49.471(7)(c)2.
2. Disregard earnings of children under 18 years of age.
49.471(7)(c)3.
3. Determine separately the family incomes of caretaker relatives and the children for whom they are caring and not legally responsible.
49.471(7)(c)4.
4. Not include in the calculation any income of an individual receiving benefits under
s. 49.77 or federal Title XVI.
49.471(8)
(8) Health insurance coverage and eligibility. 49.471(8)(a)1.1. Except as provided in
subd. 2., any individual who is otherwise eligible under this section and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for BadgerCare Plus and if the department determines that it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor's behalf.
49.471(8)(a)2.
2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with
subd. 1., the failure does not affect the minor's eligibility under this section.
49.471(8)(b)
(b) Except as provided in
pars. (c) and
(d), an individual whose family income exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of the following applies:
49.471(8)(b)1.
1. The individual has individual or family health insurance coverage that is any of the following:
49.471(8)(b)1.a.
a. Coverage provided by an employer and for which the employer pays at least 80 percent of the premium.
49.471(8)(b)2.
2. The individual, in the 12 months before applying, had access to the health insurance coverage specified in
subd. 1.
49.471(8)(b)3.
3. The individual could be covered under the health insurance coverage specified in
subd. 1. if the coverage is applied for, and the coverage could become available to the individual in the month in which the individual applies for benefits under this section or in any of the next 3 calendar months.
49.471(8)(c)
(c) An unborn child, regardless of family income, is not eligible for BadgerCare Plus if any of the following applies:
49.471(8)(c)1.
1. The unborn child or the unborn child's mother has individual or family health insurance coverage.
49.471(8)(c)2.
2. The unborn child or the unborn child's mother, in the 12 months before applying, had access to the health insurance coverage specified in
par. (b) 1.
49.471(8)(c)3.
3. The unborn child or the unborn child's mother could be covered under individual or family health insurance coverage if the coverage is applied for, and the coverage could become available to the unborn child or the unborn child's mother in the month in which the unborn child applies for benefits under this section or in any of the next 3 calendar months.
49.471(8)(d)1.1. None of the following is ineligible for BadgerCare Plus by reason of having health insurance coverage or access to health insurance coverage:
49.471(8)(d)1.c.
c. Except as provided in
par. (c), a child who has health insurance coverage, or access to health insurance coverage, as a dependent of an absent parent but who resides outside of the service area of the absent parent's plan.
49.471(8)(d)2.
2. An individual under
par. (b) 2., or an individual who is an unborn child or an unborn child's mother under
par. (c) 2., is not ineligible if any of the following good cause reasons is the reason that the individual did not obtain the health insurance coverage under
par. (b) 1. to which they had access:
49.471(8)(d)2.b.
b. The individual's employer discontinued health insurance coverage for all employees.
49.471(8)(d)2.c.
c. One or more members of the individual's family were eligible for other health insurance coverage or Medical Assistance at the time the employee failed to enroll in the health insurance coverage under
par. (b) 1. and no member of the family was eligible for coverage under this section at that time.
49.471(8)(d)2.d.
d. The individual's access to health insurance coverage has ended due to the death or change in marital status of the subscriber.
49.471(8)(d)2.e.
e. Any other reason that the department determines is a good cause reason.
49.471(8)(e)
(e) If a pregnant woman has health insurance coverage and her family income exceeds 200 percent of the poverty line, the woman is required, as a condition of eligibility, to maintain the health insurance coverage.
49.471(8)(f)
(f) If an individual with a family income that exceeds 150 percent of the poverty line had the health insurance coverage specified in
par. (b) 1. but no longer has the coverage, if an individual who is an unborn child or an unborn child's mother, regardless of family income, had health insurance coverage but no longer has the coverage, or if a pregnant woman specified in
par. (e) has health insurance coverage and does not maintain the coverage, the individual or pregnant woman is not eligible for BadgerCare Plus for the 3 calendar months following the month in which the insurance coverage ended without a good cause reason specified in
par. (g).
49.471(8)(g)
(g) Any of the following is a good cause reason for purposes of
par. (f):
49.471(8)(g)1.
1. The individual or pregnant woman was covered by a group health 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, unless the voluntary termination was a result of the incapacitation of the subscriber or because on [of] an immediate family member's health condition.
49.471 Note
NOTE: The correct word is shown in brackets. Corrective legislation is pending.
