49.665(4)(am)4.
4. The child meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements.
49.665(4)(ap)
(ap) An unborn child whose mother is not eligible for health care coverage under
par. (a) or
(am) or for medical assistance under
s. 49.46 or
49.47, except that she may be eligible for benefits under
s. 49.45 (27), is eligible for health care coverage under this section, which shall be limited to coverage for prenatal care, if all of the following requirements are met:
49.665(4)(ap)1.
1. The income of the unborn child's mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 185 percent of the poverty line, except as provided in
par. (at) and except that, if an unborn child is already receiving health care coverage under this section, the applicable specified person or persons may have an income that does not exceed 200 percent of the poverty line. The department shall establish by rule the criteria to be used to determine income.
49.665(4)(ap)3.
3. The unborn child's mother provides medical verification of her pregnancy, in the manner specified by the department.
49.665(4)(ap)4.
4. The unborn child and the mother of the unborn child meet all other requirements established by the department by rule except for any of the following:
49.665(4)(at)1.a.a. Except as provided in
subd. 1. b., the department shall establish a lower maximum income level for the initial eligibility determination if funding under
s. 20.435 (4) (jz),
(p), and
(x) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding.
49.665(4)(at)1.b.
b. The department may not lower the maximum income level for initial eligibility unless the department first submits to the joint committee on finance a plan for lowering the maximum income level. If, within 14 days after the date on which the plan is submitted to the joint committee on finance, the cochairpersons of the committee do not notify the secretary that the committee has scheduled a meeting for the purpose of reviewing the plan, the department shall implement the plan as proposed. If, within 14 days after the date on which the plan is submitted to the committee, the cochairpersons of the committee notify the secretary that the committee has scheduled a meeting to review the plan, the department may implement the plan only as approved by the committee.
49.665(4)(at)1.cm.
cm. Notwithstanding
s. 20.001 (3) (b), if, after reviewing the plan submitted under
subd. 1. b., the joint committee on finance determines that the amounts appropriated under
s. 20.435 (4) (jz),
(p), and
(x) are insufficient to accommodate the projected enrollment levels, the committee may transfer appropriated moneys from the general purpose revenue appropriation account of any state agency, as defined in
s. 20.001 (1), other than a sum sufficient appropriation account, to the appropriation account under
s. 20.435 (4) (b) to supplement the health care program under this section if the committee finds that the transfer will eliminate unnecessary duplication of functions, result in more efficient and effective methods for performing programs, or more effectively carry out legislative intent, and that legislative intent will not be changed by the transfer.
49.665(4)(at)2.
2. If, after the department has established a lower maximum income level under
subd. 1., projections indicate that funding under
s. 20.435 (4) (jz),
(p), and
(x) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185% of the poverty line.
49.665(4)(at)3.
3. The department may not adjust the maximum income level of 200% of the poverty line for persons already receiving health care coverage under this section or for applicable persons specified in
par. (ap) 1. with respect to an unborn child already receiving health care coverage under this section.
49.665(4)(b)
(b) Notwithstanding fulfillment of the eligibility requirements under this subsection, no person is entitled to health care coverage under this section.
49.665(4)(c)
(c) No person may be denied health care coverage under this section solely because of a health condition of that person, of any family member of that person, or of the mother of an unborn child.
49.665(4)(d)
(d) An unborn child's eligibility for coverage under
par. (ap) shall not begin before the first day of the month in which the unborn child's mother provides the medical verification required under
par. (ap) 3.
49.665(4g)
(4g) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under
sub. (4m), the department shall develop and implement, for individuals who are eligible under
sub. (4), disease management programs. These programs shall have at least the following characteristics:
49.665(4g)(a)
(a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
49.665(4g)(b)
(b) Educating health care providers on health care process improvement by developing best practice models.
49.665(4g)(c)
(c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
49.665(4g)(d)
(d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
49.665(4g)(e)
(e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
49.665(4m)
(4m) Physical health risk assessment. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible under
sub. (4) to receive a physical health risk assessment as part of the first physical examination the individual receives under Badger Care.
49.665(5)(ac)(ac) In this subsection, "cost" means total cost-sharing charges, including premiums, copayments, coinsurance, deductibles, enrollment fees, and any other cost-sharing charges.
49.665(5)(ag)
(ag) Except as provided in
pars. (am),
(b), and
(bm), a family, a child who does not reside with his or her parent, or the mother of an unborn child, who receives health care coverage under this section shall pay a percentage of the cost of that coverage in accordance with a schedule established by the department by rule. The department may not establish or implement a schedule that requires a contribution, including the amounts required under
par. (am), of more than 5% of the income of the family, child, or applicable persons specified in
sub. (4) (ap) 1. towards the cost of the health care coverage provided under this section.
