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b. Except as provided in subd. 4. c., the individual's family income does not
20exceed 200 percent of the poverty line and does not include self-employment income.
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c. If the individual's family income includes self-employment income, the
22individual's family income does not exceed 200 percent of the poverty line as
23calculated under sub. (7) (a) 2.
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5. An individual who, regardless of family income, was born on or after January
251, 1990, and who, on his or her 18th birthday, was in a foster care or treatment foster
1care placement under the responsibility of a state, as determined by the department.
2The coverage for an individual under this subdivision ends on the last day of the
3month in which the individual becomes 21 years of age, unless he or she otherwise
4loses eligibility sooner.
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6. Migrant workers and their dependents who are determined eligible under
6sub. (6) (f).
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(b) Except as otherwise provided in this section, all of the following individuals
8are eligible for the benefits described in sub. (11):
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1. A pregnant woman whose family income exceeds 200 percent but does not
10exceed 300 percent of the poverty line.
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1m. A pregnant woman or unborn child who obtains eligibility under sub. (7)
12(b) 1.
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2. A child who is under one year of age, whose mother was determined to be
14eligible under subd. 1., and who lives with his or her mother in this state.
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3. A child whose family income exceeds 200 percent but does not exceed 300
16percent of the poverty line. For a child under this subdivision who is an unborn child,
17benefits are limited to prenatal care.
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4. An individual who satisfies all of the following criteria:
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a. The individual is a parent or caretaker relative of a child who is living in the
20home with the parent or caretaker relative or who is temporarily absent from the
21home for not more than 6 months or, if the child has been removed from the home for
22more than 6 months, the parent or caretaker relative is working toward unifying the
23family by complying with a permanency plan under s. 48.38.
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b. The individual's family income includes self-employment income and does
25not exceed 200 percent of the poverty line as calculated under sub. (7) (a) 3.
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1(c) Except as otherwise provided in this section, a child who is not an unborn
2child and whose family income exceeds 300 percent of the poverty line is eligible to
3purchase coverage of the benefits described in sub. (11), at the full per member per
4month cost of the coverage.
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5(5) Presumptive eligibility. (a) In this subsection:
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1. "Qualified entity" means an entity that satisfies the requirements under
42
7USC 1396r-1a (b) (3) (A), as determined by the department.
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2. "Qualified provider" means a provider that satisfies the requirements under
942 USC 1396r-1 (b) (2), as determined by the department.
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(b) 1. Except as provided in sub. (6) (a), a pregnant woman is eligible for the
11benefits specified in par. (c) during the period beginning on the day on which a
12qualified provider determines, on the basis of preliminary information, that the
13woman's family income does not exceed 300 percent of the poverty line and ending
14on the applicable day specified in subd. 3.
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2. Except as provided in sub. (6) (a), a child who is not an unborn child is eligible
16for the benefits described in s. 49.46 (2) (a) and (b) during the period beginning on
17the day on which a qualified entity determines, on the basis of preliminary
18information, that the child's family income does not exceed 150 percent of the poverty
19line and ending on the applicable day specified in subd. 3.
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3. a. If the woman or child applies for benefits under sub. (4) within the time
21required under par. (d), the benefits specified in subd. 1. or 2., whichever is
22applicable, end on the day on which the department or the county department under
23s. 46.215, 46.22, or 46.23 determines whether the woman or child is eligible for
24benefits under sub. (4).
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1b. If the woman or child does not apply for benefits under sub. (4) within the
2time required under par. (d), the benefits specified in subd. 1. or 2., whichever is
3applicable, end on the last day of the month following the month in which the
4provider or entity makes the determination under this paragraph.
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(c) On behalf of a woman under par. (b) 1., the department shall audit and pay
6allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory
7prenatal care services under the benefits under sub. (11).
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(d) A woman or child who is determined to be eligible under par. (b) shall apply
9for benefits under sub. (4) on or before the last day of the month following the month
10in which the qualified provider or entity makes the eligibility determination.
