a. Access to individual or family health coverage provided by an employer in which the monthly premium that an employee would pay for an employee-only policy does not exceed 9.5 percent of the family's monthly income.
b. Access to individual or family health coverage under the state employee health plan.
2. The individual has access to any coverage described in subd. 1. during any of the following times:
a. The 12 months before the first day of the month in which an individual applies for and the month in which an individual applies for BadgerCare Plus.
b. The 3 months after the last day of the month in which the individual applies for BadgerCare Plus.
c. The month including the date of the annual determination of the individual's eligibility for Medical Assistance.
3. The individual does not have as a reason for not obtaining health insurance any of the good cause reasons under par. (d) 2. a. to e.
20,1128
Section
1128. 49.471 (8) (cr) of the statutes is created to read:
49.471 (8) (cr) 1. Subject to subd. 4., an individual who is any of the following is not eligible for BadgerCare Plus if the criteria under par. (cg) 1. and 2. apply to that individual:
a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
c. An adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
2. An individual under subd. 1. is not ineligible if any of the good cause reasons described in par. (d) 2. a. to e. is the reason that the individual did not obtain health insurance coverage.
3. An individual under subd. 1. c. is not ineligible if any of the following good cause reasons is the reason the individual did not obtain health insurance coverage:
a. The parent of the individual is no longer employed by the employer through which the parent was eligible for coverage, and the parent does not have current coverage.
b. The employer of the parent of the individual discontinued providing health benefits to all employees.
4. The department may apply this paragraph to eligibility determinations for BadgerCare Plus only if the federal department of health and human services approves of the conditions to make that individual ineligible, if approval is required.
20,1129
Section
1129. 49.471 (8) (ct) of the statutes is created to read:
49.471 (8) (ct) 1. If the federal department of health and human services approves the department's request to add private major medical insurance as a type of coverage which causes ineligibility, an individual who is not disabled and not pregnant, who is over 18 years of age, whose family income exceeds 133 percent of the poverty line, and who has coverage provided by private major medical insurance in which the monthly premium does not exceed 9.5 percent of the family's monthly income is not eligible for BadgerCare Plus.
2. If the federal department of health and human services approves of the conditions to make that individual ineligible for BadgerCare Plus, an individual who is any of the following is not eligible for BadgerCare Plus if he or she has the major medical insurance coverage described under subd. 1.:
a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
20,1130
Section
1130. 49.471 (8) (d) 1. a. of the statutes is amended to read:
49.471 (8) (d) 1. a. A pregnant woman, except as provided in pars. (cr) 1. c. and (fm) 4.
20,1131
Section
1131. 49.471 (8) (d) 1. b. of the statutes is amended to read:
49.471 (8) (d) 1. b. A child described in sub. (4) (a) 2. or (b) 2. 2m.
20,1132
Section
1132. 49.471 (8) (d) 1. g. of the statutes is created to read:
49.471 (8) (d) 1. g. An adult who is disabled.
20,1133
Section
1133. 49.471 (8) (d) 2. dg. of the statutes is created to read:
49.471 (8) (d) 2. dg. The insurance is owned by someone not residing with the family and continuation of the coverage is beyond the family's control.
20,1134
Section
1134. 49.471 (8) (d) 2. dr. of the statutes is created to read:
49.471 (8) (d) 2. dr. The insurance only covers services provided in a service area that is beyond a reasonable driving distance.
20,1137
Section
1137. 49.471 (8) (fm) of the statutes is created to read:
49.471 (8) (fm) If an individual who is one of the following individuals had the health insurance coverage specified in par. (cg) 1. or (ct) but no longer has the coverage, the individual 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):
1. An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line.
2. If the federal department of health and human services approves of the department's request to make such an individual ineligible, an individual who is not disabled and who is a child of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
3. If the federal department of health and human services approves of the department's request to make such an individual ineligible, a parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
4. If the federal department of health and human services approves of the department's request to make such an individual ineligible, an adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
20,1138
Section
1138. 49.471 (8) (g) (intro.), 1., 2., 3., 4. and 5. of the statutes are amended to read:
49.471 (8) (g) (intro.) Any of the following is a good cause reason for purposes of par. pars. (f) and (fm):
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 of an immediate family member's health condition.
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.
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.
4. The
pregnant woman's individual's coverage was continuation coverage and the continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.
20,1139
Section
1139. 49.471 (8) (g) 5g. of the statutes is created to read:
49.471 (8) (g) 5g. The insurance coverage is owned by someone not residing with the family and continuation of the coverage is beyond the family's control.
20,1140
Section
1140. 49.471 (8) (g) 5r. of the statutes is created to read:
49.471 (8) (g) 5r. The insurance coverage only covers services provided in a service area that is beyond a reasonable driving distance.
20,1141
Section
1141. 49.471 (9) (a) 2. b. of the statutes is amended to read:
49.471 (9) (a) 2. b. A child described in sub. (4) (a) 2. or (b) 2. 2m.
20,1142
Section
1142. 49.471 (10) (b) 1. of the statutes is amended to read:
49.471 (10) (b) 1. Except as provided in subd. subds. 1m. and 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.
20,1143
Section
1143
. 49.471 (10) (b) 1. of the statutes, as affected by 2013 Wisconsin Act .... (this act), is amended to read:
49.471 (10) (b) 1. Except as provided in subds. 1m. and 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.