49.471(8)(g)2.
2. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, the subscriber changed employers, and the new employer does not offer health insurance coverage.
49.471(8)(g)3.
3. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.
49.471(8)(g)4.
4. The pregnant woman's coverage was continuation coverage and the continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
49.471(8)(g)5.
5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.
49.471(8)(g)6.
6. Any other reason determined by the department to be a good cause reason.
49.471(9)
(9) Employer verification of insurance coverage. 49.471(9)(a)1.1. Except as provided in
subd. 2., for an applicant or recipient with a family income that exceeds 150 percent of the poverty line, the department shall verify insurance coverage and access information directly with the employer through which the applicant or recipient may have health insurance coverage or access to coverage.
49.471(9)(b)
(b) An employer that receives a request from the department for insurance coverage and access to coverage information shall supply the information requested by the department in the format specified by the department within 30 calendar days after receiving the request.
49.471(9)(c)1.1. Subject to
subds. 2. and
3., an employer that does not comply with the requirements under
par. (b) shall be required to pay, within 45 days after the requested information was due, a penalty equal to the full per member per month cost of coverage under BadgerCare Plus for the individual about whom the information is requested, and for each of the individual's family members with coverage under BadgerCare Plus, for each month in which the individual and the individual's family members are covered before the employer provides the information.
49.471(9)(c)2.
2. An employer with fewer than 250 employees may not be required to pay more than $1,000 in penalties under this paragraph that are attributable to any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in penalties under this paragraph that are attributable to any 6-month period.
49.471(9)(c)3.
3. Notwithstanding
subd. 1., an employer shall not be subject to any penalties if the employer, at least once per year, timely provides to the department, in the manner and format specified by the department, information from which the department may determine whether the employer provides its employees with access to health insurance coverage.
49.471(9)(d)
(d) An employer may contest a penalty assessment under
par. (c) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by
ch. 227.
49.471(10)(b)1.1. Except as provided in
subd. 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income. If the recipient has self-employment income and is eligible under
sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted.
49.471(10)(b)2.
2. Except as provided in
subds. 3. and
4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in
sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.
49.471(10)(b)3.
3. Except as provided in
subd. 4., a recipient who is an unborn child, or a pregnant woman eligible under
sub. (4) (b) 1., whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in
sub. (11) that does not exceed the full per member per month cost of coverage for an adult with a family income of 300 percent of the poverty line.
49.471(10)(b)4.a.
a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line.
49.471(10)(b)4.c.
c. A child whose family income does not exceed 200 percent of the poverty line.
49.471(10)(b)4.d.
d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
49.471(10)(b)5.
5. If a recipient who is required to pay a premium under this paragraph or under
sub. (2m) or
(4) (c) does not pay a premium when due, the recipient's coverage terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar months following the date on which the recipient's coverage terminated.
49.471(11)
(11) Benchmark plan benefits and copayments. Recipients who are not eligible for the benefits described in
s. 49.46 (2) (a) and
(b) shall have coverage of the following benefits and pay the following copayments:
49.471(11)(a)
(a) Subject to
sub. (6) (k), prescription drugs bearing only a generic name, as defined in
s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and subject to the Badger Rx Gold program discounts.
49.471(11)(b)
(b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.
49.471(11)(c)
(c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.
49.471(11)(d)
(d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in
s. 632.85 (1) (a), shall require a copayment of no more than $75.
49.471(11)(e)
(e) Laboratory and X-ray services, including mammography.
49.471(11)(f)
(f) Home health services, limited to 60 visits per year.
49.471(11)(g)
(g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(h)
(h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(i)
(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(j)
(j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(k)
(k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under
s. 40.51 (6).
49.471(11)(L)
(L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the articles provided.
49.471(11)(m)
(m) Transportation to obtain emergency medical care only, as medically necessary, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(n)
(n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.
49.471(11)(o)
(o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.
49.471(11)(p)
(p) Early childhood developmental services, for children under 6 years of age.
49.471(11)(q)
(q) Smoking cessation treatment, for pregnant women only.
49.471(11)(r)
(r) Prenatal care coordination, for pregnant women at high risk only.
49.471(11m)
(11m) Provider payments and requirements. The provider of a service or equipment under
sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under
sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under
sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under
sub. (11) to a recipient who is unable to share costs as specified in
sub. (11), the recipient is not relieved of liability for those costs.
