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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.
DHS 103.085(3)(c)2. 2. For a BadgerCare group with a reason under par. (b) 2. for the re-enrollment restriction not to apply, the restriction on re-enrollment shall not apply to the remainder of the 6-month period. Beginning the first of the month after the adult has been out of the home for 30 days, the group may again be eligible for BadgerCare, provided that payment of any outstanding premiums owed is made and the group is otherwise eligible. The BadgerCare group remains ineligible for any prior months when the restriction on re-enrollment was in effect.
DHS 103.085(4) (4)Enroll in available employer-subsidized health plan.
DHS 103.085(4)(a)(a) A BadgerCare recipient is ineligible for BadgerCare when one of the following fail to enroll in an available employer-subsidized health care coverage:
DHS 103.085(4)(a)1. 1. The recipient.
DHS 103.085(4)(a)2. 2. The recipient's spouse when the spouse is residing with the recipient.
DHS 103.085(4)(a)3. 3. The recipient's parent, step-parent or other caretaker relative residing with the recipient, when the recipient is under 19 years of age.
DHS 103.085(4)(b) (b) Except as provided in par. (c), the recipient is ineligible for BadgerCare effective on the first day of the month that the employer-subsidized health care coverage would have been in effect for the recipient if the family had been enrolled in the plan. The individual remains ineligible for each month that coverage would have been available up to 19 months from the month the failure to enroll in the plan occurred.
DHS 103.085(4)(c) (c) Paragraph (b) does not apply if there was coverage and it ended for a good cause reason. A good cause reason is any of the following:
DHS 103.085(4)(c)1. 1. The employment ended for a reason other than voluntary termination.
DHS 103.085(4)(c)2. 2. The person changed to a new employer that does not offer family coverage.
DHS 103.085(4)(c)3. 3. The person's employer discontinued health plan coverage for all employees.
DHS 103.085(4)(c)4. 4. Any other reason determined by the department to be a good cause reason.
DHS 103.085(5) (5)Cooperation with buy-in to a group health insurance plan. An adult in a group eligible for BadgerCare shall cooperate when the department determines whether it is cost-effective to purchase coverage for the group in an employer's group health insurance plan under s. DHS 108.02 (13). In this subsection, “cooperation" means providing necessary information in order to determine cost effectiveness, signing up with the plan when requested by the department and cooperating with any other requirements of the health insurance plan. A person who fails or refuses to cooperate with buy-in is not eligible for BadgerCare.
DHS 103.085(6) (6)Maximum income. A BadgerCare group remains eligible for BadgerCare while the fiscal test group's income is at or below 200% of the poverty line and the group is otherwise eligible for BadgerCare.
DHS 103.085 History History: Emerg. cr. eff. 7-1-99; cr. Register, March, 2000, No. 531, eff. 4-1-00; correction in (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 103.087 DHS 103.087Conditions for continuation of eligibility.
DHS 103.087(1)(1)Premiums.
DHS 103.087(1)(a)(a) Authority. Subject to this section and s. 49.472, Stats., a person eligible for the medicaid purchase plan shall pay a monthly premium.
DHS 103.087(1)(b) (b) Applicability.
DHS 103.087(1)(b)1.1. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is at or above 150% of the poverty line for the applicable household size shall pay a monthly premium and the applicant shall pay all retroactive premium amounts assessed or other premium payments due.
DHS 103.087(1)(b)2. 2. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is below 150% of the poverty line for the applicable household size need not pay a monthly premium.
DHS 103.087(1)(b)3. 3. An applicant or recipient eligible for the medicaid purchase plan whose premium, calculated as described in par. (c), is greater than $10.00 shall pay a premium for the cost of the health care coverage offered under the medicaid purchase plan.
DHS 103.087(1)(c) (c) Premium amounts.
DHS 103.087(1)(c)1.1. An applicant or recipient eligible for the medicaid purchase plan shall pay a monthly premium in accordance with this subsection and the premium schedule in Table 103.087.
DHS 103.087(1)(c)2. 2. The county agency shall determine the amount of the premium an applicant shall pay according to the guidelines described in this subsection at the time of application.
DHS 103.087(1)(c)3. 3. All earned and unearned sources of income available to the applicant or recipient, except for the interest, dividends or other gains accrued from a recipient's independence account, shall be used in the premium determination.
DHS 103.087(1)(c)4. 4. The applicant's or recipient's monthly premium shall be calculated by locating the sum of the monthly adjusted unearned income plus the monthly adjusted earned income on the premium schedule in Table 103.087.
DHS 103.087(1)(d) (d) Calculating the monthly adjusted unearned income.
DHS 103.087(1)(d)1.1. An applicant's or recipient's monthly adjusted unearned income shall be calculated by subtracting the monthly income disregards in subd. 1. a. to c. from 100% of the applicant's or recipient's gross monthly countable unearned income.
DHS 103.087(1)(d)1.a. a. The allowance shall be equal to the sum of the monthly federal supplemental security income cash benefit, the monthly state supplemental security cash benefit, and $20, rounded to the nearest dollar.
DHS 103.087(1)(d)1.b. b. To be claimed as a monthly income disregard, the cost may not have been claimed by the applicant or recipient under any other medicaid purchase plan income disregard.
DHS 103.087(1)(d)1.c. c. To be claimed as a monthly income disregard, the cost may not have been claimed by the applicant or recipient under any other medicaid purchase plan income disregard.
DHS 103.087(1)(d)2. 2. If the applicant or recipient has monthly unearned income equal to $0, the monthly income disregards described in subd. 1. a. to c. apply to the applicant's or recipient's gross monthly earned income. If the applicant or recipient has monthly income disregards greater than his or her monthly unearned income, the difference shall be applied as a deduction to the applicant's or recipient's monthly earned income.
DHS 103.087(1)(e) (e) Calculating monthly adjusted earned income. An applicant's or recipient's monthly adjusted earned income shall be 3% of the applicant's or recipient's gross monthly earned income after the amount of any monthly income disregards greater than the applicant's or recipient's total unearned income have been subtracted.
DHS 103.087(1)(f) (f) Calculating the total monthly premium.
DHS 103.087(1)(f)1.1. The sum of the amounts determined in pars. (d) and (e) shall be applied to the premium schedule in Table 103.087. If the sum of the monthly adjusted earned and monthly adjusted unearned income is greater than $1025.00, the total monthly premium amount is the exact amount of the sum.
Table 103.087: Medicaid Purchase Plan Premium Schedule - See PDF for table PDF
DHS 103.087(1)(f)2. 2. The monthly premium shall be recalculated by the county agency to reflect any changes in earned or unearned income as reported by the recipient. A recipient's premium amount may change for any of the following reasons:
DHS 103.087(1)(f)2.a. a. Termination of the recipient from the medicaid purchase plan.
DHS 103.087(1)(f)2.b. b. A change in the poverty line or SSI federal or state benefit payment rate.
DHS 103.087(1)(f)2.c. c. Changes in income, impairment-related work expense costs or medical and remedial expense costs.
DHS 103.087(1)(f)2.d. d. Contributions to a recipient's independence account greater than an amount equal to 50% of earned income as described in s. DHS 103.06 (15).
DHS 103.087(1)(f)2.e. e. Other changes in personal or financial status that alter medical assistance eligibility.
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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.