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 AFDC-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 or AFDC-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)(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.
DHS 103.04(5)(a)(a) Mixture of AFDC and SSI-relatedness. When there is a mixture in an MA group of AFDC-relatedness and SSI-relatedness, AFDC-related financial eligibility procedures shall be used except when no minor child is in the home, in which case SSI-related procedures shall be used.
DHS 103.04(5)(b) (b) Fiscal test groups in which some are receiving AFDC and some are applying for MA only.
DHS 103.04(5)(b)1.1. If some members of the fiscal test group are receiving AFDC and some are not, the eligibility of the non-AFDC recipients shall be determined by comparing the assets of the entire fiscal test group to the appropriate asset standard and by comparing the income of the non-AFDC members or, if appropriate, the fiscal test group, to the appropriate share of the total family income standard.
DHS 103.04(5)(b)2. 2. For purposes of this paragraph, the family consists of parents and all children, including AFDC recipients, in the household for whom either spouse is legally responsible, except that the family does not include SSI recipients and children who do not have a legally responsible parent in the home.
DHS 103.04(5)(c) (c) SSI-related child when family is ineligible. A blind or disabled child in a family found financially ineligible for AFDC-related MA may have his or her eligibility determined individually according to SSI-related financial procedures for child-only cases specified in s. DHS 103.05.
DHS 103.04(5)(d) (d) Non-legally responsible relative (NLRR) case.
DHS 103.04(5)(d)1.1. If SSI-related adults are caring for a minor child for whom they are not legally responsible, the adults shall have their financial eligibility determined according to AFDC-related procedures, except that their eligibility may be determined according to SSI-related financial procedures if they are found ineligible for AFDC-related MA because of earned income or if they elect to be processed as SSI-related.
DHS 103.04(5)(d)2. 2. The income and assets of a child residing with an NLRR shall be measured against the AFDC-related standard for one person, except that when the NLRR child is blind or disabled eligibility shall be determined according to SSI-related financial procedures.
DHS 103.04(5)(d)3. 3. If the child is found financially ineligible, the eligibility of the NLRR caretaker relative shall be determined by measuring that relative's income and assets against AFDC-related eligibility standards.
DHS 103.04(5)(e) (e) Child residing in a licensed foster or group home. For a child who lives in a foster or group home licensed under chs. DCF 56 or 57, only the child's own income and assets shall be used when determining the child's financial eligibility. The child's income and assets shall be measured against the AFDC-related income and asset standards for one person.
DHS 103.04(6) (6) BadgerCare.
DHS 103.04(6)(a)(a) A group that meets the requirements of s. DHS 103.03 (1) (f) and (2) to (9) and the income limits in this subsection or in s. DHS 103.085 (6) is eligible for BadgerCare.
DHS 103.04 Note Note: Section DHS 103.085 (6) has been repealed.
DHS 103.04(6)(b) (b) For all applicant BadgerCare fiscal test groups, the income limit is 185% of the poverty line, or a lower percentage of the poverty line established by the department in accordance with s. 49.665 (4) (at), Stats.
DHS 103.04(7) (7) Special BadgerCare budgeting procedures.
DHS 103.04(7)(a) (a) BadgerCare group. The following persons who reside in the home with the primary person shall be included in the BadgerCare group if otherwise non-financially eligible and applying for BadgerCare:
DHS 103.04(7)(a)1. 1. The primary person.
DHS 103.04(7)(a)2. 2. The primary person's spouse.
DHS 103.04(7)(a)3. 3. A natural or adoptive child under age 19 of the primary person.
DHS 103.04(7)(a)4. 4. A parent of a child under subd. 3.
DHS 103.04(7)(a)5. 5. The spouse of a parent under subd. 4.
DHS 103.04(7)(a)6. 6. The natural or adoptive child of the primary person's child under subd. 3.
DHS 103.04(7)(a)7. 7. The spouse of the child in subd. 3., if that child is a parent.
DHS 103.04(7)(b) (b) BadgerCare fiscal test group.
DHS 103.04(7)(b)1.1. The income of the following persons shall be included when determining the eligibility of the BadgerCare group:
DHS 103.04(7)(b)1.a. a. Any person listed in par. (a).
DHS 103.04(7)(b)1.b. b. Except for SSI recipients, any person residing with members of the BadgerCare group who is legally responsible for any member.
DHS 103.04(7)(b)2. 2. Except for SSI recipients, the needs of the following persons shall be used to determine the eligibility of the BadgerCare group:
DHS 103.04(7)(b)2.a. a. Any person listed in par. (a).
