Amendment SSA1-SB40

SB40-SSA1,737,25 (j) All of the following apply to BadgerCare Plus in the same respect as they apply under s. 49.46:

SB40-SSA1,738,2 1. Section 49.46 (2) (c) and (cm), relating to benefits for individuals who are eligible for Medicare.

SB40-SSA1,738,5 2. Section 49.46 (2) (d), relating to prohibiting payments for any part of any service payable through 3rd-party liability or any governmental or private benefit system.

SB40-SSA1,738,7 3. Section 49.46 (2) (dm), relating to prohibiting payment for services to residents of institutions for mental diseases.

SB40-SSA1,738,9 4. Section 49.46 (2) (f), relating to prohibiting payment for gastric bypass or stapling surgery.

SB40-SSA1,738,15 (k) For an individual who is eligible for medical assistance under this section and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under sub. (11) (a) or s. 49.46 (2) (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug.

SB40-SSA1,738,20 (7) Special income provisions. (a) 1. In the calculation of family income, if an adult member of the family has self-employment income, the department shall count the net self-employment earnings. Net self-employment earnings shall be determined by subtracting from gross self-employment income all self-employment expenses that are allowed under federal and state tax law, except for depreciation.

SB40-SSA1,738,23 2. If a parent's or caretaker relative's family income includes self-employment income and, without deducting depreciation, does not exceed 200 percent of the poverty line, the parent or caretaker relative is eligible under sub. (4) (a) 4.

SB40-SSA1,739,2 3. If a parent's or caretaker relative's family income includes self-employment income and, without deducting depreciation, exceeds 200 percent of the poverty line, the parent or caretaker relative is eligible under sub. (4) (b) 4. if his or her family income does not exceed 200 percent of the poverty line after depreciation is deducted.

SB40-SSA1,739,14 (b) 1. A pregnant woman, or an unborn child, whose family income exceeds 300 percent of the poverty line may become eligible for coverage under this section if the difference between the pregnant woman's or unborn child's family income and the applicable income limit under sub. (4) (b) is obligated or expended for any member of the pregnant woman's or unborn child's family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision continues without regard to any change in family income for the balance of the pregnancy and, for a pregnant woman but not for an unborn child, to the last day of the month in which the 60th day after the last day of the woman's pregnancy falls. Eligibility obtained by a pregnant woman under this subdivision extends to all pregnant women in the pregnant woman's family.

SB40-SSA1,739,22 2. A child who is not an unborn child and whose family income exceeds 150 percent of the poverty line may obtain eligibility under this section if the difference between the child's family income and 150 percent of the poverty line is obligated or expended on behalf of the child or any member of the child's family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision during any 6-month period, as determined by the department, continues for the remainder of the 6-month period and extends to all children in the family.

SB40-SSA1,740,5 3. For a pregnant woman or an unborn child to obtain eligibility under subd. 1., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the pregnant woman's or unborn child's monthly family income and the monthly family income that is 300 percent of the poverty line. For a child to obtain eligibility under subd. 2., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the child's monthly family income and the monthly family income that is 150 percent of the poverty line.

SB40-SSA1,740,7 (c) When calculating an individual's family income, the department shall do all of the following:

SB40-SSA1,740,9 1. Deduct from family income any payments made by the individual for court-ordered child or family support or maintenance.

SB40-SSA1,740,10 2. Disregard earnings of children under 18 years of age.

SB40-SSA1,740,12 3. Determine separately the family incomes of caretaker relatives and the children for whom they are caring and not legally responsible.

SB40-SSA1,740,14 4. Not include in the calculation any income of an individual receiving benefits under s. 49.77 or federal Title XVI.

SB40-SSA1,740,20 (8) Health insurance coverage and eligibility. (a) 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.

SB40-SSA1,740,23 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.

SB40-SSA1,741,3 (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:

SB40-SSA1,741,5 1. The individual has individual or family health insurance coverage that is any of the following:

SB40-SSA1,741,7 a. Coverage provided by an employer and for which the employer pays at least 80 percent of the premium.

SB40-SSA1,741,8 b. Coverage under the state employee health plan under s. 40.51 (6).

SB40-SSA1,741,10 2. The individual, in the 12 months before applying, had access to the health insurance coverage specified in subd. 1.

SB40-SSA1,741,14 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.

