Chapter DHS 103

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.

DHS 103.03(2)(d)2. 2. Has provided satisfactory documentary evidence of lawfully residing in the U.S.

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

DHS 103.03(2m) (2m) Limitation on medical assistance for noncitizens. A noncitizen who does not meet the conditions in sub. (2) (a), (b), (c), or (d) may not receive medical assistance benefits except as provided under s. 49.45 (27), Stats.

DHS 103.03(3) (3) Wisconsin residence.

DHS 103.03(3)(a) (a) Definitions. In this subsection:

DHS 103.03(3)(a)1. 1. “Incapable of indicating intent” means:

DHS 103.03(3)(a)1.a. a. The individual’s IQ is 49 or less, or the individual has a mental age of 7 or less, based on tests acceptable to the department;

DHS 103.03(3)(a)1.b. b. The individual is found legally incompetent under guardianship statutes; or

DHS 103.03(3)(a)1.c. c. Medical documentation or other documentation acceptable to the department supports a finding that the individual is incapable of indicating intent.

DHS 103.03(3)(a)2. 2. “Intent to reside” means that a person intends that Wisconsin is the person’s place of residence and that the person intends to maintain the residence indefinitely.

DHS 103.03(3)(a)3. 3. “Physical presence” means living in Wisconsin.

DHS 103.03(3)(b) (b) Physical presence and intention. An eligible person shall be a Wisconsin resident, as determined under 42 CFR 435.403. Residence shall be based on physical presence, except as provided in an interstate agreement, and on the person’s intent to maintain Wisconsin residence indefinitely, except as otherwise provided in pars. (c) to (g).

DHS 103.03(3)(c) (c) Migrant farm workers. A migrant farm worker who is living in Wisconsin and who entered with a job commitment or to seek employment shall be considered a resident so long as there is no medical assistance being received from another state. In this paragraph, “migrant farm worker” means any person whose primary employment in Wisconsin is in the agricultural field or cannery work, is authorized to work in the United States, who is not immediate family by blood or marriage of the employer, and routinely leaves an established place of residence to travel to another locality to accept seasonal or temporary employment. Members of the migrant farm worker’s family who live with the worker in Wisconsin shall also be considered Wisconsin residents.

DHS 103.03(3)(d) (d) Non-institutionalized persons. The residence of a person under age 21 shall be determined in accordance with the rules governing residence under the AFDC program except that non-institutionalized persons under age 21 whose MA eligibility is based on blindness or disability are residents if they are physically present in Wisconsin.

DHS 103.03(3)(e) (e) Institutionalized persons.

DHS 103.03(3)(e)1. 1. For any institutionalized person who is under age 21, or who is age 21 or older and became incapable of indicating intent before age 21, the state of residence is that of:

DHS 103.03(3)(e)1.a. a. The parents or the legal guardian, if one has been appointed, and parental rights have terminated at the time of placement in an institution; or

DHS 103.03(3)(e)1.b. b. The parent applying for MA on behalf of the applicant if the parent resides in another state and there is no appointed legal guardian.

DHS 103.03(3)(e)2. 2. Institutionalized persons over age 21 are Wisconsin residents when they are physically present with the intent to reside in Wisconsin except that persons who become incapable of indicating intent at or after age 21 are residents of the state in which they are physically present.

DHS 103.03(3)(f) (f) Out-of-state institutional placements. When a state arranges for a person to be placed in an institution located in another state, the state making the placement is the state of residence irrespective of the person’s indicated intent or ability to indicate intent.

DHS 103.03(3)(g) (g) Establishment of residence. Once established, residence is retained until superseded by a new place of residence.

DHS 103.03(4) (4) Furnishing of a social security number.

DHS 103.03(4)(a) (a) All individuals for whom MA benefits are requested shall have a social security number and shall furnish the number to the agency, except an individual who is one of the following:

DHS 103.03(4)(a)1. 1. An alien who is requesting medical assistance only for emergency services.

DHS 103.03(4)(a)2. 2. A child who is eligible for medical assistance under 42 USC 1396a (e) (4). During the time that the child is eligible under 42 USC 1396a (e) (4), the agency shall use the mother’s MA identification number.

DHS 103.03(4)(a)3. 3. An individual who is not eligible to receive a social security number.

DHS 103.03(4)(a)4. 4. An individual who does not have a social security number and may only be issued a social security number for a valid non-work reason in accordance with 20 CFR 422.104.

DHS 103.03(4)(a)5. 5. An individual who refuses to obtain a social security number because of well-established religious objections as provided in s. 49.82 (2) (b) 3., Stats.

DHS 103.03(4)(b) (b) If an applicant who is required to furnish a social security number under par. (a) does not have a social security number, application for the number shall be made by or on behalf of the applicant to the federal social security administration. If there is a refusal to furnish a number or apply for a number, the person for whom there is a refusal is not eligible for MA. The department may not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual’s social security number.

