DHS 108.02(13)
(13) BadgerCare buy-in to employer-provided health care coverage. DHS 108.02(13)(a)(a)
Authority. The department may purchase coverage under a group health insurance plan offered by the employer of a member of an eligible family if the department determines that purchasing that coverage would not be more costly than providing coverage under BadgerCare.
DHS 108.02(13)(b)1.1. The department may not buy in to a group health insurance plan when any member of a family has been covered by a group health insurance plan offered by the employer of a member of an eligible family in the 6 months prior to the buy-in decision.
DHS 108.02(13)(b)2.
2. Children in a family are not eligible for buy-in to a group health insurance plan if the family had health care coverage through the employer of a member of the family for these children within the previous 6 months.
DHS 108.02(13)(b)3.
3. The employer shall pay at least 60% of the cost of the premiums for the group health insurance plan, but not more than 80% of the cost, for the department to purchase coverage under a group health insurance plan.
DHS 108.02(13)(c)
(c) Buy-in method. The department shall purchase coverage by making payment to one of the following:
DHS 108.02(13)(c)2.
2. The insurance company that provides the group health insurance plan offered by the employer.
DHS 108.02(13)(c)3.
3. If it is not practical or feasible for the department to purchase coverage by making payment to those specified in
subd. 1. or
2., and if requested by the employer or the insurance company offering the group health insurance plan, directly to the employee as reimbursement for premiums paid by the employee.
DHS 108.02(14)
(14) Medicaid purchase plan buy-in to employer-provided health care coverage. DHS 108.02(14)(a)(a)
Authority. The department may purchase a group health plan offered by the employer of an eligible person or non-eligible family member if the department determines that purchasing that coverage and the associated administrative expense would not be more costly than providing the medical assistance coverage described under this chapter.
DHS 108.02(14)(b)1.1. The department shall pay on behalf of the recipient all deductibles, coinsurance and other cost sharing obligations under the group health plan that are for services covered under the state plan, except for the nominal cost sharing amounts otherwise permitted under section 1916 of the social security act that are the responsibility of the recipient.
DHS 108.02(14)(b)2.
2. The department shall purchase coverage by making payment to one of the following:
DHS 108.02(14)(b)2.b.
b. The insurance company that provides the health care coverage offered by the employer.
DHS 108.02(14)(b)3.
3. If a non-medical assistance eligible family member is enrolled in the group health plan in order to obtain coverage for the medical assistance eligible family member, the department shall pay for premiums only and not other cost sharing expenses for the non-medical assistance eligible family member. Premium payments for non-eligible members shall be included in the determination of cost-effectiveness under
par. (c).
DHS 108.02(14)(b)4.
4. If a person's group health plan offers more services than are covered under the state plan, the department may not pay any deductibles, coinsurance or other cost sharing obligations for non-covered services.
DHS 108.02(14)(b)5.
5. Medicaid purchase plan eligible persons enrolled in a group health plan under this section shall be eligible for wrap-around coverage as described in
ch. DHS 101.
DHS 108.02(14)(c)
(c)
Cost-effectiveness determination. A person's enrollment in a group health plan shall be cost-effective when the amount the department pays for premiums, coinsurance, deductibles, other cost sharing obligations, wrap-around costs and additional administrative cost is likely to be less than or equal to the medical assistance expenditures for an equivalent set of services.
DHS 108.02(15)(b)
(b) Amounts recovered in estate recovery from a recipient of the medicaid purchase plan shall be reduced by the total amount of monthly premiums paid by the recipient as a condition of eligibility for the medicaid purchase plan.
DHS 108.02 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (4), cr. (8) and (9), eff. 7-1-92; am. (4), cr. (8) and (9),
Register, February, 1993, No. 446, eff. 3-1-93; correction in (6) (a) made under s. 13.93 (2m) (b) 7., Stats.,
Register, June, 1994, No. 462; cr. (10) to (12),
Register, June, 1995, No. 474, eff. 7-1-95; am. (10) (intro.), (b), (c) (intro.), 3. to 6., (11) (a), (b) 1. (intro.), c., 2. (intro.), c., (12) (a) 2., 4. and 5., cr. (10) (d) and (12) (f) 2., renum. (12) (f) to be (12) (f) 1.,
Register, April, 1996, No. 484, eff. 5-1-96; correction in (9) (e) made under s. 13.93 (2m) (b) 6., Stats.,
Register, April, 1999, No. 520; emerg. cr. (13), eff. 7-1-99; emerg. cr. (9) (f), eff. 12-23-99; cr. (13),
Register, March, 2000, No. 531, eff. 4-1-00; cr. (14) and (15),
Register, November, 2000, No. 539, eff. 12-1-00; corrections in (2), (4), (9) (d) 1., (10) (b), (c) 1., 2., 4. to 6., (12) (b) 2. c. and (14) (b) 5. made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636; correction in (12) (b) 2. c. made under s. 13.92 (4) (b) 7., Stats.,
Register May 2010 No. 653.
DHS 108.03(1)
(1)
Determination of eligibility. Agencies shall be responsible for determination of eligibility for MA. These determinations shall comply with standards for eligibility found in ss.
49.46 (1),
49.47 (4) and
49.665 (4), Stats., and
ch. DHS 103.
DHS 108.03(2)
(2) Informing recipients of rights and duties. Agencies shall inform recipients of the recipients' rights and duties under the program, including those rights enumerated in
s. DHS 106.04 (3).
DHS 108.03(3)(a)(a) Agencies shall begin recovery action, as provided by statute for civil liabilities, on behalf of the department against any MA recipient to whom or on whose behalf an incorrect payment was made.
