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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: • Has an unusual expense related to their health or ability to work. An unusual expense is an expense that is necessary for the ability of the individual to work or take care of their health that is not a regular, recurring, or planned expense. The expense cannot be anything that was used to establish eligibility or the premium amount for the individual, as these should be regular and recurring. • Has experienced a decrease in work hours. • Has lost a job but remains non-financially eligible due to a medical exemption or participation in a HEC plan. • Is the survivor of a crime, such as someone who has experienced domestic violence or sexual assault, battery, theft, and other crimes. As a result, the member has incurred extra expenses or is unable to access their funds due to the crime. • Is experiencing temporary transportation issues, causing a decrease in the hours they can work. • Is experiencing temporary child care issues, causing a decrease in the number of hours they can work. Situations that do not qualify for a temporary premium waiver include, but are not limited to: • Expenses that are not related to an applicant or member’s health or ability to work. • Inflation or other regular increase in price, such as groceries or gasoline. • Regular, recurring expenses that can be budgeted for, like rent or utilities, that are not the result of an unexpected or unplanned change. 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: • Agency form • Employer statement/paystub/taxes/Employer Verification of Earnings form (EVF-E) • Collateral contact • A statement from a health care or mental health provider, such as a medical doctor, psychiatrist, social worker, AODA professional, or psychologist, that identifies there is an issue and time period in which the individual cannot work. • A receipt for the unusual health or work related expense.