DHS 103.01(1)(a)(a) Eligibility for medical assistance shall be determined pursuant to ss.
49.455,
49.46 (1),
49.47 (4) and
49.472, Stats., and this chapter, except that medical assistance shall be provided without eligibility determination to persons receiving SSI or those persons who would currently be eligible under the AFDC program that was in place on July 16, 1996 in this state pursuant to s.
49.19, Stats.
DHS 103.01(1)(b)
(b) Presumptive eligibility for pregnant women shall be determined under s.
49.465, Stats., and this chapter.
DHS 103.01(2)
(2)
Singular enrollment. No person may be certified eligible in more than one MA case.
DHS 103.01 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; renum. (1) to be (1) (a) and cr. (1) (b),
Register, February, 1988, No. 386, eff. 3-1-88; am. (1) (a),
Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1) (a), eff. 7-1-99; am. (1) (a),
Register, March, 2000, No. 531, eff. 4-1-00; am. (1) (a),
Register, November, 2000, No. 539, eff. 12-1-00.
DHS 103.03
DHS 103.03 Non-financial conditions for eligibility. In order to be eligible for MA, a person shall meet both non-financial conditions for eligibility in this section and financial conditions for eligibility under s.
DHS 103.04. The non-financial conditions for eligibility are:
DHS 103.03(1)
(1)
AFDC-relatedness, SSI-relatedness or BadgerCare eligibility. DHS 103.03(1)(a)(a)
Requirement. To be non-financially eligible for MA, an applicant shall be AFDC-related, SSI-related or meet the non-financial requirements under par.
(f) for BadgerCare.
DHS 103.03(1)(b)
(b) AFDC-related persons. In this subsection, “AFDC-related" means a person who meets one of the following conditions:
DHS 103.03(1)(b)4.
4. The person is a foster child under 19 years of age living in a foster home licensed under s.
48.62, Stats., or a group home licensed under s.
48.625, Stats., or is a child in an adoption assistance placement under s.
48.975, Stats.
DHS 103.03(1)(c)
(c) SSI-related persons. In this subsection, “SSI-related person" means a person who meets one of the following conditions:
DHS 103.03(1)(d)
(d) Verification of blindness or disability. Except as provided under par.
(e), the blindness or disability claimed under par.
(c) 2. shall be verified in one of the following ways:
DHS 103.03(1)(d)1.
1. By presentation of a current old age and survivors disability insurance (OASDI) disability award notice;
DHS 103.03(1)(d)2.
2. By presentation of a current medicare card indicating blindness or disability; or
DHS 103.03(1)(d)3.
3. By receipt of a disability determination made by the department's bureau of social security disability insurance, along with current medical reports.
DHS 103.03(1)(e)1.1. Under emergency circumstances, a person may be presumed disabled for purposes of demonstrating SSI-relatedness and be eligible for MA without the verification required under par.
(d).
DHS 103.03(1)(e)2.
2. When an emergency need for MA exists, the department shall make a preliminary disability determination within 7 days of the date a completed disability determination form is received.
DHS 103.03(1)(e)3.b.
b. Seriously impaired and the attending physician states the applicant will be unable to work or return to normal functioning for at least 12 months;
DHS 103.03(1)(e)3.c.
c. In need of long-term care and the nursing home will not admit the applicant until MA benefits are in effect; or
DHS 103.03(1)(e)3.d.
d. Unable to return home from a nursing home unless in-home service or equipment is available and this cannot be obtained without MA benefits.
DHS 103.03 Note
Note: Copies of the disability determination form may be obtained from the county or tribal income maintenance agency.
DHS 103.03(1)(f)
(f)
BadgerCare eligibility. To be non-financially eligible for BadgerCare, a person shall meet all of the following conditions:
DHS 103.03(1)(f)1.
1. The person is under age 19, a custodial parent living with his or her child who is under age 19 or the spouse of a custodial parent if the spouse resides with the custodial parent's child who is under the age of 19.