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(e) A qualified provider or entity that determines that a woman or child is
12eligible under par. (b) shall do all of the following:
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1. Notify the department of that determination within 5 working days after the
14day on which the determination is made.
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2. Notify the woman or child of the requirement under par. (d) at the time of
16the determination.
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(f) The department shall provide qualified providers and qualified entities with
18application forms for the benefits under sub. (4) and information on how to assist
19women and children in completing the forms.
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20(6) Miscellaneous eligibility and benefit provisions. (a) Any pregnant
21woman, including a pregnant woman under sub (5) (b) 1., child who is not an unborn
22child, including a child under sub. (5) (b) 2., parent, or caretaker relative whose
23family income is less than 150 percent of the poverty line is eligible for medical
24assistance under this section for any of the 3 months prior to the month of application
1if the individual met the eligibility criteria under this section and had a family
2income of less than 150 percent of the poverty line in that month.
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(b) A pregnant woman who is determined to be eligible for benefits under sub.
4(4) remains eligible for benefits under sub. (4) for the balance of the pregnancy and
5to the last day of the month in which the 60th day after the last day of the pregnancy
6falls without regard to any change in the woman's family income.
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(c) If a child who is eligible for benefits under sub. (4) is receiving inpatient
8services covered under sub. (4) on the day before his or her 19th birthday and, but
9for attaining 19 years of age, the child would remain eligible for benefits under sub.
10(4), the child remains eligible for benefits until the end of the stay for which the
11inpatient services are being furnished.
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(d) If an application under this section shows that an individual is an essential
13person, the individual shall be provided the benefits specified under sub. (4) (a) or
14(b).
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(e) The medical assistance eligibility extensions under s. 49.46 (1) (c), (cg), and
16(co) for individuals who lose eligibility due to increased income do not apply to
17BadgerCare Plus.
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(f) The medical assistance eligibility provisions for migrant workers and their
19dependents under s. 49.47 (4) (av) apply to BadgerCare Plus.
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(g) 1. Except as provided in subd. 2., as a condition of eligibility for coverage
21under this section, an individual with income shall provide verification, as
22determined by the department, of that income.
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2. Subdivision 1. does not apply to an individual under sub. (4) (a) 5. or a child
24under the age of 18.
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1(h) Within 10 days after the change occurs, a recipient shall report to the
2department any change that might affect his or her eligibility or any change that
3might require premium payment by a recipient who was not required to pay
4premiums before the change.
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(i) For purposes of determining eligibility and family income, the department
6shall include a family member who is temporarily absent from the home for not more
7than 6 months, as determined by the department.
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(j) All of the following apply to BadgerCare Plus in the same respect as they
9apply under s. 49.46:
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1. Section 49.46 (2) (c) and (cm), relating to benefits for individuals who are
11eligible for Medicare.
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2. Section 49.46 (2) (d), relating to prohibiting payments for any part of any
13service payable through 3rd-party liability or any governmental or private benefit
14system.
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3. Section 49.46 (2) (dm), relating to prohibiting payment for services to
16residents of institutions for mental diseases.
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4. Section 49.46 (2) (f), relating to prohibiting payment for gastric bypass or
18stapling surgery.
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(k) For an individual who is eligible for medical assistance under this section
20and who is eligible for coverage under Part D of Medicare under
42 USC 1395w-101 21et seq., benefits under sub. (11) (a) or s. 49.46 (2) (b) 6. h. do not include payment for
22any Part D drug, as defined in
42 CFR 423.100, regardless of whether the individual
23is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her
24Part D plan, as defined in
42 CFR 423.4, covers the Part D drug.
SB40,737,5
1(7) Special income provisions. (a) 1. In the calculation of family income, if an
2adult member of the family has self-employment income, the department shall count
3the net self-employment earnings. Net self-employment earnings shall be
4determined by subtracting from gross self-employment income all self-employment
5expenses that are allowed under federal and state tax law, except for depreciation.
