DHS 103.085(3) (3)Re-enrollment restriction.
DHS 103.085(3)(a)(a) Period of ineligibility. A BadgerCare group that fails to make a premium payment under sub. (1) or quits BadgerCare under sub. (2) is not eligible for BadgerCare for a period of at least 6 consecutive calendar months following the date that BadgerCare eligibility ends, unless one of the circumstances in par. (b) applies. Eligibility is restored as described in par. (c). After 6 calendar months, the group shall be eligible for BadgerCare only if all past premiums due are paid in full or 12 calendar months have passed after the expiration of BadgerCare eligibility, whichever is sooner.
DHS 103.085(3)(b) (b) Reasons restriction on re-enrollment may not apply. The restriction on re-enrollment under this section does not apply for either of the following reasons:
DHS 103.085(3)(b)1. 1. The failure to pay premiums was due to a circumstance beyond the group's control, provided that all past due premiums have been paid in full. A circumstance beyond the group's control includes any of the following:
DHS 103.085(3)(b)1.a. a. A problem with an electronic funds transfer from a bank account to the BadgerCare program.
DHS 103.085(3)(b)1.b. b. A problem with an employer's wage withholding.
DHS 103.085(3)(b)1.c. c. An administrative error in processing the premium.
DHS 103.085(3)(b)1.d. d. Any other circumstance affecting payment of the premium which the department determines is beyond the group's control, but not including insufficient funds.
DHS 103.085(3)(b)2. 2. A significant change in household composition occurred. A significant change occurs when one of the following events occurs:
DHS 103.085(3)(b)2.a. a. A parent or a parent's spouse in the group eligible for BadgerCare no longer resides in the home and has not resided in the home for at least 30 consecutive days.
DHS 103.085(3)(b)2.b. b. A person not in the group eligible for BadgerCare, but who is legally responsible for a group member, no longer resides in the home and has not resided in the home for at least 30 consecutive days.
DHS 103.085(3)(b)2.c. c. A caretaker relative of a minor in a group eligible for BadgerCare, or the caretaker relative's spouse, no longer resides in the home and has not resided in the home for at least 30 consecutive days.
DHS 103.085(3)(c) (c) Resuming BadgerCare eligibility. Eligibility for BadgerCare shall resume in the following manner for persons with a re-enrollment restriction that ended due to a reason described in par. (b):
DHS 103.085(3)(c)1. 1. For a BadgerCare group with a reason under par. (b) 1. for the re-enrollment restriction not to apply, BadgerCare eligibility shall be restored for any months that the group had been closed during the restriction period, provided that payment of any outstanding premiums owed is made and the group was otherwise eligible for BadgerCare in those months.
DHS 103.085(3)(c)2. 2. For a BadgerCare group with a reason under par. (b) 2. for the re-enrollment restriction not to apply, the restriction on re-enrollment shall not apply to the remainder of the 6-month period. Beginning the first of the month after the adult has been out of the home for 30 days, the group may again be eligible for BadgerCare, provided that payment of any outstanding premiums owed is made and the group is otherwise eligible. The BadgerCare group remains ineligible for any prior months when the restriction on re-enrollment was in effect.
DHS 103.085(4) (4)Enroll in available employer-subsidized health plan.
DHS 103.085(4)(a)(a) A BadgerCare recipient is ineligible for BadgerCare when one of the following fail to enroll in an available employer-subsidized health care coverage:
DHS 103.085(4)(a)1. 1. The recipient.
DHS 103.085(4)(a)2. 2. The recipient's spouse when the spouse is residing with the recipient.
DHS 103.085(4)(a)3. 3. The recipient's parent, step-parent or other caretaker relative residing with the recipient, when the recipient is under 19 years of age.
DHS 103.085(4)(b) (b) Except as provided in par. (c), the recipient is ineligible for BadgerCare effective on the first day of the month that the employer-subsidized health care coverage would have been in effect for the recipient if the family had been enrolled in the plan. The individual remains ineligible for each month that coverage would have been available up to 19 months from the month the failure to enroll in the plan occurred.
DHS 103.085(4)(c) (c) Paragraph (b) does not apply if there was coverage and it ended for a good cause reason. A good cause reason is any of the following:
DHS 103.085(4)(c)1. 1. The employment ended for a reason other than voluntary termination.
