STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10127 (07/08)
MEDICAID PURCHASE PLAN (MAPP) WORK REQUIREMENT EXEMPTION
Instructions: To be completed by an Income Maintenance worker. A copy should be sent to the member and one placed in the case file.
Member Name (First, MI, Last) Worker Number CARES Case Number Social Security Number PIN Filing Date
A Medicaid Purchase Plan (MAPP) member may request to be exempted from the work requirement for up to six calendar months. This would allow an individual who has been participating in MAPP for the last six months, who can not continue to work or participate in a Health and Employment Counseling Program, to continue his or her enrollment in MAPP. In order to qualify for the work requirement exemption the member must be experiencing a health-related hardship. According to HFS 103.03(1)(g) of the Wisconsin Administrative Code, a health-related hardship includes those situations in which the member's health deteriorates to a point where s/he is unable to work or participate in the Health and Employment Counseling program. In order to qualify, the member must: Expect to return to work or his/her Health and Employment Counseling program within the next six calendar months. Have participated in MAPP for the last six calendar months; Currently be enrolled in MAPP and has paid all MAPP premiums owed; and Not have been exempted for more than 12 months in the last 36 months.
I, (member name) requirement beginning (date - mm/dd/yy) (number of months)
request an exemption of the MAPP work due to a health-related hardship. I expect this hardship to last for
months. I understand that I must provide a doctor's statement, to my Income Maintenance
worker within 10 days of date on the CARES Verification Check List I receive, as verification that I cannot work or participate in a Health and Employment Counseling program due to a health-related hardship. I understand that I may still be required to pay a premium based upon my income.
(Signature - Client)
Name (Income Maintenance Worker) (First and Last)
Date Begin Date End Date
Reason for Non-Approval (HFS 103.03(1)(g))
WI. Stats. s. 49.472