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2. If a parent's or caretaker relative's family income includes self-employment
7income and, without deducting depreciation, does not exceed 200 percent of the
8poverty line, the parent or caretaker relative is eligible under sub. (4) (a) 4.
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3. If a parent's or caretaker relative's family income includes self-employment
10income and, without deducting depreciation, exceeds 200 percent of the poverty line,
11the parent or caretaker relative is eligible under sub. (4) (b) 4. if his or her family
12income does not exceed 200 percent of the poverty line after depreciation is deducted.
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(b) 1. A pregnant woman, or an unborn child, whose family income exceeds 300
14percent of the poverty line may become eligible for coverage under this section if the
15difference between the pregnant woman's or unborn child's family income and the
16applicable income limit under sub. (4) (b) is obligated or expended for any member
17of the pregnant woman's or unborn child's family for medical care or any other type
18of remedial care recognized under state law or for personal health insurance
19premiums or for both. Eligibility obtained under this subdivision continues without
20regard to any change in family income for the balance of the pregnancy and, for a
21pregnant woman but not for an unborn child, to the last day of the month in which
22the 60th day after the last day of the woman's pregnancy falls. Eligibility obtained
23by a pregnant woman under this subdivision extends to all pregnant women in the
24pregnant woman's family.
SB40,738,8
12. A child who is not an unborn child and whose family income exceeds 150
2percent of the poverty line may obtain eligibility under this section if the difference
3between the child's family income and 150 percent of the poverty line is obligated or
4expended on behalf of the child or any member of the child's family for medical care
5or any other type of remedial care recognized under state law or for personal health
6insurance premiums or for both. Eligibility obtained under this subdivision during
7any 6-month period, as determined by the department, continues for the remainder
8of the 6-month period and extends to all children in the family.
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3. For a pregnant woman or an unborn child to obtain eligibility under subd.
101., the amount that must be obligated or expended in any 6-month period is equal
11to the sum of the differences in each of those 6 months between the pregnant woman's
12or unborn child's monthly family income and the monthly family income that is 300
13percent of the poverty line. For a child to obtain eligibility under subd. 2., the amount
14that must be obligated or expended in any 6-month period is equal to the sum of the
15differences in each of those 6 months between the child's monthly family income and
16the monthly family income that is 150 percent of the poverty line.
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(c) When calculating an individual's family income, the department shall do all
18of the following:
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1. Deduct from family income any payments made by the individual for
20court-ordered child or family support or maintenance.
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2. Disregard earnings of children under 18 years of age.
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3. Determine separately the family incomes of caretaker relatives and the
23children for whom they are caring and not legally responsible.
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4. Not include in the calculation any income of an individual receiving benefits
25under s. 49.77 or federal Title XVI.
SB40,739,6
1(8) Health insurance coverage and eligibility. (a) 1. Except as provided in
2subd. 2., any individual who is otherwise eligible under this section and who is
3eligible for enrollment in a group health plan shall, as a condition of eligibility for
4BadgerCare Plus and if the department determines that it is cost-effective to do so,
5apply for enrollment in the group health plan, except that, for a minor, the parent
6of the minor shall apply on the minor's behalf.
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2. If a parent of a minor fails to enroll the minor in a group health plan in
8accordance with subd. 1., the failure does not affect the minor's eligibility under this
9section.
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(b) Except as provided in pars. (c) and (d), an individual whose family income
11exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of
12the following applies:
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1. The individual has individual or family health insurance coverage that is any
14of the following:
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a. Coverage provided by an employer and for which the employer pays at least
1680 percent of the premium.
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b. Coverage under the state employee health plan under s. 40.51 (6).
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2. The individual, in the 12 months before applying, had access to the health
19insurance coverage specified in subd. 1.
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3. The individual could be covered under the health insurance coverage
21specified in subd. 1. if the coverage is applied for, and the coverage could become
22available to the individual in the month in which the individual applies for benefits
23under this section or in any of the next 3 calendar months.