DHS 103.085(4)(c)2. 2. The person changed to a new employer that does not offer family coverage.
DHS 103.085(4)(c)3. 3. The person's employer discontinued health plan coverage for all employees.
DHS 103.085(4)(c)4. 4. Any other reason determined by the department to be a good cause reason.
DHS 103.085(5) (5)Cooperation with buy-in to a group health insurance plan. An adult in a group eligible for BadgerCare shall cooperate when the department determines whether it is cost-effective to purchase coverage for the group in an employer's group health insurance plan under s. DHS 108.02 (13). In this subsection, “cooperation" means providing necessary information in order to determine cost effectiveness, signing up with the plan when requested by the department and cooperating with any other requirements of the health insurance plan. A person who fails or refuses to cooperate with buy-in is not eligible for BadgerCare.
DHS 103.085(6) (6)Maximum income. A BadgerCare group remains eligible for BadgerCare while the fiscal test group's income is at or below 200% of the poverty line and the group is otherwise eligible for BadgerCare.
DHS 103.085 History History: Emerg. cr. eff. 7-1-99; cr. Register, March, 2000, No. 531, eff. 4-1-00; correction in (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 103.087 DHS 103.087Conditions for continuation of eligibility.
DHS 103.087(1)(1)Premiums.
DHS 103.087(1)(a)(a) Authority. Subject to this section and s. 49.472, Stats., a person eligible for the medicaid purchase plan shall pay a monthly premium.
DHS 103.087(1)(b) (b) Applicability.
DHS 103.087(1)(b)1.1. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is at or above 150% of the poverty line for the applicable household size shall pay a monthly premium and the applicant shall pay all retroactive premium amounts assessed or other premium payments due.
DHS 103.087(1)(b)2. 2. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is below 150% of the poverty line for the applicable household size need not pay a monthly premium.
DHS 103.087(1)(b)3. 3. An applicant or recipient eligible for the medicaid purchase plan whose premium, calculated as described in par. (c), is greater than $10.00 shall pay a premium for the cost of the health care coverage offered under the medicaid purchase plan.
DHS 103.087(1)(c) (c) Premium amounts.
DHS 103.087(1)(c)1.1. An applicant or recipient eligible for the medicaid purchase plan shall pay a monthly premium in accordance with this subsection and the premium schedule in Table 103.087.
DHS 103.087(1)(c)2. 2. The county agency shall determine the amount of the premium an applicant shall pay according to the guidelines described in this subsection at the time of application.
DHS 103.087(1)(c)3. 3. All earned and unearned sources of income available to the applicant or recipient, except for the interest, dividends or other gains accrued from a recipient's independence account, shall be used in the premium determination.
DHS 103.087(1)(c)4. 4. The applicant's or recipient's monthly premium shall be calculated by locating the sum of the monthly adjusted unearned income plus the monthly adjusted earned income on the premium schedule in Table 103.087.
DHS 103.087(1)(d) (d) Calculating the monthly adjusted unearned income.
DHS 103.087(1)(d)1.1. An applicant's or recipient's monthly adjusted unearned income shall be calculated by subtracting the monthly income disregards in subd. 1. a. to c. from 100% of the applicant's or recipient's gross monthly countable unearned income.
DHS 103.087(1)(d)1.a. a. The allowance shall be equal to the sum of the monthly federal supplemental security income cash benefit, the monthly state supplemental security cash benefit, and $20, rounded to the nearest dollar.
DHS 103.087(1)(d)1.b. b. To be claimed as a monthly income disregard, the cost may not have been claimed by the applicant or recipient under any other medicaid purchase plan income disregard.
DHS 103.087(1)(d)1.c. c. To be claimed as a monthly income disregard, the cost may not have been claimed by the applicant or recipient under any other medicaid purchase plan income disregard.
DHS 103.087(1)(d)2. 2. If the applicant or recipient has monthly unearned income equal to $0, the monthly income disregards described in subd. 1. a. to c. apply to the applicant's or recipient's gross monthly earned income. If the applicant or recipient has monthly income disregards greater than his or her monthly unearned income, the difference shall be applied as a deduction to the applicant's or recipient's monthly earned income.
DHS 103.087(1)(e) (e) Calculating monthly adjusted earned income. An applicant's or recipient's monthly adjusted earned income shall be 3% of the applicant's or recipient's gross monthly earned income after the amount of any monthly income disregards greater than the applicant's or recipient's total unearned income have been subtracted.
