Alert! This chapter may be affected by an emergency rule:
DHS 103.075(6)(b)2.c. c. A sibling of either the institutionalized spouse or the community spouse who is claimed as a dependent by either the institutionalized spouse or the community spouse for tax purposes under the internal revenue service code or who could be claimed as a dependent for tax purposes if a tax return were filed and who resides with the community spouse; or
DHS 103.075(6)(b)2.d. d. A parent of either the institutionalized spouse or the community spouse who is claimed as a dependent by either the institutionalized spouse or the community spouse for tax purposes under the internal revenue service code or who could be claimed as a dependent for tax purposes if a tax return were filed and who resides with the community spouse.
DHS 103.075(6)(c) (c) Computing income available towards the cost of care. An institutionalized recipient shall apply his or her available income toward the cost of his or her care. In this paragraph, “available income" means any income remaining after the following deductions are made from the recipient's gross monthly income:
DHS 103.075(6)(c)1. 1. A personal needs allowance as provided under s. 49.45 (7) (a), Stats., or 42 CFR 435.726 (c), as appropriate;
DHS 103.075(6)(c)2. 2. The community spouse monthly income allowance under par. (b) 1. that is actually made available by the institutionalized spouse to the community spouse or to another individual for the benefit of the community spouse;
DHS 103.075(6)(c)3. 3. The total family member income allowance calculated under par. (b) 2., whether or not actually made available by the institutionalized spouse to a family member; and
DHS 103.075(6)(c)4. 4. The amount incurred as expenses for remedial or medical care for the institutionalized spouse as follows:
DHS 103.075(6)(c)4.a. a. For an individual participating in a community-based care waiver program, the amount incurred as expenses for remedial or medical care and the cost of the individual's health insurance premiums; and
DHS 103.075(6)(c)4.b. b. For an individual residing in a medical institution, the cost of the institutionalized spouse's health insurance premiums.
DHS 103.075(7) (7)Notice. The agency shall notify both spouses when it determines that an institutionalized spouse is eligible for MA, or it shall notify the spouse who requested a determination of MA eligibility. The notice shall be in writing and shall include the following information:
DHS 103.075(7)(a) (a) The amount of the community spouse monthly income allowance calculated under sub. (6) (b) 1.;
DHS 103.075(7)(b) (b) The amount of any family allowance calculated under sub. (6) (b) 2;
DHS 103.075(7)(c) (c) The amount of the couple's total countable assets determined under sub. (4) (c);
DHS 103.075(7)(d) (d) The amount of the community spouse resource allowance and the method used to calculate the allowance under sub. (4) (c) 3.;
DHS 103.075(7)(e) (e) The amount of income that the institutionalized spouse is required to contribute toward the cost of his or her care; and
DHS 103.075(7)(f) (f) Each spouse's right to a fair hearing under sub. (8) concerning ownership or availability of income or resources and the determination of the community spouse monthly income or resource allowance.
DHS 103.075(8) (8)Fair hearing.
DHS 103.075(8)(a)(a) An institutionalized spouse or a community spouse may request a fair hearing in accordance with the procedures set out in s. DHS 104.01 (5) in regard to any of the following:
DHS 103.075(8)(a)1. 1. The determination of the community spouse monthly income allowance under sub. (6) (b) 1.;
DHS 103.075(8)(a)2. 2. The determination of the amount of the monthly income otherwise available to the community spouse used in the calculation under sub. (6) (b) 1.;
DHS 103.075(8)(a)3. 3. The amount of the couple's total countable assets determined under sub. (4) (c);
DHS 103.075(8)(a)4. 4. The determination of the spousal share of resources under sub. (4) (c) 3.; and
DHS 103.075(8)(a)5. 5. The determination of the community spouse resource allowance under sub. (4) (c) 3.
DHS 103.075(8)(b) (b) If the institutionalized spouse has made an application for MA and a fair hearing is requested under par. (a), the agency shall hold the hearing within 30 days after the request.