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(c) An unborn child, regardless of family income, is not eligible for BadgerCare
25Plus if any of the following applies:
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11. The unborn child or the unborn child's mother has individual or family
2health insurance coverage.
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2. The unborn child or the unborn child's mother, in the 12 months before
4applying, had access to the health insurance coverage specified in par. (b) 1.
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3. The unborn child or the unborn child's mother could be covered under
6individual or family health insurance coverage if the coverage is applied for, and the
7coverage could become available to the unborn child or the unborn child's mother in
8the month in which the unborn child applies for benefits under this section or in any
9of the next 3 calendar months.
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(d) 1. None of the following is ineligible for BadgerCare Plus by reason of having
11health insurance coverage or access to health insurance coverage:
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a. A pregnant woman.
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b. A child described in sub. (4) (a) 2. or (b) 2.
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c. Except as provided in par. (c), a child who has health insurance coverage, or
15access to health insurance coverage, as a dependent of an absent parent but who
16resides outside of the service area of the absent parent's plan.
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d. An individual described in sub. (4) (a) 5.
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e. A child who obtains eligibility under sub. (7) (b) 2., but only for the remainder
19of the child's eligibility period under sub. (7) (b) 2.
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2. An individual under par. (b) 2., or an individual who is an unborn child or
21an unborn child's mother under par. (c) 2., is not ineligible if any of the following good
22cause reasons is the reason that the individual did not obtain the health insurance
23coverage under par. (b) 1. to which they had access:
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a. The individual's employment ended.
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1b. The individual's employer discontinued health insurance coverage for all
2employees.
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c. One or more members of the individual's family were eligible for other health
4insurance coverage or Medical Assistance at the time the employee failed to enroll
5in the health insurance coverage under par. (b) 1. and no member of the family was
6eligible for coverage under this section at that time.
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d. The individual's access to health insurance coverage has ended due to the
8death or change in marital status of the subscriber.
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e. Any other reason that the department determines is a good cause reason.
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(e) If a pregnant woman has health insurance coverage and her family income
11exceeds 200 percent of the poverty line, the woman is required, as a condition of
12eligibility, to maintain the health insurance coverage.
SB40,741,2013
(f) If an individual with a family income that exceeds 150 percent of the poverty
14line had the health insurance coverage specified in par. (b) 1. but no longer has the
15coverage, if an individual who is an unborn child or an unborn child's mother,
16regardless of family income, had health insurance coverage but no longer has the
17coverage, or if a pregnant woman specified in par. (e) has health insurance coverage
18and does not maintain the coverage, the individual or pregnant woman is not eligible
19for BadgerCare Plus for the 3 calendar months following the month in which the
20insurance coverage ended without a good cause reason specified in par. (g).
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(g) Any of the following is a good cause reason for purposes of par. (f):
SB40,742,222
1. The individual or pregnant woman was covered by a group health plan that
23was provided by a subscriber through his or her employer, and the subscriber's
24employment ended for a reason other than voluntary termination, unless the
1voluntary termination was a result of the incapacitation of the subscriber or because
2on an immediate family member's health condition.
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2. The individual or pregnant woman was covered by a group health plan that
4was provided by a subscriber through his or her employer, the subscriber changed
5employers, and the new employer does not offer health insurance coverage.
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3. The individual or pregnant woman was covered by a group health plan that
7was provided by a subscriber through his or her employer, and the subscriber's
8employer discontinued health plan coverage for all employees.
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4. The pregnant woman's coverage was continuation coverage and the
10continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
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5. The individual's or pregnant woman's coverage terminated due to the death
12or change in marital status of the subscriber.
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6. Any other reason determined by the department to be a good cause reason.
SB40,742,18
14(9) Employer verification of insurance coverage. (a) 1. Except as provided
15in subd. 2., for an applicant or recipient with a family income that exceeds 150
16percent of the poverty line, the department shall verify insurance coverage and
17access information directly with the employer through which the applicant or
18recipient may have health insurance coverage or access to coverage.
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2. Subdivision 1. does not apply to any of the following: