholding must pay their monthly premiums using another method until they receive confirmation that their EFT or Wage Withholding enrollment is complete.
Members enrolled in ACCESS AutoPay or EFT or Wage Withholding will be mailed a monthly automatic premium payment reminder letter instead of a monthly premium statement.
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:
The member’s estate can receive a refund if he or she dies between adverse action and the beginning of the benefit month.
The fiscal agent either issues a refund or applies an excess payment to the next month’s premium if a change is reported that results in no premium or a lower premium amount.
If the change is reported within 10 days of when the change occurred, the lower premium amount or $0 premium amount is effective during the month in which the change occurred. If the change is not reported within 10 days of when the change occurred, the lower premium amount or $0 premium amount is effective during the month in which it was reported. See Section 26.7 MAPP Changes for information on change reporting.
| Note | When determining if a change was reported within 10 days of when the change occurred, the member’s reported date of change is used. If the reported date is questionable, verification may be required. |
If a MAPP member does not pay an ongoing monthly premium by the due date, but the member pays the premium and the premium is processed in the benefit month or the next month, the member will remain enrolled in MAPP.
| Example 9 | Darren is enrolled in MAPP with an ongoing monthly premium of $25. His premium for August is due August 10. Darren does not pay the August premium by the due date but makes a $25 payment on August 12 via ACCESS. On August 13, ACCESS shows that his August premium is paid. Darren will remain enrolled in MAPP. In late August, Darren is mailed a premium statement for September. |
| Example 10 | Fatima is enrolled in MAPP with an ongoing monthly premium of $43. Her premium for February is due February 10. Fatima does not pay the February premium by the due date. She will remain enrolled in MAPP through March. In late February, Fatima is mailed a premium statement for the March premium along with a cover letter that specifies the February premium is late. Fatima submits a $43 payment via ACCESS on March 5. The payment is applied to the past due February premium, and on March 6, ACCESS shows that her February premium is paid. The March premium remains unpaid. Fatima will remain enrolled in MAPP through April. In late March, Fatima is mailed a premium statement for the April premium along with a cover letter that specifies the March premium is late. |
If a late payment is received and processed after the closure notice has been sent but before eligibility has ended, the member will remain enrolled in MAPP.
| Example 11 | Ahmed is enrolled in MAPP with an ongoing monthly premium of $51. His premium for May is due May 10. Ahmed does not pay the May premium by the due date. He will remain enrolled in MAPP through June. In late May, Ahmed is mailed a premium statement for the June premium along with a cover letter that specifies the May premium is late. As of mid-June, Ahmed has not made a payment and is mailed a notice that his MAPP eligibility will end June 30 due to not paying the May premium. Ahmed submits a $51 payment via ACCESS on June 26, and the payment is applied to the past due May premium. Because Ahmed has now paid the past due May premium, he is eligible for MAPP through the month of July. The June premium remains unpaid, and Ahmed is mailed a premium statement for the July premium along with a cover letter that specifies the June premium is late. |
A payment received and processed in the month after eligibility ended is treated as a re-request and 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 12 | Rick is enrolled in MAPP with an ongoing monthly premium of $37. His premium for December is due December 10. As of mid-January, Rick has not made a payment and is mailed a notice that his MAPP eligibility is ending January 31. Rick’s last day of MAPP coverage is January 31. Rick mails a check for $37 on February 3 that the fiscal agent receives on February 5. This payment is treated as a re-request for MAPP. The $37 payment is applied as the initial premium for February, and Rick re-opens for MAPP effective February 1. |
A payment received more than a calendar month after eligibility ended will be refunded unless the individual has reapplied for MAPP or, if other health care benefits are open on the case, has re-requested MAPP.
Payment of a premium is a condition of eligibility for MAPP. If a MAPP member does not pay an ongoing premium, the member will lose MAPP eligibility for non-payment of a premium at the end of the month following the month in which the unpaid premium was due.
| Example 13 | Aarav is enrolled in MAPP with an ongoing monthly premium of $30. His premium for April is due April 10. Aarav does not pay the April premium by the due date. He will continue to remain enrolled in MAPP. In late April, Aarav is mailed a premium statement for the May premium along with a cover letter that specifies the April premium is late. If Aarav does not pay the April premium, he will be sent a notice in mid-May that his MAPP eligibility will end May 31. |
MAPP members that lose coverage due to non-payment of a premium 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.
If an individual loses MAPP eligibility for any reason, any past due premiums are no longer owed. An individual does not have to pay any past due premiums to reopen MAPP, but they must pay any premiums owed for the month(s) in which MAPP is being requested.
| Example 14 | Tatiana is enrolled in MAPP with an ongoing monthly premium of $41. Tatiana does not pay the October or November premiums, so her MAPP eligibility ends November 30. Tatiana re-requests MAPP on December 5. There is no RRP, and Tatiana does not need to pay the October or November premiums to regain MAPP eligibility. She only needs to pay an initial premium to gain eligibility for December. Tatiana pays the initial premium on December 6 and opens for MAPP as of December 1. Tatiana will receive a premium statement in mid-December for her premium due January 10. |
If a MAPP member does not pay an ongoing premium that is owed and then has an income reduction that results in not being charged a premium before losing MAPP eligibility, the member will remain eligible for MAPP without paying any past due premiums.
| Example 15 | Wei is enrolled in MAPP with an ongoing monthly premium of $39. Wei does not pay the March premium by the due date. He remains enrolled in MAPP through April. On April 8, Wei reports a reduction in income that began in April; the reduction in income is verified the same day. Wei’s gross monthly income is now under 100% FPL, and he no longer owes a premium for April. Since he no longer owes a premium as of April, Wei will remain eligible for MAPP for May even if he does not pay the past due March premium. |
Unless a temporary premium waiver is in place, members with gross monthly income over 100% of the FPL must pay their entire MAPP premium 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 following benefit month, the MAPP member will lose eligibility due to non-payment of premium.
| Example 16 | Gisele is enrolled in MAPP with an ongoing monthly premium of $35. Her premium for July is due July 10. Gisele submits a $20 payment on July 3. Although Gisele has not paid the full July premium, she will continue to remain enrolled in MAPP through August. In late July, Gisele is mailed a premium statement for the August premium along with a cover letter that specifies the July premium is late. The premium amount due for August is $35 and the past due premium amount for July is $15. Gisele does not make a premium payment in August. In mid-August, Gisele will be sent a notice that her MAPP coverage will end August 31. |
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.
A qualifying temporary hardship is an unexpected, unusual expense or situation related to the member’s health or ability to work, such as an injury or illness, or reduction of hours worked.
A temporary hardship may include, but is not limited to, the following, when the applicant or member:
Situations that do not qualify for a temporary premium waiver include, but are not limited to:
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 17 | 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 18 | 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 19 | 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 20 | 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: 25-04
Release Date: 12/10/2025
Effective Date: 12/10/2025
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