DHS 103.075(8)(c) (c) If either spouse establishes at a fair hearing that, due to exceptional circumstances resulting in financial duress, the community spouse needs income above the level provided by the minimum monthly maintenance needs allowance determined under sub. (6) (b), the hearing officer shall determine an amount adequate to provide for the community spouse's needs. In this paragraph,“exceptional circumstances resulting in financial duress" means situations that result in the community spouse not being able to provide for his or her own necessary and basic maintenance needs. The agency shall use the amount determined by the hearing officer in place of the minimum monthly maintenance needs allowance determined under sub. (6) (b).
DHS 103.075(8)(d) (d) If either spouse establishes at a fair hearing that the community spouse resource allowance determined by the agency under sub. (4) (c) 3. does not generate enough income to raise the community spouse's income to the minimum monthly maintenance needs allowance under s. 49.455 (4) (c), Stats., the hearing officer shall establish an amount to be used under sub. (5) (b) that results in a community spouse resource allowance that generates sufficient income to raise the community spouse's monthly income to the minimum monthly maintenance needs allowance under s. 49.455 (4) (c), Stats.
DHS 103.075(8)(e) (e) Neither the institutionalized spouse nor the community spouse shall have the right to a fair hearing under this section until after an MA application is filed and MA eligibility and the benefit level are determined.
DHS 103.075 History History: Cr. Register, March, 1993, No. 447, eff. 4-1-93; correction in (8) (a) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 103.08 DHS 103.08Beginning of eligibility.
DHS 103.08(1) (1)Date. Except as provided in subs. (2) to (5), eligibility shall begin on the date on which all eligibility requirements were met, but no earlier than the first day of the month 3 months prior to the month of application. Retroactive eligibility of up to 3 months may occur even though the applicant is found ineligible in the month of application.
DHS 103.08(2) (2)Spend-down period.
DHS 103.08(2)(a)1.1. The spend-down period shall begin on the first day of the month in which all eligibility factors except income were met, but no earlier than the first day of the month 3 months prior to the month of application. However, at the recipient's option, it may begin on the first day of any of the 3 months prior to the date of application if all eligibility factors, except income, were met in that month. A recipient's decision to choose an optional beginning date shall be recorded in the agency's case record. For persons who previously received MA and then reapply, the spend-down period cannot cover the time during which they were receiving MA.
DHS 103.08(2)(a)2. 2. The AFDC-related or SSI-related MA group shall be eligible as of the date within the spend-down period on which the expenditure of excess income or the obligation to expend excess income is achieved.
DHS 103.08(2)(a)3. 3. The applicant shall be responsible for some bills or parts of bills for services received on the first day of eligibility if there is remaining unspent and unobligated excess income on that day.
DHS 103.08(2)(b) (b) If the amount of the monthly excess income changes before the expenditure or obligation of excess income is achieved, the expenditure or obligation of excess income for the remainder of the 6–month period shall be recalculated. When the size of the AFDC-related or SSI-related MA group changes, the monthly income limit shall be adjusted appropriately to the size of the new group, and the amount of excess income to be expended or obligated shall be adjusted accordingly. If any change is reported that may affect eligibility, the eligibility of the entire AFDC-related or SSI-related MA group may be redetermined and, if there is determined to be excess income, a new spend–down period shall be established.
DHS 103.08(2)(c)1.1. Once the expenditure or obligation of excess income has been achieved, the AFDC-related or SSI-related MA group shall be eligible for the balance of the 6–month spend–down period, unless it is determined that assets have increased enough to make the MA group ineligible, or that a change in circumstances has caused someone in the MA group to become ineligible for non-financial reasons.
DHS 103.08(2)(c)2. 2. If the entire group is determined ineligible, the MA benefits shall be discontinued with proper notice. If only one person in the MA group is determined ineligible for non-financial reasons, only that person's AFDC-related or SSI-related MA benefits shall, with proper notice, be discontinued. The other person or persons in the MA group continue their eligibility until the end of the 6–month period.
DHS 103.08(2)(c)3. 3. If the size of the MA group increases due to the addition of a child, that child is eligible for benefits during the rest of the spend–down period. An adult caretaker who enters the AFDC-related or SSI-related MA group, except a woman who is medically verified as pregnant or a person who is SSI–related, is not eligible for benefits during the remainder of the spend–down period.