DHS 103.03(1)(f)2.
2. The person does not have health insurance coverage and has not been covered at any time in the previous 3 calendar months. The 3 calendar month period does not apply if the coverage ended for a good cause reason. A good cause reason is any of the following:
DHS 103.03(1)(f)2.a.
a. The person was covered by a group health insurance plan that was provided by a subscriber through his or her employer, and the subscriber's employment ended for a reason other than voluntary termination, except for cases in which the voluntary termination was a result of the incapacitation of the subscriber.
DHS 103.03(1)(f)2.b.
b. The person was covered by a group health insurance plan that was provided by a subscriber through his or her employer, and the subscriber changed to a new employer who does not offer family coverage.
DHS 103.03(1)(f)2.c.
c. The person was covered by a group health insurance plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.
DHS 103.03(1)(f)2.e.
e. The person was covered by insurance that has ended due to the death or change in marital status of the subscriber.
DHS 103.03(1)(f)3.
3. The person does not have access to family coverage under a group health insurance plan offered by an employer for which the employer pays 80% of the cost, excluding any deductibles or co-payments that may be required under the plan, or to a state employee health plan through any of the following:
DHS 103.03(1)(f)3.b.
b. The employer of the person's spouse when the spouse is residing with the person.
DHS 103.03(1)(f)3.c.
c. The employer of the person's parent, step-parent or other caretaker relative residing with the person, when the person is under 19 years of age.
DHS 103.03(1)(f)4.
4. Except as provided in subd.
5., the applicant for BadgerCare did not at any time in the 18 months immediately preceding application for BadgerCare have access to employer-subsidized health care coverage, or a state employee's health plan. The applicant is ineligible for BadgerCare the first day of the month that the employer's plan would have provided coverage for the recipient if the family had been enrolled in the plan. The applicant remains ineligible for each month that coverage would have been available up to 18 months from the month the failure to enroll in the plan occurred. The insurance the applicant had access to shall have been available only through one of the following:
DHS 103.03(1)(f)4.b.
b. The employer of the person's spouse when the spouse is residing with the person.
DHS 103.03(1)(f)4.c.
c. The employer of the person's parent, step-parent or other caretaker relative residing with the person, when the person is under 19 years of age.
DHS 103.03(1)(f)5.
5. The 18 month period in subd.
4. does not apply if one of the following statements is true about access to employer-subsidized health care coverage:
DHS 103.03(1)(f)5.c.
c. A member or members of the family were eligible for other health insurance coverage or MA at the time the employee failed to enroll in the employer-subsidized health care coverage and no member of the group was eligible for BadgerCare at that time.
DHS 103.03(1)(f)5.d.
d. The person was covered by insurance that has ended due to the death or change in marital status of the subscriber.
DHS 103.03(1)(f)6.
6. The person is not eligible for MA under AFDC-related or SSI-related criteria in this chapter.
DHS 103.03(1)(f)8.
8. A person has not chosen to receive AFDC-related or SSI-related MA through a spend-down, as described in s.
DHS 103.08 (2) (a), or has chosen to end a spend-down period at any time prior to the date at which the expenditure or obligation of excess income has been achieved.
DHS 103.03(1)(g)
(g)
Medicaid purchase plan non-financial eligibility. To be non-financially eligible for the medicaid purchase plan a person shall meet the conditions described in par.
(c) for SSI-related persons and shall be age 18 or older and the person shall meet any of the following conditions:
DHS 103.03(1)(g)1.b.
b. The person shall be enrolled in a department-certified health and employment counseling program.
DHS 103.03(1)(g)1.c.
c. The health of the person participating in the medicaid purchase plan for at least 6 months shall have deteriorated to the point that he or she is unable to participate under subd.
