Alert! This chapter may be affected by an emergency rule:
DHS 103.087(1)(g)1.1. Before the county agency may certify an applicant as eligible for the medicaid purchase plan, the applicant who owes a premium under this subsection shall pay the premium amount. The premium amount owed shall include the premiums for all retroactive and current months in which the applicant owes a premium as of the date eligibility is determined.
DHS 103.087(1)(g)2. 2. An applicant may claim retroactive medicaid purchase plan eligibility for a period of up to 3 months prior to the month of application, but not prior to January 1, 2000. To be eligible for retroactive eligibility, an applicant shall pay the retroactive premium amount for each month claimed, in full, to the state's fiscal agent via the county agency, prior to the county agency certifying the applicant's eligibility for the medicaid purchase plan.
DHS 103.087(1)(g)3. 3. Based on arrangements made by the applicant or recipient, entities other than the applicant or recipient may pay monthly premiums on behalf of the applicant or recipient. The applicant or recipient shall be ultimately responsible for his or her monthly premium payment.
DHS 103.087(1)(g)4. 4. If the county agency does not receive payment by the last day of the calendar month for which the premium is owed, the department shall terminate the recipient's eligibility for the medicaid purchase plan, effective the last calendar day of the month.
DHS 103.087(1)(g)5. 5. An applicant or recipient may pay monthly premiums in advance, but only for the months in the applicant's or recipient's current medicaid review period. The applicant or recipient shall pay advance monthly premium amounts in full.
DHS 103.087(1)(g)6. 6. If no premium is required and the applicant meets all other eligibility factors, the county agency shall approve the applicant for the medicaid purchase plan.
DHS 103.087(1)(h) (h) Non-payment of medicaid purchase plan premiums.
DHS 103.087(1)(h)1.1. An applicant or recipient required to pay a monthly premium shall be ineligible for re-enrollment for the period specified in par. (i) 2. when the applicant or recipient fails to pay his or her monthly premium within the time specified in par. (g) 4. resulting in a finding of premium non-payment.
DHS 103.087(1)(h)2. 2. Premium non-payment shall include attempted payment with an instrument such as a check or direct deposit, that has been returned, refused or dishonored. A guaranteed form of payment such as a cashier's check or money order shall be required to replace a returned, refused or dishonored payment.
DHS 103.087(1)(h)3. 3. Failure to pay premiums due to circumstances beyond the recipient's control may not be considered non-payment, provided that all past due premiums are paid in full. Circumstances beyond the recipient's control are any of the following:
DHS 103.087(1)(h)3.a. a. Problems with an electronic funds transfer or direct deposit from a financial institution to the medicaid purchase plan program.
DHS 103.087(1)(h)3.b. b. Problems with an employer's wage withholding.
DHS 103.087(1)(h)3.c. c. Administrative error in processing the premium.
DHS 103.087(1)(h)3.d. d. Any other circumstances that may be found to be good cause as determined by the department on a case-by-case basis.
DHS 103.087(1)(h)4. 4. At the time of application or anytime thereafter, an applicant or recipient may sign a release statement identifying an emergency contact to receive copies of the person's notice of decision letters.
DHS 103.087(1)(i) (i) Consequences of premium non-payment.
DHS 103.087(1)(i)1.1. A person eligible for the medicaid purchase plan who fails to pay his or her monthly premium shall be terminated from the medicaid purchase plan and subject to restrictive re-enrollment as described under subd. 2.
DHS 103.087(1)(i)2. 2. A medicaid purchase plan participant who fails to make his or her monthly premium payments in the medicaid purchase plan shall be ineligible for a period of at least 6 consecutive calendar months following the date that the medicaid purchase plan eligibility ends. After 6 calendar months, the person shall be eligible for the medicaid purchase plan only if all past premiums due are paid in full or 12 calendar months have passed since the expiration of medicaid purchase plan eligibility, whichever is sooner.
DHS 103.087(2) (2)Cooperation with buy-in to employer-provided health care coverage.
DHS 103.087(2)(a)(a) The applicant eligible for the medicaid purchase plan and the applicant's parent, if the applicant is a dependent child aged 18 or 19, shall cooperate when the department determines whether it is cost-effective to purchase coverage under the employer-provided health plan for the person under s. DHS 108.02 (14). In this subsection, “cooperate" means provide necessary information in order to determine cost-effectiveness, sign up with the health plan when requested by the department and comply with any other requirements of the health plan.
DHS 103.087(2)(b)1.1. Except as provided in subd. 2., a person who fails or refuses to cooperate with the department's buy-in to employer-provided health care coverage is not eligible for the medicaid purchase plan.
DHS 103.087(2)(b)2. 2. An exception to subd. 1. shall be made in cases where a person who is otherwise eligible for medical assistance is unable to enroll in the group health plan on his or her own behalf. An example of a person who is otherwise eligible for medical assistance but unable to enroll in the group health plan on his or her own behalf may be a child whose parent refuses to enroll the child or a spouse unable to enroll on his or her own behalf.
DHS 103.087 History History: Cr. Register, November, 2000, No. 539, eff. 12-1-00; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 103.09 DHS 103.09Termination of medical assistance.
DHS 103.09(1)(1)Final month coverage. When eligibility ends, except in the case of death of the recipient, the MA benefits shall continue until the end of the calendar month.