SB40-SSA1,741,16 (c) An unborn child, regardless of family income, is not eligible for BadgerCare Plus if any of the following applies:

SB40-SSA1,741,18 1. The unborn child or the unborn child's mother has individual or family health insurance coverage.

SB40-SSA1,741,20 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.

SB40-SSA1,741,25 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.

SB40-SSA1,742,2 (d) 1. None of the following is ineligible for BadgerCare Plus by reason of having health insurance coverage or access to health insurance coverage:

SB40-SSA1,742,3 a. A pregnant woman.

SB40-SSA1,742,4 b. A child described in sub. (4) (a) 2. or (b) 2.

SB40-SSA1,742,7 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.

SB40-SSA1,742,8 d. An individual described in sub. (4) (a) 5.

SB40-SSA1,742,10 e. A child who obtains eligibility under sub. (7) (b) 2., but only for the remainder of the child's eligibility period under sub. (7) (b) 2.

SB40-SSA1,742,14 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:

SB40-SSA1,742,15 a. The individual's employment ended.

SB40-SSA1,742,17 b. The individual's employer discontinued health insurance coverage for all employees.

SB40-SSA1,742,21 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.

SB40-SSA1,742,23 d. The individual's access to health insurance coverage has ended due to the death or change in marital status of the subscriber.

SB40-SSA1,742,24 e. Any other reason that the department determines is a good cause reason.

SB40-SSA1,743,3 (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.

SB40-SSA1,743,11 (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).

SB40-SSA1,743,12 (g) Any of the following is a good cause reason for purposes of par. (f):

SB40-SSA1,743,17 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 an immediate family member's health condition.

SB40-SSA1,743,20 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.

SB40-SSA1,743,23 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.

SB40-SSA1,743,25 4. The pregnant woman's coverage was continuation coverage and the continuation coverage was exhausted in accordance with 29 CFR 2590.701-2 (4).

SB40-SSA1,744,2 5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.

SB40-SSA1,744,3 6. Any other reason determined by the department to be a good cause reason.

SB40-SSA1,744,8 (9) Employer verification of insurance coverage. (a) 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.

SB40-SSA1,744,9 2. Subdivision 1. does not apply to any of the following:

SB40-SSA1,744,10 a. A pregnant woman.

SB40-SSA1,744,11 b. A child described in sub. (4) (a) 2. or (b) 2.

SB40-SSA1,744,12 c. An individual described in sub. (4) (a) 5.

SB40-SSA1,744,16 (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.

SB40-SSA1,744,24 (c) 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.

SB40-SSA1,745,5 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.

SB40-SSA1,745,10 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.

SB40-SSA1,745,12 4. All penalty assessments collected under this paragraph shall be credited to the appropriation accounts under s. 20.435 (4) (jw) and (jz).

SB40-SSA1,745,16 (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.

SB40-SSA1,745,20 (10) Cost sharing. (a) Copayments. Except as provided in s. 49.45 (18) (am), all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to a person eligible for medical assistance under s. 49.46, 49.468, or 49.47.

SB40-SSA1,746,2 (b) Premiums. 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.

SB40-SSA1,746,7 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.

SB40-SSA1,746,12 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.

SB40-SSA1,746,13 4. None of the following shall pay a premium:

SB40-SSA1,746,15 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.

SB40-SSA1,746,16 b. A child who is eligible under sub. (4) (a) 2. or (b) 2.

SB40-SSA1,746,17 c. A child whose family income does not exceed 200 percent of the poverty line.

SB40-SSA1,746,19 d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.

SB40-SSA1,746,20 e. A child who obtains eligibility under sub. (7) (b) 2.

SB40-SSA1,746,21 f. An individual who is eligible under sub. (4) (a) 5.

SB40-SSA1,746,25 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.

SB40-SSA1,747,3 (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:

SB40-SSA1,747,6 (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.

SB40-SSA1,747,8 (b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.

SB40-SSA1,747,12 (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.

SB40-SSA1,747,17 (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.

SB40-SSA1,747,18 (e) Laboratory and X-ray services, including mammography.

SB40-SSA1,747,19 (f) Home health services, limited to 60 visits per year.

SB40-SSA1,747,22 (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.

SB40-SSA1,747,25 (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.

SB40-SSA1,748,3 (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.

SB40-SSA1,748,6 (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.

SB40-SSA1,748,10 (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).

SB40-SSA1,748,13 (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.

SB40-SSA1,748,16 (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.

SB40-SSA1,748,18 (n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.

SB40-SSA1,748,23 (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.