DHS 103.03(5) (5) Assignment of medical support. The parent or caretaker relative of a dependent child enumerated in s. 49.19 (1) (a), Stats., shall be deemed to have assigned all rights to medical support to the state as provided in s. 49.45 (19) (a), Stats. If there is a refusal to make the assignment, the person who refuses is not eligible for MA.

DHS 103.03(6) (6) Not a person detained by legal process. A person detained by legal process is not eligible for MA benefits. For purposes of this subsection, “detained by legal process” means incarcerated because of law violation or alleged law violation, which includes misdemeanors, felonies, and delinquent acts. A person who returns to the court after observation, is found not guilty of a law violation by reason of mental deficiency and is subsequently committed to a mental institution shall not be considered detained by legal process.

DHS 103.03(7) (7) Not a person residing in an institution for mental diseases. A person 21 to 64 years of age who resides in an institution for mental diseases (IMD) is not eligible for MA benefits, unless the person is 21 years of age, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident of the IMD since then. An IMD resident 21 to 64 years of age may be eligible for MA benefits while on convalescent leave from the IMD.

DHS 103.03(8) (8) Not an ineligible caretaker relative. A caretaker relative enumerated in s. 49.19 (1) (a), Stats., with whom a dependent child as defined in s. 49.19 (1) (a), Stats., is living when the income and resources of the MA group or fiscal test group exceed the limitations of ss. 49.19 and 49.77, Stats., or title XVI of the social security act of 1935, as amended, is not eligible unless the caretaker relative is SSI-related in accordance with sub. (1) (c), or is a woman who is medically verified to be pregnant.

DHS 103.03(9) (9) Not a striker. A person on strike is not eligible. When the striker is a caretaker relative, all members of the MA group who are 18 years of age or older shall be ineligible except that if the member of the MA group who is on strike is medically verified pregnant or, if the MA group includes a medically verified pregnant woman, the pregnant woman continues to be eligible during her pregnancy and through the month in which the 60th day following the end of pregnancy falls. In this subsection, “striker” means anyone who on the last day of the month is involved in a strike or a concerted effort with other employees to stop work, including a stoppage of work due to the expiration of a collective bargaining agreement, or any concerted slowdown or other concerted interruption of operations by employees.

DHS 103.03 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (b) 1., Register, February, 1988, No. 386, eff. 3-1-88; emerg. r. and recr. (7), eff. 8-1-88; r. and recr. (7), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (7), eff. 6-1-89; am. (7), Register, February, 1990, No. 410, eff. 3-1-90; am. (1) (b) 1., 2. and 4, (2), (3) (b) and (9), r. and recr. (4), Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1) (a) and (b) 3., eff. 7-1-99; am. (1) (a) and (b) 3. and cr. (1) (f), Register, March, 2000, No. 531, eff. 4-1-00; cr. (1) (g) and (h), Register, November, 2000, No. 539, eff. 12-1-00; correction in (1) (b) 1. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 21-067: am. (intro.), cr. (1) (g) 4., (h) 5. Register March 2022 No. 795, eff. 4-1-22, am. (intro.), r. (1) (g) 4., (h) 5. eff. the first day of the month after the emergency period, as defined in 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (intro.) made under s. 35.17, Stats., and correction in (1) (g) 4., (h) 5. made under ss. 13.92 (4) (b) 4., 35.17, Stats., Register March 2022 No. 795; CR 23-046: am. (1) (title), (a), (b) (title), (intro.), 1., 2., cr. (1) (b) 2m., am. (1) (b) 3., 4., cr. (1) (b) 5. to 8, am. (1) (f) (title), (intro.), 1., r. and recr. (1) (f) 2., cr. (1) (f) 2m., am. (1) (f) 3. (intro.), r. and recr. (1) (f) 3. a., b., cr. (1) (f) 3. cm., d., 3m., r. and recr. (1) (f) 4., cr. (1) (f) 4g., 4r., am. (1) (f) 5. (intro.), c., r. (1) (f) 5. d., am. (1) (f) 6., 8., cr. (1) (fm), renum. (2) to (2) (intro.) and am., cr. (2) (a) to (e), (2m), am. (4) (a) 1., 2., cr. (4) (a) 3. to 5., am. (4) (b) Register April 2024 No. 820, eff. 5-1-24; correction in (1) (b) 1., (f) 5. made under s. 35.17, Stats., and correction in numbering of (1) (f) cm. and (fm) 1. to 4. made under s. 13.92 (4) (b) 7. Register April 2024 No. 820.

DHS 103.04 DHS 103.04 Asset and income limits. The nonexempt assets and budgetable income of the MA group or, when applicable, the fiscal test group, shall be compared to the following asset and income limits established in this section to determine the eligibility of the MA group:

DHS 103.04(1) (1) Categorically needy.

DHS 103.04(1)(a) (a) The MA group or fiscal test group shall first be tested against the categorically needy standard. Persons who meet the non-financial eligibility conditions and who meet the income and asset standards specified in this subsection shall be determined eligible as categorically needy in accordance with s. 49.46 (1) (e), Stats., and shall receive MA benefits in accordance with s. 49.46 (2), Stats., and chs. DHS 101 to 108.

