2013 Wisconsin Act 20

2. If, before the 90 days under subd. 1. expire, the department determines it has not yet received a certification of an American health benefit exchange, as described in 42 USC 18031, from the federal department of health and human services, if such certification is required under federal law, the department shall apply subd. 1. a. and b. income eligibility levels to eligibility determinations under sub. (4) (a) 4. and s. 49.45 (23) for a 90-day period beginning on the day after the determination is made. The department may continue to apply the income eligibility levels under subd. 1. a. and b. for additional 90-day periods if the department has not yet received any required certification of an American health benefit exchange.

3. The department shall request any necessary approval from the federal department of health and human services to provide benefits under subd. 1. b. to only those individuals receiving benefits under s. 49.45 (23) as of December 31, 2013.

(b) 1. If, after consulting with the office of the commissioner of insurance, the department determines that in at least one county of the state, but not in all counties of the state, there is no qualified health plan, as defined in 42 USC 18021 (a), offered through an American health benefit exchange in which residents of the county may enroll, the department shall allow, for 90 days after the day the department makes the determination, individuals whose family income does not exceed 200 percent of the poverty line, who would otherwise be eligible for benefits under sub. (4) (a) 4. except for the income limit, and who reside in a county in which there is no qualified health plan available for enrollment under an American health benefit exchange to be eligible to receive benefits under sub. (4) (a) 4. if any of the following is satisfied.

a. The department determines that a waiver of federal Medicaid law is not required to implement the income eligibility levels described under this subdivision.

b. The department requests a waiver of federal Medicaid law to allow parents and caretaker relatives whose income levels do not exceed 200 percent of the poverty line and who would otherwise be eligible for benefits under sub. (4) (a) 4. to receive benefits and the federal department of health and human services approves the waiver request.

2. If, before the 90 days under subd. 1. expire, and before the expiration of any subsequent 90-day period expires, the department determines that a county still has no qualified health plan available for enrollment under an American health benefit exchange, the department shall apply the income eligibility exception under subd. 1.

20,1109 Section 1109. 49.471 (5) (b) 2. of the statutes is renumbered 49.471 (5) (b) 2. (intro.) and amended to read:

49.471 (5) (b) 2. (intro.) Except as provided in sub. (6) (a) 2., a child who is not an unborn child is eligible for the benefits described in s. 49.46 (2) (a) and (b) during the period beginning on the day on which a qualified entity determines, on the basis of preliminary information, that the child's family income does not exceed 150 percent of the poverty line any of the following and ending on the applicable day specified in subd. 3., unless the federal department of health and human services approves the department's request to not extend eligibility to children during this period:

20,1110 Section 1110. 49.471 (5) (b) 2. a. to c. of the statutes are created to read:

49.471 (5) (b) 2. a. 150 percent of the poverty line for a child who is 6 years of age or older but has not yet attained the age of 19.

b. 185 percent of the poverty line for a child who is one year of age or older but has not yet attained the age of 6.

c. 300 percent of the poverty line for a child who is under one year of age.

20,1111 Section 1111. 49.471 (5) (b) 3. a. of the statutes is amended to read:

49.471 (5) (b) 3. a. If the woman or child applies for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the day on which the department or the county department under s. 46.215, 46.22, or 46.23 determines whether the woman or child is eligible for benefits under sub. (4), except that a child who is not an unborn child is not eligible for benefits described in s. 49.46 (2) (a) and (b) during that time if the federal department of health and human services approves the department's request not to provide those benefits during that time.

20,1114 Section 1114. 49.471 (6) (a) 1. of the statutes is amended to read:

49.471 (6) (a) 1. Any Except as provided in subd. 4., any pregnant woman, including a pregnant woman under sub. (5) (b) 1., is eligible for medical assistance under this section for any of the 3 months prior to the month of application if she met the eligibility criteria under this section in that month.

