The employer shall pay at least 60% of the cost of the premiums for the group health insurance plan, but not more than 80% of the cost, for the department to purchase coverage under a group health insurance plan.
(c) Buy-in method.
The department shall purchase coverage by making payment to one of the following:
The insurance company that provides the group health insurance plan offered by the employer.
If it is not practical or feasible for the department to purchase coverage by making payment to those specified in subd. 1.
, and if requested by the employer or the insurance company offering the group health insurance plan, directly to the employee as reimbursement for premiums paid by the employee.
(14) Medicaid purchase plan buy-in to employer-provided health care coverage. DHS 108.02(14)(a)
The department may purchase a group health plan offered by the employer of an eligible person or non-eligible family member if the department determines that purchasing that coverage and the associated administrative expense would not be more costly than providing the medical assistance coverage described under this chapter.
The department shall pay on behalf of the recipient all deductibles, coinsurance and other cost sharing obligations under the group health plan that are for services covered under the state plan, except for the nominal cost sharing amounts otherwise permitted under section 1916 of the social security act that are the responsibility of the recipient.
The department shall purchase coverage by making payment to one of the following:
The insurance company that provides the health care coverage offered by the employer.
If a non-medical assistance eligible family member is enrolled in the group health plan in order to obtain coverage for the medical assistance eligible family member, the department shall pay for premiums only and not other cost sharing expenses for the non-medical assistance eligible family member. Premium payments for non-eligible members shall be included in the determination of cost-effectiveness under par. (c)
If a person's group health plan offers more services than are covered under the state plan, the department may not pay any deductibles, coinsurance or other cost sharing obligations for non-covered services.
Medicaid purchase plan eligible persons enrolled in a group health plan under this section shall be eligible for wrap-around coverage as described in ch. DHS 101
A person's enrollment in a group health plan shall be cost-effective when the amount the department pays for premiums, coinsurance, deductibles, other cost sharing obligations, wrap-around costs and additional administrative cost is likely to be less than or equal to the medical assistance expenditures for an equivalent set of services.
Amounts recovered in estate recovery from a recipient of the medicaid purchase plan shall be reduced by the total amount of monthly premiums paid by the recipient as a condition of eligibility for the medicaid purchase plan.
DHS 108.02 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; emerg. am. (4), cr. (8) and (9), eff. 7-1-92; am. (4), cr. (8) and (9), Register, February, 1993, No. 446
, eff. 3-1-93; correction in (6) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1994, No. 462;
cr. (10) to (12), Register, June, 1995, No. 474
, eff. 7-1-95; am. (10) (intro.), (b), (c) (intro.), 3. to 6., (11) (a), (b) 1. (intro.), c., 2. (intro.), c., (12) (a) 2., 4. and 5., cr. (10) (d) and (12) (f) 2., renum. (12) (f) to be (12) (f) 1., Register, April, 1996, No. 484
, eff. 5-1-96; correction in (9) (e) made under s. 13.93 (2m) (b) 6., Stats., Register, April, 1999, No. 520;
emerg. cr. (13), eff. 7-1-99; emerg. cr. (9) (f), eff. 12-23-99; cr.
(13), Register, March, 2000, No. 531
, eff. 4-1-00; cr. (14) and (15), Register, November, 2000, No. 539
, eff. 12-1-00;
corrections in (2), (4), (9) (d) 1., (10) (b), (c) 1., 2., 4. to 6., (12) (b) 2. c. and (14) (b) 5. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
correction in (12) (b) 2. c. made under s. 13.92 (4) (b) 7., Stats., Register May 2010 No. 653
; corrections in (10) (intro.), (11) (a), (12) (a) 2., 5., (d) 1. (intro.), (f) 1., 2., (15) made under s. 13.92 (4) (b) 7., Stats., Register December 2013 No. 696
Determination of eligibility.
Agencies shall be responsible for determination of eligibility for MA. These determinations shall comply with standards for eligibility found in ss. 49.46 (1)
, 49.47 (4)
, and 49.665 (4)
, Stats., and ch. DHS 103
(2) Informing recipients of rights and duties.
Agencies shall inform recipients of the recipients' rights and duties under the program, including those rights enumerated in s. DHS 106.04 (3)
Agencies shall begin recovery action, as provided by statute for civil liabilities, on behalf of the department against any MA recipient to whom or on whose behalf an incorrect payment was made.
The incorrect payment shall have resulted from a misstatement or omission of fact by the person supplying information during an application for MA benefits, or failure by the recipient, or any other person responsible for giving information on the recipient's behalf, to report income or assets in an amount which would affect the recipient's eligibility for benefits.
The amount of recovery may not exceed the amount of the MA benefits incorrectly provided.
Records of payment for the period of ineligibility, provided to the agency by the MA fiscal agent, shall be evidence of the amounts paid on behalf of the recipient.
The agency shall notify the recipient or the recipient's representative of the period of ineligibility and the amounts incorrectly paid, and shall request arrangement of repayment within a specified period of time.
If the effort to recover incorrect payments under par. (e)
is not successful, the agency shall refer cases of possible recovery to the district attorney or corporation counsel for investigation and the district attorney or corporation counsel may bring whatever action may be appropriate for prosecution for fraud or collection under civil liability statutes. Judgments obtained in these actions shall be filed as liens against property in any county in which the recipient is known to possess assets, if not satisfied at the time the judgment or order for restitution is rendered. Execution may be taken on the judgments as otherwise provided in statute.
The agency may seek recovery through an order for restitution by the court of jurisdiction in which the recipient or former recipient is being prosecuted for fraud.
The agency's decision concerning ineligibility and amounts owed may be appealed pursuant to ch. HA 3
. During the appeal process the agency may take no further recovery actions pending a decision. Benefits shall be continued pending the decision on the appeal. When the hearing decision is subsequently adverse to the client the benefits paid pending a decision on the appeal shall be collectable as incorrect payments.
The agency shall immediately deposit monies collected under this subsection to a designated bank account. The collection shall be reported to the department in the manner and on forms designated by the department within 30 days following the end of the month in which the collection is made, and shall be transmitted to the state in accordance with departmental instructions.
(4) Establishing a program of medical support liability.
Pursuant to s. 59.53 (5)
, Stats., counties shall contract with the department to implement and administer the child support collection program under Title IV-D of the Social Security Act of 1935, as amended. One of the responsibilities of a county's child support agency defined in s. DHS 1.07 (2) (c)
is to establish a program of medical support liability along with the child and spousal support and paternity establishment program.
DHS 108.03 History
Cr. Register, December, 1979, No. 288
, eff. 2-1-80; renum. from HSS 108.02 and am. Register, February, 1986, No. 362
, eff. 3-1-86; cr. (6), Register, December, 1988, No. 396
, eff. 1-1-89; r. (4), renum. (5) and (6) to be (4) and (5), Register, September, 1991, No. 429
, eff. 10-1-91; correction in (5) made under s. 13.93 (am) (b) 7., Stats., Register, September, 1991, No. 429
; correction in (3) (h) made under s. 13.93 (2m) (b) 7., Stats., Register, May, 1995, No. 473;
emerg. am. (1), eff. 7-1-99;
am. (1), Register, March, 2000, No. 531
, eff. 4-1-00;
corrections in (3) (h) and (4) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554
; corrections in (1), (2) and (4) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
; CR 18-046: r. (5) Register January 2019 No. 757, eff. 2-1-19.