DHS 103.087(1)(f) (f) Calculating the total monthly premium.
DHS 103.087(1)(f)1.1. The sum of the amounts determined in pars. (d) and (e) shall be applied to the premium schedule in Table 103.087. If the sum of the monthly adjusted earned and monthly adjusted unearned income is greater than $1025.00, the total monthly premium amount is the exact amount of the sum.
Table 103.087: Medicaid Purchase Plan Premium Schedule - See PDF for table PDF
DHS 103.087(1)(f)2. 2. The monthly premium shall be recalculated by the county agency to reflect any changes in earned or unearned income as reported by the recipient. A recipient's premium amount may change for any of the following reasons:
DHS 103.087(1)(f)2.a. a. Termination of the recipient from the medicaid purchase plan.
DHS 103.087(1)(f)2.b. b. A change in the poverty line or SSI federal or state benefit payment rate.
DHS 103.087(1)(f)2.c. c. Changes in income, impairment-related work expense costs or medical and remedial expense costs.
DHS 103.087(1)(f)2.d. d. Contributions to a recipient's independence account greater than an amount equal to 50% of earned income as described in s. DHS 103.06 (15).
DHS 103.087(1)(f)2.e. e. Other changes in personal or financial status that alter medical assistance eligibility.
DHS 103.087(1)(g) (g) Monthly payments.
DHS 103.087(1)(g)1.1. Before the county agency may certify an applicant as eligible for the medicaid purchase plan, the applicant who owes a premium under this subsection shall pay the premium amount. The premium amount owed shall include the premiums for all retroactive and current months in which the applicant owes a premium as of the date eligibility is determined.
DHS 103.087(1)(g)2. 2. An applicant may claim retroactive medicaid purchase plan eligibility for a period of up to 3 months prior to the month of application, but not prior to January 1, 2000. To be eligible for retroactive eligibility, an applicant shall pay the retroactive premium amount for each month claimed, in full, to the state's fiscal agent via the county agency, prior to the county agency certifying the applicant's eligibility for the medicaid purchase plan.
DHS 103.087(1)(g)3. 3. Based on arrangements made by the applicant or recipient, entities other than the applicant or recipient may pay monthly premiums on behalf of the applicant or recipient. The applicant or recipient shall be ultimately responsible for his or her monthly premium payment.
DHS 103.087(1)(g)4. 4. If the county agency does not receive payment by the last day of the calendar month for which the premium is owed, the department shall terminate the recipient's eligibility for the medicaid purchase plan, effective the last calendar day of the month.
DHS 103.087(1)(g)5. 5. An applicant or recipient may pay monthly premiums in advance, but only for the months in the applicant's or recipient's current medicaid review period. The applicant or recipient shall pay advance monthly premium amounts in full.
DHS 103.087(1)(g)6. 6. If no premium is required and the applicant meets all other eligibility factors, the county agency shall approve the applicant for the medicaid purchase plan.
DHS 103.087(1)(h) (h) Non-payment of medicaid purchase plan premiums.
DHS 103.087(1)(h)1.1. An applicant or recipient required to pay a monthly premium shall be ineligible for re-enrollment for the period specified in par. (i) 2. when the applicant or recipient fails to pay his or her monthly premium within the time specified in par. (g) 4. resulting in a finding of premium non-payment.
DHS 103.087(1)(h)2. 2. Premium non-payment shall include attempted payment with an instrument such as a check or direct deposit, that has been returned, refused or dishonored. A guaranteed form of payment such as a cashier's check or money order shall be required to replace a returned, refused or dishonored payment.
DHS 103.087(1)(h)3. 3. Failure to pay premiums due to circumstances beyond the recipient's control may not be considered non-payment, provided that all past due premiums are paid in full. Circumstances beyond the recipient's control are any of the following:
DHS 103.087(1)(h)3.a. a. Problems with an electronic funds transfer or direct deposit from a financial institution to the medicaid purchase plan program.
DHS 103.087(1)(h)3.b. b. Problems with an employer's wage withholding.
DHS 103.087(1)(h)3.c. c. Administrative error in processing the premium.
DHS 103.087(1)(h)3.d. d. Any other circumstances that may be found to be good cause as determined by the department on a case-by-case basis.