20,1115 Section 1115. 49.471 (6) (a) 2. of the statutes is amended to read:

49.471 (6) (a) 2. Any Except as provided in subd. 3. or 4., any child who is not an unborn child, including a child under sub. (5) (b) 2., parent, or caretaker relative whose family income is less than 150 percent of the poverty line is eligible for medical assistance under this section for any of the 3 months prior to the month of application if the individual met the eligibility criteria under this section and had a family income of less than 150 percent of the poverty line in that month.

20,1116 Section 1116. 49.471 (6) (a) 3. of the statutes is created to read:

49.471 (6) (a) 3. Any individual described in subd. 2. who is not disabled, not elderly, and not pregnant, who is an adult, and whose family income exceeds 133 percent of the federal poverty level is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.

20,1117 Section 1117. 49.471 (6) (a) 4. of the statutes is created to read:

49.471 (6) (a) 4. To the extent allowed by the federal department of health and human services, any individual described in subd. 1. or 2. who is not disabled is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.

20,1117k Section 1117k. 49.471 (6) (d) of the statutes is amended to read:

49.471 (6) (d) If an application under this section shows that an individual is an essential person, the individual shall be provided the benefits specified under sub. (4) (a) or (b).

20,1118 Section 1118. 49.471 (7) (a) of the statutes is repealed.

20,1119 Section 1119. 49.471 (7) (b) 1. of the statutes is amended to read:

49.471 (7) (b) 1. A pregnant woman whose family income exceeds 300 percent of the poverty line may become eligible for coverage under this section if the difference between the pregnant woman's family income and the applicable income limit under sub. (4) (b) (a) is obligated or expended for any member of the pregnant woman's family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision continues without regard to any change in family income for the balance of the pregnancy and to the last day of the month in which the 60th day after the last day of the woman's pregnancy falls. Eligibility obtained by a pregnant woman under this subdivision extends to all pregnant women in the pregnant woman's family.

20,1120 Section 1120. 49.471 (7) (b) 2. of the statutes is amended to read:

49.471 (7) (b) 2. A child who is not an unborn child, whose family income exceeds 150 percent of the poverty line, and who is ineligible under this section solely because of sub. (8) (b), or whose family income exceeds 300 percent of the poverty line, may obtain eligibility under this section if the difference between the child's family income and 150 percent of the poverty line is obligated or expended on behalf of the child or any member of the child's family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision during any 6-month period, as determined by the department, continues for the remainder of the 6-month period and extends to all children in the family.

20,1122 Section 1122. 49.471 (7) (c) (intro.) of the statutes is amended to read:

49.471 (7) (c) (intro.) When calculating an individual's family income, the department shall do all of the following, subject to par. (d):

20,1123 Section 1123. 49.471 (7) (c) of the statutes, as affected by 2013 Wisconsin Act .... (this act), is repealed.

20,1124 Section 1124. 49.471 (7) (d) of the statutes is created to read:

49.471 (7) (d) In addition to applying other income counting requirements the department shall do all of the following:

1. When calculating the family income of a member of a household who is not disabled, include the income of all adults residing in the home for at least 60 consecutive days but exclude the income of a grandparent in a household containing 3 generations, unless the grandparent applies for or receives benefits as a parent or caretaker relative under this section.

2. When determining the size of a family for purposes of determining income eligibility, exclude from family size an adult whose income is included in a calculation of family income solely under subd. 1.

3. Apply this paragraph only to the extent the federal department of health and human services approves the income eligibility calculation methods, if approval is required.

20,1125 Section 1125. 49.471 (7) (e) of the statutes is created to read:

49.471 (7) (e) For the purpose of determining family income, the department shall apply the regulations defining a household under 42 CFR 435.603 (f). To determine the family size for a pregnant woman, the department shall include the pregnant woman and the number of babies she is expecting.

20,1126 Section 1126. 49.471 (8) (b) (intro.) of the statutes is amended to read:

49.471 (8) (b) (intro.) Except as provided in pars. (c), (cg), (cr), (ct), and (d), an individual whose family income exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of the following applies:

20,1127 Section 1127. 49.471 (8) (cg) of the statutes is created to read:

49.471 (8) (cg) 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 is not eligible for BadgerCare Plus if all of the following apply:

1. The individual has any of the following:

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.