DHS 103.08(3) (3)Presumptive disability cases. If, in a presumptive disability case, the applicant meets all other conditions for eligibility, MA benefits shall begin on the date the presumptive disability finding is made and shall continue at least until the official disability determination is completed. Presumptive disability eligibility shall not be granted retroactively. MA benefits based on presumptive disability shall not be continued pending an appeal of a negative official disability determination.
DHS 103.08(4) (4)Pregnancy-related MA cases. For pregnancy-related cases pursuant to ss. 49.46 (1) (a) 1m. and 9. and 49.47 (4) (ag) 2. and (am) 1., Stats., eligibility shall begin on the date pregnancy is verified or the date of application, whichever is earlier, but eligibility may only be backdated as provided under sub. (1).
DHS 103.08(5) (5)BadgerCare cases. Eligibility for BadgerCare shall begin on the first day of the month in which all eligibility requirements are met, but no earlier than the first day of the month of application.
DHS 103.08 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (4), Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1), (2) (a) 2., (b) and (c), eff. 7-1-99; am. (1), (2) (a) 2., (b) and (c) and cr. (5), Register, March, 2000, No. 531, eff. 4-1-00; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 103.085 DHS 103.085Conditions for continuation of eligibility for BadgerCare.
DHS 103.085(1) (1)Premiums.
DHS 103.085(1)(a)(a) Authority. Subject to s. 49.665 (5), Stats., and this section, a group eligible for BadgerCare may be required to pay a premium.
DHS 103.085(1)(b) (b) Applicability.
DHS 103.085(1)(b)1.1. A group eligible for BadgerCare with budgetable income at or below 150% of the poverty line is not required to pay a premium toward the cost of the health care coverage.
DHS 103.085(1)(b)2. 2. Except as provided in subd. 3. or 4., a group eligible for BadgerCare with budgetable income above 150% of the poverty line shall pay a premium toward the cost of the health care coverage.
DHS 103.085(1)(b)3. 3. A BadgerCare applicant group does not owe a premium for the first month of BadgerCare unless a member of the BadgerCare fiscal test group was an MA recipient in the previous month.
DHS 103.085(1)(b)4. 4. A BadgerCare applicant group does not owe a premium for the first month of BadgerCare unless a member of the BadgerCare fiscal test group was a BadgerCare recipient in the previous 12 months.
DHS 103.085(1)(c) (c) Amounts. A group eligible for BadgerCare required under this subsection to pay a premium shall pay the amount indicated in the schedule provided in Table 103.085. Income shall be determined according to s. DHS 103.07. - See PDF for table PDF
DHS 103.085(1)(d) (d) Payment.
DHS 103.085(1)(d)1.1. A group otherwise eligible for BadgerCare that is required to pay a premium under this section shall pay the premium amount in full to the agency before the agency may certify the group's initial eligibility for BadgerCare.
DHS 103.085(1)(d)2. 2. Premiums are due by the 10th of the month prior to the month for which the premium is required.
DHS 103.085(1)(d)3. 3. If no payment is received by the end of the month for which the premium is required, the department shall terminate the group's eligibility for BadgerCare, effective at the end of the month.
DHS 103.085(1)(d)4. 4. The department shall allow a variety of premium payment methods. A group may choose one of the following methods for premium payment:
DHS 103.085(1)(d)4.a. a. Wage withholding.
DHS 103.085(1)(d)4.b. b. Electronic funds transfer (EFT).
DHS 103.085(1)(d)4.c. c. Direct payment by check or money order.
DHS 103.085(1)(d)5. 5. A group may pay premiums in advance for more than one month, but only for months in the group's BadgerCare eligibility period.
DHS 103.085(1)(e) (e) Refunds. The department shall issue a refund for a premium which has been paid in advance when the premium is for one of the following:
DHS 103.085(1)(e)1. 1. A month that the group is ineligible for BadgerCare.
DHS 103.085(1)(e)2. 2. A month that the group's budgetable income drops to or below 150% of the poverty line and the change in income that brought the group's budgetable income to or below 150% of the poverty line was reported within 10 days of the date the change occurred.