DHS 103.087(1)(h)4. 4. At the time of application or anytime thereafter, an applicant or recipient may sign a release statement identifying an emergency contact to receive copies of the person's notice of decision letters.
DHS 103.087(1)(i) (i) Consequences of premium non-payment.
DHS 103.087(1)(i)1.1. A person eligible for the medicaid purchase plan who fails to pay his or her monthly premium shall be terminated from the medicaid purchase plan and subject to restrictive re-enrollment as described under subd. 2.
DHS 103.087(1)(i)2. 2. A medicaid purchase plan participant who fails to make his or her monthly premium payments in the medicaid purchase plan shall be ineligible for a period of at least 6 consecutive calendar months following the date that the medicaid purchase plan eligibility ends. After 6 calendar months, the person shall be eligible for the medicaid purchase plan only if all past premiums due are paid in full or 12 calendar months have passed since the expiration of medicaid purchase plan eligibility, whichever is sooner.
DHS 103.087(2) (2)Cooperation with buy-in to employer-provided health care coverage.
DHS 103.087(2)(a)(a) The applicant eligible for the medicaid purchase plan and the applicant's parent, if the applicant is a dependent child aged 18 or 19, shall cooperate when the department determines whether it is cost-effective to purchase coverage under the employer-provided health plan for the person under s. DHS 108.02 (14). In this subsection, “cooperate" means provide necessary information in order to determine cost-effectiveness, sign up with the health plan when requested by the department and comply with any other requirements of the health plan.
DHS 103.087(2)(b)1.1. Except as provided in subd. 2., a person who fails or refuses to cooperate with the department's buy-in to employer-provided health care coverage is not eligible for the medicaid purchase plan.
DHS 103.087(2)(b)2. 2. An exception to subd. 1. shall be made in cases where a person who is otherwise eligible for medical assistance is unable to enroll in the group health plan on his or her own behalf. An example of a person who is otherwise eligible for medical assistance but unable to enroll in the group health plan on his or her own behalf may be a child whose parent refuses to enroll the child or a spouse unable to enroll on his or her own behalf.
DHS 103.087 History History: Cr. Register, November, 2000, No. 539, eff. 12-1-00; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 103.09 DHS 103.09Termination of medical assistance.
DHS 103.09(1)(1)Final month coverage. When eligibility ends, except in the case of death of the recipient, the MA benefits shall continue until the end of the calendar month.
DHS 103.09(2) (2)Four-month continuation of eligibility. When an MA group becomes ineligible for AFDC due solely to excess income, is receiving child support payments and all of the excess income consists of child support collections, and has received an AFDC payment in at least 3 of the 6 months immediately preceding the month in which ineligibility begins, eligibility for MA shall continue for 4 months from the date that AFDC eligibility was terminated. The 6 months preceding the month in which ineligibility begins includes the month in which the MA group became ineligible for AFDC if the MA group was eligible for and received AFDC for that month.
DHS 103.09(3) (3)Twelve-month continuation of eligibility.
DHS 103.09(3)(a)(a) When an MA group becomes ineligible for AFDC due to loss of the earned income disregards under s. 49.19 (5) (a) 4. and 4m., or (am), Stats., or to a change in the amount of earned income disregards under s. 49.19 (5) (a) 4. and 4m., or (am), Stats., eligibility for MA shall continue for 12 months from the date that AFDC eligibility was terminated.
DHS 103.09(3)(b) (b) When an MA group becomes ineligible for AFDC due to an increase in earned income or an increase in hours of employment or a combination of increased earned income and increased hours of employment, eligibility for MA shall continue for 12 months from the date that AFDC eligibility was terminated provided that at least one member of the MA group received AFDC for at least 3 of the 6 months immediately preceding the month in which AFDC was discontinued and at least one member of the MA group is continuously employed during that period.
DHS 103.09(3)(c) (c) When an MA group becomes ineligible for AFDC due to an increase in earned income, or to a combination of an increase in earned income and in increase in child support payments, and has received an AFDC payment in at least 3 of the 6 months immediately preceding the month in which ineligibility begins, eligibility for MA shall continue for 12 months from the date that AFDC eligibility was terminated. The 6 months preceding the month in which ineligibility begins includes the month in which the MA group became ineligible for AFDC if the MA group was eligible for and received AFDC for that month.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.