1. a. or
b. and the county agency has waived the requirement for a period up to 6 calendar months. The county agency may waive the requirement if the person is hospitalized, injured or suffers any other health setback. The county agency may waive the requirement as long as it had not granted a waiver of the requirement twice within the 36 months immediately preceding the current waiver request. The waiver periods shall be non-consecutive. The person shall supply proof of health difficulties. In addition to the discretion the county agency has to grant a waiver, the department may grant a temporary waiver of the work requirement upon a showing of good cause.
DHS 103.03(1)(h)
(h)
Medicaid purchase plan health and employment counseling eligibility. DHS 103.03(1)(h)1.1. `Initial eligibility.' To be eligible for the health and employment counseling program within the medicaid purchase plan, a person shall complete an employment plan.
DHS 103.03(1)(h)1.a.
a. The employment plan shall be reviewed by a screening agency and approved by the department before the person receives approval from the department as a participant.
DHS 103.03(1)(h)1.b.
b. The screening agency shall refer the person to community resources as appropriate to meet all employment plan requirements. The screening agency may assist the person in completing the written employment plan or providing any other services required under the plan.
DHS 103.03(1)(h)1.c.
c. A notice of participation status shall be sent by the department to the person, the screener and the appropriate county or tribal economic support office.
DHS 103.03(1)(h)2.a.a. A person may participate in a health and employment counseling program for a period of up to nine consecutive calendar months and for any allowable periods of extension described under subd.
3. DHS 103.03(1)(h)2.b.
b. Upon completion of a period of eligibility, a person shall be ineligible for a health and employment counseling program for a period of 6 consecutive calendar months. Following the 6-month period, a person may begin a new period of eligibility, but a given person may only use 2 periods of eligibility within a period of 5 consecutive calendar years.
DHS 103.03(1)(h)2.c.
c. Participation in a health and employment counseling program approved by the department meets the eligibility requirement in par.
(g) 1. b. DHS 103.03(1)(h)3.a.a. If a person is not employed at the end of the period of eligibility, the person may request an extended period of eligibility from the department. The extended period of eligibility shall be valid for a period of three consecutive calendar months.
DHS 103.03(1)(h)3.c.
c. The person may not request more than one extension of eligibility per period of eligibility.
DHS 103.03(1)(h)3.d.
d. After participation in a health and employment counseling [program] ends, a person may continue to receive services from an agency that also provides screening services, in accordance with the agency's rules.
DHS 103.03(1)(h)4.a.a. A person may request retroactive participation in a health and employment counseling program for a period of up to three months if the person demonstrates he or she met all eligibility requirements of the employment plan during those months.
DHS 103.03(1)(h)4.b.
b. Any retroactive months of eligibility requested by the person shall count toward the period of eligibility as described in this paragraph.
DHS 103.03(2)
(2)
Citizenship. U.S. citizenship shall be a requirement for eligibility for MA, except that an alien lawfully admitted for permanent residency may be eligible, including an alien lawfully present in the United States as a result of s. 203 (a) 7. (8. USC 1153), 207 (c) (8. USC 1157), 208 (
8 USC 1158) or 212 (d) 5 (
8 USC 1182) of the immigration and nationality act, an alien granted lawful temporary resident status under s. 245A (
8 USC 1255a), 210 (
8 USC 1160) or 210A (
8 USC 1161) of the immigration and nationality act or an alien otherwise permanently residing in the United States under color of law within the meaning of
42 CFR 435.408. An alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under
8 USC 1255a (h) (3) or
42. USC
1396b (v).
DHS 103.03(3)(a)1.a.
a. The individual's IQ is 49 or less, or the individual has a mental age of 7 or less, based on tests acceptable to the department;
DHS 103.03(3)(a)1.c.
c. Medical documentation or other documentation acceptable to the department supports a finding that the individual is incapable of indicating intent.
DHS 103.03(3)(a)2.
2. “Intent to reside" means that a person intends that Wisconsin is the person's place of residence and that the person intends to maintain the residence indefinitely.