DHS 103.085(1)(e)3. 3. A month which requires a lower premium amount due to a change in circumstances which was in effect for the entire month so long as the change was reported within 10 days of the date it occurred. In a case where the change was not reported within 10 days of the date it occurred, the effective date of the lower premium amount due is the first day of the month in which the change was reported.
DHS 103.085(1)(f) (f) Consequence of failure to pay BadgerCare premiums. A group required to pay a premium shall be ineligible for re-enrollment for the period specified in sub. (3) when the group fails to pay its premium within the time specified in par. (d).
DHS 103.085(2) (2)Quitting BadgerCare.
DHS 103.085(2)(a)(a) Termination of benefits. Except as provided in par. (b), a group eligible for BadgerCare and required under sub. (1) to pay a premium shall be subject to re-enrollment restrictions under sub. (3) when that group voluntarily terminates BadgerCare eligibility.
DHS 103.085(2)(b) (b) Reasons for quitting BadgerCare. A group that quits BadgerCare shall not be subject to a restrictive re-enrollment period if the group requests termination of BadgerCare for one of the following reasons:
DHS 103.085(2)(b)1. 1. The BadgerCare group is moving out of Wisconsin.
DHS 103.085(2)(b)2. 2. No one in the BadgerCare group remains non-financially eligible for BadgerCare.
DHS 103.085(2)(b)3. 3. A member of the BadgerCare group is starting employment that provides health care benefits.
DHS 103.085(2)(b)4. 4. Other health insurance coverage has become available to the BadgerCare group.
DHS 103.085(2)(b)5. 5. Any other reason, as determined by the department, not related to payment of the premium.
DHS 103.085(3) (3)Re-enrollment restriction.
DHS 103.085(3)(a)(a) Period of ineligibility. A BadgerCare group that fails to make a premium payment under sub. (1) or quits BadgerCare under sub. (2) is not eligible for BadgerCare for a period of at least 6 consecutive calendar months following the date that BadgerCare eligibility ends, unless one of the circumstances in par. (b) applies. Eligibility is restored as described in par. (c). After 6 calendar months, the group shall be eligible for BadgerCare only if all past premiums due are paid in full or 12 calendar months have passed after the expiration of BadgerCare eligibility, whichever is sooner.
DHS 103.085(3)(b) (b) Reasons restriction on re-enrollment may not apply. The restriction on re-enrollment under this section does not apply for either of the following reasons:
DHS 103.085(3)(b)1. 1. The failure to pay premiums was due to a circumstance beyond the group's control, provided that all past due premiums have been paid in full. A circumstance beyond the group's control includes any of the following:
DHS 103.085(3)(b)1.a. a. A problem with an electronic funds transfer from a bank account to the BadgerCare program.
DHS 103.085(3)(b)1.b. b. A problem with an employer's wage withholding.
DHS 103.085(3)(b)1.c. c. An administrative error in processing the premium.
DHS 103.085(3)(b)1.d. d. Any other circumstance affecting payment of the premium which the department determines is beyond the group's control, but not including insufficient funds.
DHS 103.085(3)(b)2. 2. A significant change in household composition occurred. A significant change occurs when one of the following events occurs:
DHS 103.085(3)(b)2.a. a. A parent or a parent's spouse in the group eligible for BadgerCare no longer resides in the home and has not resided in the home for at least 30 consecutive days.
DHS 103.085(3)(b)2.b. b. A person not in the group eligible for BadgerCare, but who is legally responsible for a group member, no longer resides in the home and has not resided in the home for at least 30 consecutive days.
DHS 103.085(3)(b)2.c. c. A caretaker relative of a minor in a group eligible for BadgerCare, or the caretaker relative's spouse, no longer resides in the home and has not resided in the home for at least 30 consecutive days.
DHS 103.085(3)(c) (c) Resuming BadgerCare eligibility. Eligibility for BadgerCare shall resume in the following manner for persons with a re-enrollment restriction that ended due to a reason described in par. (b):
DHS 103.085(3)(c)1. 1. For a BadgerCare group with a reason under par. (b) 1. for the re-enrollment restriction not to apply, BadgerCare eligibility shall be restored for any months that the group had been closed during the restriction period, provided that payment of any outstanding premiums owed is made and the group was otherwise eligible for BadgerCare in those months.
Loading...
Loading...
Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.