DHS 103.04(7)(b)2.b. b. Children under age 19 of the primary person who are eligible for AFDC-related or SSI-related MA.
DHS 103.04(7)(b)2.c. c. Any person residing with members of the BadgerCare group, and who is legally responsible for any member.
DHS 103.04(7)(c) (c) Non-legally responsible relative (NLRR) case. The income of a minor child residing with an NLRR caretaker shall be measured against the BadgerCare income limits for one person.
DHS 103.04(7)(d) (d) Case of a person under 19 years old. Any person under 19 years old who resides with a parent or parents must include the parents in the BadgerCare application.
DHS 103.04(8) (8) Medicaid purchase plan financial eligibility criteria.
DHS 103.04(8)(a)(a) A person who meets the requirements of s. DHS 103.03 (1) (g) and (2) to (9) and the income and asset limits described in this subsection is eligible for the medicaid purchase plan.
DHS 103.04(8)(b) (b) The person's total net family income is less than 250% of the federal poverty line as determined by the person's family size. Net income is calculated using the standard SSI disregards and exemptions. The income disregards are the following:
DHS 103.04(8)(b)1. 1. Sixty-five dollars and one-half of the family's remaining earned income. If the family does not have any unearned income, $85 and one-half of the family's remaining earned income.
DHS 103.04(8)(b)2. 2. Twenty dollars of any unearned income.
DHS 103.04(8)(b)3. 3. Impairment-related work expenses.
DHS 103.04(8)(c) (c) The person has non-exempt assets less than the asset limit described under s. 49.472 (3) (b), Stats.
DHS 103.04(8)(d) (d) If the person leaves the medicaid purchase plan and subsequently re-enrolls in the program, the person's independence account and any interest, gains, or dividends from that account are disregarded for purposes of subsequent eligibility determinations.
DHS 103.04(9) (9) Special medicaid purchase plan budgeting procedures.
DHS 103.04(9)(a)(a) Medicaid purchase plan group. Any of the following persons who reside in the home with the applicant or recipient shall be included in determining the family size of the person applying for the medicaid purchase plan, with this family size used in calculating the person's financial eligibility under this section:
DHS 103.04(9)(a)1. 1. The applicant.
DHS 103.04(9)(a)2. 2. The applicant's spouse.
DHS 103.04(9)(a)3. 3. Any dependent child of the applicant as described in s. 49.141, Stats.
DHS 103.04(9)(b) (b) Medicaid purchase plan fiscal test group. The income of any person listed in par. (a) 1. or 2. shall be included when determining financial eligibility of the applicant.
DHS 103.04(9)(c) (c) Medicaid purchase plan coverage.
DHS 103.04(9)(c)1. 1. Medical assistance under the medicaid purchase plan applies to the applicant or recipient only.
DHS 103.04(9)(c)2. 2. The monthly premium for the medicaid purchase plan is calculated using only the income of the applicant or recipient.
DHS 103.04 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (4) (intro.), Register, March, 1993, No. 447, eff. 4-1-93; correction in (1) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520; emerg. am. (3) (a), eff. 7-1-99; am. (3) (a) and cr. (6) and (7), Register, March, 2000, No. 531, eff. 4-1-00; cr. (8) and (9), Register, November, 2000, No. 539, eff. 12-1-00; corrections in (1) (b), (2), (3) (b) and (5) (e) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; correction in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register July 2015 No. 715; correction in (1) (b) made under s. 13.92 (4) (b) 7., Stats., Register January 2021 No. 781; CR 20-039: am. (7) (d) Register October 2021 No. 790, eff. 11-1-21.
DHS 103.05 DHS 103.05Determining assets and income in child-only cases.
DHS 103.05(1)(1)Meaning of child-only case. A child-only case exists when:
DHS 103.05(1)(a) (a) A family has been determined financially ineligible for AFDC-related MA only and there is a child in the family who is SSI-related but not receiving SSI payments;
DHS 103.05(1)(b) (b) A step-parent family requests MA exclusively for a stepchild;
DHS 103.05(1)(c) (c) A step-parent family refuses or is determined ineligible for AFDC;
DHS 103.05(1)(d) (d) A step-parent family is determined financially ineligible for MA only; or
DHS 103.05(1)(e) (e) A step-parent family is determined ineligible for MA because a caretaker relative is a striker.
DHS 103.05(2) (2) Establishing child-only MA groups. In child-only cases, the child or children of each legal parent shall form their own MA group and shall be tested for financial eligibility with the children's own income and assets, if any, plus the income and assets deemed to the children of this group according to subs. (3) and (4).