DHS 108.03(3)(b)
(b) The incorrect payment shall have resulted from a misstatement or omission of fact by the person supplying information during an application for MA benefits, or failure by the recipient, or any other person responsible for giving information on the recipient's behalf, to report income or assets in an amount which would affect the recipient's eligibility for benefits.
DHS 108.03(3)(c)
(c) The amount of recovery may not exceed the amount of the MA benefits incorrectly provided.
DHS 108.03(3)(d)
(d) Records of payment for the period of ineligibility, provided to the agency by the MA fiscal agent, shall be evidence of the amounts paid on behalf of the recipient.
DHS 108.03(3)(e)
(e) The agency shall notify the recipient or the recipient's representative of the period of ineligibility and the amounts incorrectly paid, and shall request arrangement of repayment within a specified period of time.
DHS 108.03(3)(f)
(f) If the effort to recover incorrect payments under
par. (e) is not successful, the agency shall refer cases of possible recovery to the district attorney or corporation counsel for investigation and the district attorney or corporation counsel may bring whatever action may be appropriate for prosecution for fraud or collection under civil liability statutes. Judgments obtained in these actions shall be filed as liens against property in any county in which the recipient is known to possess assets, if not satisfied at the time the judgment or order for restitution is rendered. Execution may be taken on the judgments as otherwise provided in statute.
DHS 108.03(3)(g)
(g) The agency may seek recovery through an order for restitution by the court of jurisdiction in which the recipient or former recipient is being prosecuted for fraud.
DHS 108.03(3)(h)
(h) The agency's decision concerning ineligibility and amounts owed may be appealed pursuant to
ch. HA 3. During the appeal process the agency may take no further recovery actions pending a decision. Benefits shall be continued pending the decision on the appeal. When the hearing decision is subsequently adverse to the client the benefits paid pending a decision on the appeal shall be collectable as incorrect payments.
DHS 108.03(3)(i)
(i) The agency shall immediately deposit monies collected under this subsection to a designated bank account. The collection shall be reported to the department in the manner and on forms designated by the department within 30 days following the end of the month in which the collection is made, and shall be transmitted to the state in accordance with departmental instructions.
DHS 108.03(4)
(4) Establishing a program of medical support liability. Pursuant to s.
59.53 (5), Stats., counties shall contract with the department to implement and administer the child support collection program under Title IV-D of the Social Security Act of 1935, as amended. One of the responsibilities of a county's child support agency defined in
s. DHS 1.07 (2) (c) is to establish a program of medical support liability along with the child and spousal support and paternity establishment program.
DHS 108.03(5)(a)(a) Pursuant to approval by the federal health care financing administration, the department shall make payments under s.
49.45 (3) (am), Stats., to county and tribal agencies under this subsection, including agencies subject to the requirements under
sub. (4), to encourage identification and reporting by these agencies of MA applicants and recipients who are covered by other medical insurance. Unless
par. (b) applies, an agency shall receive an incentive payment if:
DHS 108.03 Note
Note: Section 49.45 (3) (am), Stats., was repealed by
2003 Wis. Act 33.
DHS 108.03(5)(a)1.
1. The agency identifies an MA applicant or recipient who is medically insured, identifies the person's insurance carrier providing the medical insurance coverage, and supplies information describing the person's insurance plan. The department's requirement for reporting specific information necessary to receive payment is further described in the Medical Assistance Eligibility Handbook: and
DHS 108.03(5)(a)2.
2. The department makes a reasonable effort to verify with the insurance carrier that the person's medical insurance was in effect during a coverage period corresponding to a period of MA eligibility occurring within the period of 12 months prior to the month in which the department received the county agency's information report for any MA applicant or recipient.
DHS 108.03(5)(b)
(b) Insurance policies which do not qualify for payment under this subsection shall be identified by the department based on factors that include cost effectiveness and the limitation of coverage. Policies which do not qualify under this subsection include the following:
DHS 108.03(5)(b)1.
1. A policy with coverage limited to specific diagnoses unless the policyholder has a diagnosis covered by the policy;
DHS 108.03(5)(b)2.
2. A policy limiting benefits to specific circumstances such as accidental injury;
DHS 108.03(5)(b)3.
3. A policy limiting benefits to the extent that coordinating benefits is administratively unfeasible; and
DHS 108.03(5)(b)4.
4. A policy not primarily intended as providing medical insurance coverage, such as a policy providing periodic benefits for disability or hospitalization, a policy providing liability insurance with payment for medical benefits or a policy which does not specifically cover medical services.
DHS 108.03 History
History: Cr.
Register, December, 1979, No. 288, eff. 2-1-80; renum. from HSS 108.02 and am.
Register, February, 1986, No. 362, eff. 3-1-86; cr. (6),
Register, December, 1988, No. 396, eff. 1-1-89; r. (4), renum. (5) and (6) to be (4) and (5),
Register, September, 1991, No. 429, eff. 10-1-91; correction in (5) made under s. 13.93 (am) (b) 7., Stats.,
Register, September, 1991, No. 429; correction in (3) (h) made under s. 13.93 (2m) (b) 7., Stats.,
Register, May, 1995, No. 473; emerg. am. (1), eff. 7-1-99; am. (1),
Register, March, 2000, No. 531, eff. 4-1-00; corrections in (3) (h) and (4) made under s. 13.93 (2m) (b) 7., Stats.,
Register February 2002 No. 554; corrections in (1), (2) and (4) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