DHS 103.04(1)(b) (b) The BadgerCare Plus-related categorically needy income standard for MA applicants shall be the appropriate standard as specified in s. DHS 103.03 (1) (a).

DHS 103.04(1)(c) (c) The SSI-related categorically needy income standard shall be the maximum SSI payment including state supplement that a single person or a couple, as appropriate, could receive in Wisconsin under s. 49.77, Stats., or federal title XVI of the social security act of 1935, as amended. The SSI-related categorically needy asset standard shall be the same as specified in section 1613 of title XVI of the social security act of 1935, as amended.

DHS 103.04(2) (2) Medically needy. If the MA group or fiscal test group is not eligible as categorically needy, the medically needy standard shall be applied. SSI-related persons who meet non-financial conditions for eligibility and meet the income and assets criteria set forth in s. 49.47 (4) (b) and (c), Stats., and this chapter shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 through 108.

DHS 103.04(3) (3) Excess income cases.

DHS 103.04(3)(a) (a) In this subsection, “spend–down period” means the period during which excess income may be expended or obligations to expend excess income may be incurred for the purpose of obtaining BadgerCare Plus-related or SSI-related MA eligibility, as described under s. DHS 103.08 (2) (a).

DHS 103.04(3)(b) (b) When an SSI-related fiscal test group is found ineligible as medically needy and excess income is the only reason, the group may expend or incur obligations to expend the excess income above the appropriate medically needy income limit pursuant to s. 49.47 (4) (c) 2., Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.

DHS 103.04(3)(bg) (bg) When a child is found ineligible for BadgerCare Plus-related MA solely under s. DHS 103.03 (1) (f), the BadgerCare Plus-related fiscal test group may expend or incur obligations to expend the excess income above the appropriate income limit pursuant to s. 49.471 (7) (b) 2., Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.

DHS 103.04(3)(br) (br) When a pregnant woman is found ineligible for BadgerCare Plus-related MA solely under s. DHS 103.03 (1) (f), the BadgerCare Plus-related fiscal test group may expend or incur obligations to expend the excess income above the appropriate income limit pursuant to s. 49.471 (7) (b) 1., Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.

DHS 103.04(3)(c) (c) Health insurance premiums actually incurred or paid, plus any medical service recognized by state law received by a member of the MA or fiscal test group shall be counted toward fulfilling the excess income expenditure or incurrence requirement when the service is prescribed or provided by a medical practitioner who is licensed by Wisconsin or another state and if either or both of the following conditions are met:

DHS 103.04(3)(c)1. 1. The service is received during the spend-down period; or

DHS 103.04(3)(c)2. 2. The expense was incurred prior to the spend-down period and a fiscal test group member is still legally responsible for the debt and is consistently making payments, in which case the payments made during the spend-down period shall be counted.

DHS 103.04(3)(d) (d) No medical costs that are incurred and are to be paid or have been paid by a person other than the applicant or members of the fiscal test group may be counted toward fulfilling the excess income expenditure or incurrence requirement. No expense for which a third party is liable, including but not limited to medicare, private health insurance, or a court-ordered medical support obligation, may be used to meet the expenditure of excess income requirement.

DHS 103.04(4) (4) Special financial standards for institutionalized persons. The categorically needy and medically needy asset standards shall be the same for institutionalized persons as for non-institutionalized persons, except that in determining initial eligibility under s. DHS 103.075 for an institutionalized individual with a community spouse the asset standard shall be the regular SSI-related MA group size one asset standard as provided under s. 49.47 (4) (b) 3g., Stats., plus the community spouse resource allowance as provided under s. 49.455 (6) (b), Stats. The eligibility standards against which an institutionalized person’s income is tested shall be the following:

DHS 103.04(4)(a) (a) Categorically needy standard. The categorically needy standard for an institutionalized person shall be an amount equal to 3 times the federal share of the SSI payment for one person living in that person’s own home.

DHS 103.04(4)(b) (b) Medically needy standard. An institutionalized person shall be determined medically needy in accordance with requirements under 42 CFR 435.1007.

DHS 103.04(5) (5) Irregular cases; mixture of BadgerCare Plus and SSI-relatedness. When there is a mixture in an MA group of BadgerCare Plus-relatedness and SSI-relatedness, each individual will be tested using the appropriate modified adjusted gross income rules under sub. (7) or SSI-related standards.

DHS 103.04(6) (6) BadgerCare Plus.

DHS 103.04(6)(a) (a) An individual who meets the requirements of s. DHS 103.03 (1) (f) and (2) to (9) and the income limits in this subsection is eligible for BadgerCare Plus.

DHS 103.04(6)(b) (b) For all children under age 19, pregnant women and individuals requesting only family planning services under s. 49.45 (24s), Stats., in BadgerCare Plus fiscal test groups, the income limit is 306% of the poverty line.