Chapter DHS 103

DHS 103.03(1)(e)1. 1. Under emergency circumstances, a person may be presumed disabled for purposes of demonstrating SSI-relatedness and be eligible for MA without the verification required under par. (d).

DHS 103.03(1)(e)2. 2. When an emergency need for MA exists, the department shall make a preliminary disability determination within 7 days of the date a completed disability determination form is received.

DHS 103.03(1)(e)3. 3. An emergency need for MA shall exist when the applicant is:

DHS 103.03(1)(e)3.a. a. A patient in a hospital;

DHS 103.03(1)(e)3.b. b. Seriously impaired and the attending physician states the applicant will be unable to work or return to normal functioning for at least 12 months;

DHS 103.03(1)(e)3.c. c. In need of long-term care and the nursing home will not admit the applicant until MA benefits are in effect; or

DHS 103.03(1)(e)3.d. d. Unable to return home from a nursing home unless in-home service or equipment is available and this cannot be obtained without MA benefits.

DHS 103.03 Note Note: Copies of the disability determination form may be obtained from the county or tribal income maintenance agency.

DHS 103.03(1)(f) (f) BadgerCare Plus eligibility. To be non-financially eligible for BadgerCare Plus, a person shall meet all of the following conditions:

DHS 103.03(1)(f)1. 1. The person meets one of the conditions in par. (b).

DHS 103.03(1)(f)2. 2. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and does not have health insurance coverage that meets both of the following criteria:

DHS 103.03(1)(f)2.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is provided under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)2.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)2m. 2m. The person is an unborn child and the unborn child’s mother does not have health insurance coverage that covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)3. 3. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and the person does not have access to coverage under a group health insurance plan that meets all of the following criteria:

DHS 103.03(1)(f)3.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)3.b. b. The health insurance coverage would begin within 3 calendar months following the BadgerCare Plus application filing date, the BadgerCare Plus annual renewal month, or the start date of the employment through which the child can access the health insurance coverage.

DHS 103.03(1)(f)3.c. c. The employer of the person’s parent, step-parent or other caretaker relative residing with the person, when the person is under 19 years of age.

DHS 103.03(1)(f)3.cm. cm. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)3.d. d. The health insurance policy is through the child’s employer, the employer of the child’s spouse when the spouse is residing with the child, or the employer of the child’s parent, step-parent or other caretaker relative residing with the child.

DHS 103.03(1)(f)3m. 3m. If the person is an unborn child, the unborn child’s mother does not have access to coverage under a group health insurance plan that meets all of the following criteria:

DHS 103.03(1)(f)3m.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)3m.b. b. The health insurance coverage would begin within 3 calendar months following the BadgerCare Plus application filing date, the BadgerCare Plus annual renewal month, or the start date of the employment through which the mother can access the health insurance coverage.

DHS 103.03(1)(f)3m.c. c. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)3m.d. d. The health insurance policy is through the mother’s employer or the employer of the mother’s spouse when the spouse is residing with the mother.

DHS 103.03(1)(f)3m.e. e. When the mother is under 19 years old, the health insurance coverage is through the employer of the mother’s parent, step-parent, or other caretaker relative residing with the mother.

DHS 103.03(1)(f)4. 4. Except as provided in subd. 5. or 5m., if the person did not, at any time in the 12 months immediately preceding application for BadgerCare Plus, have access to employer-subsidized health care coverage or a state employee health plan and is any of the following:

DHS 103.03(1)(f)4.a. a. A child ages 1 through 5 with household income over 191% of the federal poverty level.

DHS 103.03(1)(f)4.b. b. A child ages 6 through 18 with household income over 156% of the federal poverty line.

DHS 103.03(1)(f)4g. 4g. The child under subd. 4. is ineligible for BadgerCare Plus the first day of the month that the employer’s plan would have provided coverage for the child if the family had been enrolled in the plan. The child remains ineligible for each month that coverage would have been available up to 18 12 months from the month the failure to enroll in the plan occurred if the health insurance plan meets all of the following criteria:

DHS 103.03(1)(f)4g.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)4g.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)4g.c. c. The health insurance policy is through the child’s employer, the employer of the child’s spouse when the spouse is residing with the child, or the employer of the child’s parent, step-parent or other caretaker relative residing with the child.