DHS 103.05(3) (3) Deeming of parental assets.
DHS 103.05(3)(a) (a) All of the legal parent's nonexempt assets shall be deemed to the child in 3-generation and stepparent cases.
DHS 103.05(3)(b) (b) In cases of an SSI-related child where 2 parents are in the home, parental assets in excess of the SSI asset limit for 2 persons shall be deemed to the blind or disabled child. Where there is one parent, parental assets in excess of the SSI asset limit for one person shall be deemed to the blind or disabled child in accordance with 42 CFR 435.845.
DHS 103.05(4) (4) Deeming of parental income.
DHS 103.05(4)(a) (a) To the third-generation child. All of the net income of the second-generation minor parent shall be deemed to the third-generation child.
DHS 103.05(4)(b) (b) To the stepchild. The income deemed to the stepchild shall be the remainder of the total of the net income of the legal parent minus the categorically needy income standard based on the number of ineligible family members.
DHS 103.05(4)(c) (c) To the SSI-related child. The amount of parental monthly income deemed to the SSI-related child shall be determined according to the procedure set out in this paragraph. The department shall adjust the monthly amounts in accordance with changes in the SSI program. Beginning with unearned income, parental monthly gross income shall be deemed to each ineligible child to bring the child's income up to an amount equal to one-half the maximum federal share of the SSI benefit paid to a single individual living in his or her own household. The remaining parental income shall be deemed to the SSI-related child as follows:
DHS 103.05(4)(c)1. 1. When the only type of parental income remaining is unearned, $20 shall be subtracted. Then, where there are 2 parents, an amount equal to the maximum federal share of the SSI benefit paid to a couple living in their own household shall be subtracted, and where there is one parent, an amount equal to the maximum federal share of the SSI benefit paid to an individual living in his or her own household shall be subtracted. The remaining income shall be considered available to the SSI-related child as unearned income.
DHS 103.05(4)(c)2. 2. When the only type of parental income remaining is earned, $85 shall be subtracted. Then, where there are 2 parents, an amount equal to 3 times the maximum federal share of the SSI benefit paid to an individual living in his or her own household shall be subtracted, and where there is one parent, an amount equal to 2 times the maximum federal share of the SSI benefit paid to an individual living in his or her own household shall be subtracted. The remaining income shall be considered available to the SSI-related child as unearned income.
DHS 103.05(4)(c)3. 3. When parental income remaining is a mix of unearned and earned, $20 shall be subtracted using unearned income first. From any remaining earned income, $65 shall be subtracted and then one-half of the remainder. When there are 2 parents, an additional amount equal to the maximum federal share of the SSI benefit paid to a couple living in their own household shall be subtracted, and when there is one parent, an additional amount equal to the maximum federal share of the SSI benefit paid to an individual living in his or her own household shall be subtracted. The remaining income shall be considered available to the SSI-related child as unearned income.
DHS 103.05(5) (5) Income limits for child-only MA groups.
DHS 103.05(5)(a) (a) In third-generation and stepchild cases, each MA group shall be tested against an income standard consisting of a proportionate share of the AFDC-related standard for the appropriate family size. For purposes of this paragraph, “family" means parents and all children in the household for whom either spouse is legally responsible, including the third-generation, but not SSI recipients or NLRR children. If the stepchild or third-generation child is ineligible for MA because of excess income, the applicant may elect either a family spend-down period or a child-only spend-down period to gain MA eligibility.
DHS 103.05(5)(b) (b) The eligibility of an SSI-related child shall be determined by testing against the SSI-related income standard for one person.
DHS 103.05 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 103.06 DHS 103.06Assets.
DHS 103.06(1)(1)Special situations of institutionalized persons.
DHS 103.06(1)(a) (a) In determining the eligibility of an institutionalized person, only the assets actually available to that person shall be considered.
DHS 103.06(1)(b) (b) The homestead property of an institutionalized person is not counted as an asset if:
DHS 103.06(1)(b)1. 1. The institutionalized person's home is currently occupied by the institutionalized person's spouse or a dependent relative. In this subdivision,“dependent relative" means a son, daughter, grandson, granddaughter, stepson, stepdaughter, in-law, mother, father, stepmother, stepfather, grandmother, grandfather, aunt, uncle, sister, brother, stepbrother, stepsister, halfsister, halfbrother, niece, nephew or cousin who is financially, medically or otherwise dependent on the institutionalized person;
DHS 103.06(1)(b)2. 2. The institutionalized person intends to return to the home and the anticipated absence from the home, as verified by a physician, is less than 12 months; or
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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.