49.665(5)(am)
(am) Except as provided in
pars. (b) and
(bm), a child, a family member, or the mother of an unborn child, who receives health care coverage under this section shall pay the following cost-sharing amounts:
49.665(5)(b)
(b) The department may not require a family, child who does not reside with his or her parent, or applicable persons specified in
sub. (4) (ap) 1., with an income below 150% of the poverty line, to contribute to the cost of health care coverage provided under this section.
49.665(5)(bm)
(bm) If the federal department of health and human services notifies the department of health services that Native Americans may not be required to contribute to the cost of the health care coverage provided under this section, the department of health services may not require Native Americans to contribute to the cost of health care coverage under this section.
49.665(5)(c)
(c) The department may establish by rule requirements for wage withholding as a means of collecting a family's or an unborn child's mother's share of the cost of the health care coverage under this section.
49.665(5m)
(5m) Information about Badger Care recipients. The department shall obtain and share information about Badger Care health care program recipients as provided in
s. 49.475.
49.665(7)
(7) Employer verification forms; forfeiture and penalty assessment. 49.665(7)(a)1.1. Notwithstanding
sub. (4) (a) 3m., the department shall mail information verification forms to the employers of the individuals required to provide the verifications under
sub. (4) (a) 3m. to obtain the information specified.
49.665(7)(a)2.
2. An employer that receives a verification form shall complete the form and return it to the department, by mail, with a postmark that is not more than 30 working days after the date on which the department mailed the form to the employer.
49.665(7)(a)3.
3. As an alternative to the method under
subd. 2., an employer may, within 30 working days after the date on which the department mailed the form to the employer, return the completed form to the department by any electronic means approved by the department. The department must be able to determine, or the employer must be able to verify, the date on which the form was sent to the department electronically.
49.665(7)(b)1.1. Subject to
subd. 3., an employer that does not comply with the requirements under
par. (a) 2. or
3. shall be required to pay a forfeiture of $50 for each verification form not returned in compliance with
par. (a) 2. or
3.
49.665(7)(b)2.
2. Subject to
subd. 3., whenever the department imposes a forfeiture under
subd. 1., the department shall also levy a penalty assessment of $50.
49.665(7)(b)3.
3. An employer with fewer than 250 employees may not be required to pay more than $1,000 in forfeitures and penalty assessments under this paragraph in any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in forfeitures and penalty assessments under this paragraph in any 6-month period.
49.665(7)(b)4.
4. All penalty assessments collected under
subd. 2. shall be credited to the appropriation account under
s. 20.435 (4) (jz) and all forfeitures collected under
subd. 1. shall be credited to the common school fund.
49.665(7)(c)
(c) An employer may contest an assessment of forfeiture or penalty assessment under
par. (b) 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.
49.67
49.67
BadgerCare Plus Basic Plan. 49.67(1)
(1)
Definitions. In this section:
49.67(1)(a)
(a) "Certified provider" means a provider that is certified by the department under
s. 49.45 (2) (a) 11. as a provider of medical assistance.
49.67(1)(b)
(b) "Enrollment year" means a 12-month period during which an individual has coverage under the plan under this section beginning with the effective date of the individual's coverage or with the anniversary of that date.
49.67(2)
(2) Establishment and operation. The department may establish and, no sooner than March 1, 2010, begin operating a plan providing coverage of limited primary and preventive health care benefits to individuals who satisfy the eligibility criteria under
sub. (3). The department shall pay for its administrative costs and for the cost of benefits provided under the plan under this section from the appropriation under
s. 20.435 (4) (hm) and, if needed, may pay the costs of incurred program benefits from the appropriation under
s. 20.435 (4) (ma).
49.67(3)(a)(a)
Criteria. Subject to
pars. (b) and
(c) and
sub. (4) (a) 2., an individual may receive coverage for benefits under the plan under this section if the individual satisfies all of the following criteria:
49.67(3)(a)1.
1. The individual meets the eligibility requirements, and is on the waiting list established, for the health care benefit plan under
s. 49.45 (23).
49.67(3)(a)2.
2. The individual applies for coverage for benefits under the plan under this section in the manner prescribed by the department.
49.67(3)(am)
(am)
Verification and information. The department shall do all of the following:
49.67(3)(am)1.
1. Verify monthly that an individual with coverage under the plan under this section meets the eligibility criteria, including by using income, insurance coverage, and other eligibility verification systems.
49.67(3)(am)2.a.
a. Information about the Health Insurance Risk-Sharing Plan under
ch. 149, including an estimate of the applicant's premium under that plan and the differences between the benefits provided under that plan and the benefits provided under the health care benefit plan under
s. 49.45 (23).
49.67(3)(am)2.b.
b. If the applicant is under 26 years of age, notice that he or she may be eligible for coverage as a dependent under his or her parent's health care plan in accordance with
s. 632.885, and that his or her parent's plan must include coverage for services that are not covered under the plan under this section.