20,1144
Section
1144. 49.471 (10) (b) 1m. of the statutes is created to read:
49.471 (10) (b) 1m. Except as provided in subd. 4., a recipient who is an adult parent or adult caretaker relative; who is not disabled, pregnant, or American Indian; and whose family income exceeds 133 percent of the federal poverty line shall pay a premium for coverage under BadgerCare Plus in an amount determined by the department that is based on a formula in which costs decrease for those with lower family incomes and that is no less than 3 percent of family income but no greater than 9.5 percent of 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. If the department intends to impose a premium under this subdivision after December 31, 2013, the department shall request from the federal department of health and human services any necessary approval to continue imposing premiums under this subdivision.
20,1146
Section
1146. 49.471 (10) (b) 2. of the statutes is amended to read:
49.471 (10) (b) 2. Except as provided in subds. 3. 3m. 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.
20,1147
Section
1147. 49.471 (10) (b) 3. of the statutes is repealed.
20,1148
Section
1148. 49.471 (10) (b) 3m. of the statutes is created to read:
49.471 (10) (b) 3m. A recipient who is a child, who is not disabled, and whose family income is at a level determined by the department that is at least 150 percent of the poverty line shall pay a premium in an amount determined by the department. The department may apply this subdivision only to the extent the federal department of health and human services approves applying a premium to those individuals, if approval is required.
20,1149
Section
1149. 49.471 (10) (b) 4. (intro.) of the statutes is amended to read:
49.471 (10) (b) 4. (intro.) None of the following shall pay a premium, except as provided in subd. 3m.:
20,1150
Section
1150. 49.471 (10) (b) 4. b. of the statutes is amended to read:
49.471 (10) (b) 4. b. A child who is eligible under sub. (4) (a) 2. or (b) 2. 2m.
20,1151
Section
1151. 49.471 (10) (b) 5. of the statutes is amended to read:
49.471 (10) (b) 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) or (4) (c) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient's coverage terminates and. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 6 12 consecutive calendar months following the date on which the recipient's coverage terminated, except for any month during that 6-month 12-month period when the recipient's family income does not exceed 150 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient's coverage terminated, except for any month during that period when the recipient's family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums.
20,1152
Section
1152
. 49.471 (10) (b) 5. of the statutes, as affected by 2013 Wisconsin Act .... (this act), is amended to read:
49.471 (10) (b) 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) or (4) (c) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient's coverage terminates. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 12 consecutive calendar months following the date on which the recipient's coverage terminated, except for any month during that 12-month period when the recipient's family income does not exceed 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient's coverage terminated, except for any month during that period when the recipient's family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums.
20,1153
Section
1153. 49.471 (11) (intro.) of the statutes is amended to read:
49.471 (11) Benchmark plan benefits and copayments. (intro.) Recipients Except as provided in sub. (11r) and s. 49.45 (24j), 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:
20,1154
Section
1154. 49.471 (11) (a) of the statutes is amended to read:
49.471 (11) (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.
20,1155
Section
1155. 49.471 (11r) of the statutes is created to read:
49.471 (11r) Alternate Benchmark plan benefits and copayments. (a) If the department chooses to provide the alternate benchmark plan under this subsection, the department shall provide to the recipients described under sub. (4) (e) coverage for benefits similar to those in a commercial, major medical insurance policy.
(b) The department may charge copayments to recipients receiving coverage under the alternate benchmark plan under this subsection that are higher than copayments charged to recipients receiving coverage under the standard plan under s. 49.46 (2). The department may not charge to a recipient of coverage under the alternate benchmark plan under this subsection whose family income is at or below 150 percent of the poverty line a copayment that exceeds 5 percent of the individual's family income for all members of the family.
(c) 1. The department may only provide coverage under the alternate benchmark plan under this subsection to the extent the alternate benchmark plan is approved by the federal department of health and human services.
2. If the department is providing coverage under the alternate benchmark plan under this subsection the department may discontinue coverage under the benchmark plan under sub. (11) for those individuals eligible for the alternate benchmark plan under this subsection.
3. The department may provide services to individuals enrolled in the alternate benchmark plan under this subsection through a medical home initiative similar to an initiative described under s. 49.45 (24j).
20,1170
Section
1170. 49.475 (title) of the statutes is amended to read:
49.475 (title) Information about assistance program beneficiaries; electronic submission of claims.
20,1171
Section
1171. 49.475 (2) (except 49.475 (2) (title)) of the statutes is renumbered 49.475 (2) (ac), and 49.475 (2) (ac) 1. b. and 4. (intro.), as renumbered, are amended to read:
49.475 (2) (ac) 1. b. If subd. 1. a. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.
4. (intro.) If all of the following apply, agree not to deny a claim submitted by the department under par. (b) subd. 2. solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:
20,1172
Section
1172. 49.475 (2) (bc) of the statutes is created to read:
49.475 (2) (bc) A 3rd party shall accept the submission of claims from the department under par. (ac) 2. in electronic form and shall timely pay the claims in the manner provided in s. 628.46 (1) and (2). For purposes of timely payment of claims under this paragraph, "written notice" under s. 628.46 (1) includes receipt of a claim in electronic form.
20,1173
Section
1173. 49.475 (2m) (a) of the statutes is amended to read:
49.475 (2m) (a) The information that the department may request under this section is limited to the information specified in sub. (2) (a) (ac) 1. and does not include an employer's name unless that information is necessary for the department or a provider to obtain 3rd-party payment for an item or service.