DHS 103.03(1)(f)4r. 4r. Except as provided in subd. 5., if the person is an unborn child, the unborn child’s mother did not, at any time in the 12 months immediately preceding application for BadgerCare Plus, have access to employer-subsidized health care coverage, or a state employee’s health plan. The unborn child is ineligible for BadgerCare Plus the first day of the month that the employer’s plan would have provided coverage for the unborn child’s mother if the family had been enrolled in the plan. The unborn child remains ineligible for each month that coverage would have been available up to 12 months from the month the failure to enroll in the plan occurred if the health insurance plan meets all of the following criteria:

DHS 103.03(1)(f)4r.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)4r.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)4r.c. c. The health insurance policy is provided through the mother’s employer, the employer of the mother’s spouse when the spouse is residing with the mother, or the employer of the mother’s parent, step-parent or other caretaker relative residing with the child, if the mother is under 19 years of age.

DHS 103.03(1)(f)5. 5. The 12 month period in subds. 4. and 4m. does not apply if one of the following statements is true about access to employer-subsidized health care coverage:

DHS 103.03(1)(f)5.a. a. The employment ended.

DHS 103.03(1)(f)5.b. b. The person’s employer discontinued health care coverage for all employees.

DHS 103.03(1)(f)5.c. c. A member or members of the family were eligible for other health insurance coverage or MA at the time the employee failed to enroll in the employer-subsidized health care coverage and no member of the group was eligible at that time for BadgerCare Plus with an assistance group income above 156% of the federal poverty line.

DHS 103.03(1)(f)5.e. e. Any other reason determined by the department to be a good cause reason.

DHS 103.03(1)(f)6. 6. The person is not eligible for MA under BadgerCare Plus-related or SSI-related criteria in this chapter.

DHS 103.03(1)(f)7. 7. A person required to pay a premium under s. DHS 103.085 (1) has made the first payment.

DHS 103.03(1)(f)8. 8. A person has not chosen to receive BadgerCare Plus-related or SSI-related MA through a spend-down, as described in s. DHS 103.08 (2) (a), or has chosen to end a spend-down period at any time prior to the date at which the expenditure or obligation of excess income has been achieved.

DHS 103.03(1)(fm) (fm) Exemption from health insurance coverage requirements. A child is exempt from the health insurance coverage requirements in sub. (1) (f) 2., 3., and 4., if they meet any of the following criteria:

DHS 103.03(1)(fm)1. 1. The child is younger than 19 years old, has met a deductible, and is in the deductible period.

DHS 103.03(1)(fm)2. 2. The child is in an extension.

DHS 103.03(1)(fm)3. 3. The person is age 18 and was in foster care, subsidized guardianship, or court-ordered kinship care on the date they turned 18 years old.

DHS 103.03(1)(fm)4. 4. The child is pregnant.

DHS 103.03(1)(g) (g) Medicaid purchase plan non-financial eligibility. To be non-financially eligible for the medicaid purchase plan a person shall meet the conditions described in par. (c) for SSI-related persons and shall be age 18 or older and the person shall meet any of the following conditions:

DHS 103.03(1)(g)1. 1.

DHS 103.03(1)(g)1.a. a. The person shall be employed.

DHS 103.03(1)(g)1.b. b. The person shall be enrolled in a department-certified health and employment counseling program.

DHS 103.03(1)(g)1.c. c. The health of the person participating in the medicaid purchase plan for at least 6 months shall have deteriorated to the point that he or she is unable to participate under subd. 1. a. or b. and the county agency has waived the requirement for a period up to 6 calendar months. The county agency may waive the requirement if the person is hospitalized, injured or suffers any other health setback. The county agency may waive the requirement as long as it had not granted a waiver of the requirement twice within the 36 months immediately preceding the current waiver request. The waiver periods shall be non-consecutive. The person shall supply proof of health difficulties. In addition to the discretion the county agency has to grant a waiver, the department may grant a temporary waiver of the work requirement upon a showing of good cause.

DHS 103.03(1)(g)2. 2. The person meets SSI-related non-financial eligibility requirements under par. (c) as verified under par. (d) and s. 49.472 (3) (c), Stats.

DHS 103.03(1)(g)3. 3. The applicant meets the eligibility requirements described in s. DHS 103.087.

DHS 103.03(1)(h) (h) Medicaid purchase plan health and employment counseling eligibility.