DHS 103.09(2) (2)Four-month continuation of eligibility. When an MA group becomes ineligible for AFDC due solely to excess income, is receiving child support payments and all of the excess income consists of child support collections, and has received an AFDC payment in at least 3 of the 6 months immediately preceding the month in which ineligibility begins, eligibility for MA shall continue for 4 months from the date that AFDC eligibility was terminated. The 6 months preceding the month in which ineligibility begins includes the month in which the MA group became ineligible for AFDC if the MA group was eligible for and received AFDC for that month.
DHS 103.09(3) (3)Twelve-month continuation of eligibility.
DHS 103.09(3)(a)(a) When an MA group becomes ineligible for AFDC due to loss of the earned income disregards under s. 49.19 (5) (a) 4. and 4m., or (am), Stats., or to a change in the amount of earned income disregards under s. 49.19 (5) (a) 4. and 4m., or (am), Stats., eligibility for MA shall continue for 12 months from the date that AFDC eligibility was terminated.
DHS 103.09(3)(b) (b) When an MA group becomes ineligible for AFDC due to an increase in earned income or an increase in hours of employment or a combination of increased earned income and increased hours of employment, eligibility for MA shall continue for 12 months from the date that AFDC eligibility was terminated provided that at least one member of the MA group received AFDC for at least 3 of the 6 months immediately preceding the month in which AFDC was discontinued and at least one member of the MA group is continuously employed during that period.
DHS 103.09(3)(c) (c) When an MA group becomes ineligible for AFDC due to an increase in earned income, or to a combination of an increase in earned income and in increase in child support payments, and has received an AFDC payment in at least 3 of the 6 months immediately preceding the month in which ineligibility begins, eligibility for MA shall continue for 12 months from the date that AFDC eligibility was terminated. The 6 months preceding the month in which ineligibility begins includes the month in which the MA group became ineligible for AFDC if the MA group was eligible for and received AFDC for that month.
DHS 103.09(4) (4)Timely notice. The agency shall give the recipient timely advance notice and explanation of the agency's intention to terminate MA. This notice shall be in writing and shall be mailed to the recipient at least 10 calendar days before the effective date of the proposed action. The notice shall clearly state what action the agency intends to take and the specific regulation supporting that action, and shall explain the right to appeal the proposed action and the circumstances under which MA is continued if a fair hearing is requested.
DHS 103.09 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (3) (a), r. (2) (a), renum. (2) (b) to be (2) and am., r. and recr. (3) (b), cr. (3) (c), Register, March, 1993, No. 447, eff. 4-1-93.
DHS 103.10 DHS 103.10Redetermination of eligibility. The agency shall give the recipient timely advance notice of the date on which the recipient's eligibility will be redetermined. This notice shall be in writing and mailed to the recipient at least 15 calendar days but no more than 30 calendar days before the redetermination date. The requirement for timely advance notice of eligibility redetermination does not apply to spend-down cases in which the period of certification is less than 60 days.
DHS 103.10 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 103.11 DHS 103.11Presumptive eligibility for pregnant women.
DHS 103.11(1)(1)Requirements. Pregnant women may be determined presumptively eligible for MA on the basis of verification of pregnancy and preliminary information about family income. That determination shall be made by providers designated by the department who are qualified in accordance with this section. A provider qualified to make determinations of presumptive eligibility shall meet the following requirements:
DHS 103.11(1)(a) (a) Be certified as an MA provider under ch. DHS 105; and
DHS 103.11(1)(b) (b) Provide one or more of the following services:
DHS 103.11(1)(b)1. 1. Outpatient hospital services;
DHS 103.11(1)(b)2. 2. Rural health clinic services; or
DHS 103.11(1)(b)3. 3. Clinic services furnished by or under the direction of a physician; and
DHS 103.11(1)(c) (c) Receive funding or participate in a program under:
DHS 103.11(1)(c)1. 1. The migrant health center or community health center programs under section 329 or 330 of the public health service act;
DHS 103.11(1)(c)2. 2. The maternal and child health services block grant programs;
DHS 103.11(1)(c)3. 3. The special supplemental food program for women, infants and children under section 17 of the child nutrition act of 1966;
DHS 103.11(1)(c)4. 4. The commodity supplemental food program under D.4 (a) of the agriculture and consumer protection act of 1973; or
DHS 103.11(1)(c)5. 5. A state prenatal [perinatal] program; and
DHS 103.11 Note Note: Although “prenatal" was used in the filed rule order, the department's medical assistance manual uses the term “perinatal".
DHS 103.11(1)(d) (d) Have been determined by the department to be a qualified provider under this section.
DHS 103.11(2) (2)Duties and responsibilities.
DHS 103.11(2)(a)(a) A qualified provider shall ascertain presumptive MA eligibility for a pregnant woman by:
DHS 103.11(2)(a)1. 1. Verifying or obtaining verification of the woman's pregnancy; and
DHS 103.11(2)(a)2. 2. Determining on the basis of preliminary information that the woman's family income meets the applicable income limits.
DHS 103.11(2)(b) (b) The provider shall inform the woman, in writing, of the determination of presumptive eligibility and that she has 14 calendar days from the date of the determination to file an application for MA eligibility with the county department of social services.
DHS 103.11(2)(c) (c) Within 5 working days following the date on which the determination was made, the provider shall in writing notify the department and the agency where the woman will apply for MA eligibility of the woman's presumptive eligibility.
DHS 103.11(2)(d) (d) In the event that the provider determines that a woman is not presumptively eligible, the provider shall inform her that she may file an application for MA eligibility at the county department of social services.
DHS 103.11 History History: Cr. Register, February, 1988, No. 386, 3-1-88; correction in (1) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
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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.