49.67(3)(am)2.c.
c. Information about the applicant's right to purchase continuation coverage under certain circumstances, as provided under the federal Consolidated Omnibus Budget Reconciliation Act of 1985 and under
s. 632.897, and about any state or federal premium tax credits or other premium subsidies that might be available to the applicant for that coverage.
49.67(3)(b)
(b)
No entitlement. Notwithstanding satisfaction of the criteria under
par. (a), no individual is entitled to benefits under the plan under this section.
49.67(3)(c)
(c)
After termination of coverage. An individual whose coverage under the plan under this section ends for any reason, including for failure to pay a premium when due, is ineligible for coverage under the plan for 12 calendar months, beginning with the first calendar month after the last calendar month, which need not be a full month, in which he or she had coverage. This paragraph does not apply if the department determines that the individual's coverage ended for a good cause reason.
49.67(4)(a)1.1. The plan under this section shall be funded through premiums paid by individuals with coverage under the plan. The department shall set premiums at a level necessary to pay for the benefits covered and to maintain the fiscal soundness of the plan. The department, or its agent, shall credit premiums received from individuals to the appropriation account under
s. 20.435 (4) (hm).
49.67(4)(a)2.
2. Premiums shall be due in the calendar month before the calendar month of coverage. An individual may not enroll in the plan if he or she does not submit the first month's premium with the application and may not continue coverage under the plan if he or she does not pay a premium when due.
49.67(4)(a)3.
3. If an individual with coverage under the plan under this section is removed from the waiting list for the health care benefit plan under
s. 49.45 (23) and begins receiving coverage under that health care benefit plan, the department shall not refund any portion of a premium paid by the individual for coverage under the plan under this section for the calendar month in which the individual's coverage under the health care benefit plan under
s. 49.45 (23) commences. The department shall, however, waive any enrollment fee that would be payable by the individual for enrolling in the health care benefit plan under
s. 49.45 (23).
49.67(4)(b)
(b)
Deductible. The department may set a deductible that applies to inpatient and nonemergency outpatient hospital services and that does not exceed $7,500 in an enrollment year.
49.67(4)(c)
(c)
Other. The department may set other cost-sharing requirements that the department determines are necessary to keep the plan actuarily sound.
49.67(5)(a)(a)
Certification. Only a certified provider may receive payment from the department for services provided to individuals under the plan under this section.
49.67(5)(b)1.1. The department shall pay a certified provider for a service that is covered under the plan under this section an amount that is not less than the amount that is payable for the same service under the Medical Assistance program under
subch. IV, except that the department shall make payments to federally qualified health centers and hospital outlier payments in an amount that is no higher than the amount that is payable under the Medical Assistance program under
subch. IV. A certified provider that provides a covered service to an individual with coverage under the plan under this section shall accept the department's payment as payment in full and, subject to
subd. 2., may not bill the individual to whom the service was provided for any amount other than any cost sharing required under
sub. (4).
49.67(5)(b)2.
2. A certified provider that provides to an individual with coverage under the plan under this section inpatient or nonemergency outpatient hospital services to which a deductible under
sub. (4) (b) applies may not charge for those services an amount that is higher than the amount that would be payable to the provider under
subd. 1. for those services.
49.67(6)(a)(a)
May not exceed benefits under other plan. The benefits covered under the plan under this section may not exceed the benefits covered under the health care benefit plan under
s. 49.45 (23).
49.67(6)(b)1.1. Benefits under the plan under this section shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care coverage, Medicare, or any other governmental program, except as otherwise provided by law. If an individual who has coverage under the plan under this section also has coverage under the plan under
subch. II of ch. 149, benefits under the plan under this section are secondary to the benefits provided under the plan under
subch. II of ch. 149.
49.67(6)(b)2.
2. The department is subrogated to the rights of an individual with coverage under the plan under this section to recover special damages for illness or injury to the individual caused by the act of a 3rd person to the extent that benefits are provided under the plan.
49.67(6)(c)1.1. The department may recover a payment made incorrectly for benefits provided under this section on behalf of an individual if the incorrect payment was made as a result of any of the following:
49.67(6)(c)1.a.
a. At the time the individual obtained coverage under the plan under this section, the individual was on the waiting list established for the health care benefit plan under
s. 49.45 (23) because of a misstatement or omission of fact by the individual.
49.67(6)(c)1.b.
b. The individual's coverage under the plan under this section was continued because of a misstatement or omission of fact by the individual.
49.67(6)(c)2.
2. The department's right of recovery is against the individual with coverage under the plan under this section on whose behalf the incorrect payment was made. The extent of the recovery is limited to the amount of the benefits actually paid.
49.67(6m)
(6m) Disclosure of benefits and cost sharing. When an individual applies for coverage under the plan under this section, the department shall provide to the individual written disclosure of the benefits provided under the plan and the premiums, deductibles, copayments, and any other cost sharing required under the plan.