DHS 103.03(1)(h)1. 1. ‘Initial eligibility.’ To be eligible for the health and employment counseling program within the medicaid purchase plan, a person shall complete an employment plan.

DHS 103.03(1)(h)1.a. a. The employment plan shall be reviewed by a screening agency and approved by the department before the person receives approval from the department as a participant.

DHS 103.03(1)(h)1.b. b. The screening agency shall refer the person to community resources as appropriate to meet all employment plan requirements. The screening agency may assist the person in completing the written employment plan or providing any other services required under the plan.

DHS 103.03(1)(h)1.c. c. A notice of participation status shall be sent by the department to the person, the screener and the appropriate county or tribal economic support office.

DHS 103.03(1)(h)2. 2. ‘Period of eligibility.’

DHS 103.03(1)(h)2.a. a. A person may participate in a health and employment counseling program for a period of up to nine consecutive calendar months and for any allowable periods of extension described under subd. 3.

DHS 103.03(1)(h)2.b. b. Upon completion of a period of eligibility, a person shall be ineligible for a health and employment counseling program for a period of 6 consecutive calendar months. Following the 6-month period, a person may begin a new period of eligibility, but a given person may only use 2 periods of eligibility within a period of 5 consecutive calendar years.

DHS 103.03(1)(h)2.c. c. Participation in a health and employment counseling program approved by the department meets the eligibility requirement in par. (g) 1. b.

DHS 103.03(1)(h)3. 3. ‘Extending eligibility.’

DHS 103.03(1)(h)3.a. a. If a person is not employed at the end of the period of eligibility, the person may request an extended period of eligibility from the department. The extended period of eligibility shall be valid for a period of three consecutive calendar months.

DHS 103.03(1)(h)3.b. b. The extended period of eligibility shall be approved by the department.

DHS 103.03(1)(h)3.c. c. The person may not request more than one extension of eligibility per period of eligibility.

DHS 103.03(1)(h)3.d. d. After participation in a health and employment counseling [program] ends, a person may continue to receive services from an agency that also provides screening services, in accordance with the agency’s rules.

DHS 103.03(1)(h)4. 4. ‘Retroactive eligibility.’

DHS 103.03(1)(h)4.a. a. A person may request retroactive participation in a health and employment counseling program for a period of up to three months if the person demonstrates he or she met all eligibility requirements of the employment plan during those months.

DHS 103.03(1)(h)4.b. b. Any retroactive months of eligibility requested by the person shall count toward the period of eligibility as described in this paragraph.

DHS 103.03(1)(h)4.c. c. The department shall approve requested months of retroactive eligibility.

DHS 103.03(2) (2) Citizenship. U.S. citizenship shall be a requirement for eligibility for MA, except that the following persons who are not U.S. citizens may also be eligible for MA:

DHS 103.03(2)(a) (a) A U.S. National from American Samoa or Swains Island.

DHS 103.03(2)(b) (b) A citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau who meets all of the following requirements:

DHS 103.03(2)(b)1. 1. Has declared, or someone legally responsible for the individual has declared, that the individual has a satisfactory immigration status.

DHS 103.03(2)(b)2. 2. Has provided satisfactory documentary evidence of their status.

DHS 103.03(2)(b)3. 3. Has their status verified with the U.S. Department of Homeland Security.

DHS 103.03(2)(b)4. 4. Is lawfully residing in the U.S.

DHS 103.03(2)(c) (c) A qualified non-citizen as described in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 USC 1641, who meets all of the following requirements:

DHS 103.03(2)(c)1. 1. Has declared, or someone legally responsible for the individual has declared, that the individual has a satisfactory immigration status.

DHS 103.03(2)(c)2. 2. Has provided satisfactory documentary evidence of a qualified non-citizen status.

DHS 103.03(2)(c)3. 3. Has their qualified non-citizen status verified with the U.S. Department of Homeland Security.

DHS 103.03(2)(c)4. 4. If subject to the 5-year bar under 8 USC 1613, has been in the United States for 5 years with a qualified non-citizen status.

DHS 103.03(2)(d) (d) A child under age 19, a pregnant woman or an individual under age 21 residing in an institution for mental disease who is a noncitizen lawfully residing in the U.S. as allowed under 42 USC 1396b (v) (4), who meets all of the following requirements:

DHS 103.03(2)(d)1. 1. Has declared, or someone legally responsible for the individual has declared, that the individual has a satisfactory immigration status.