AB40,577,2321 a. Access to individual or family health coverage provided by an employer in
22which the monthly premium that an employee would pay for an employee-only
23policy does not exceed 9.5 percent of the family's monthly income.
AB40,577,2524 b. Access to individual or family health coverage under the state employee
25health plan.
AB40,578,2
12. The individual has access to any coverage described in subd. 1. during any
2of the following times:
AB40,578,43 a. The 12 months before the first day of the month in which an individual
4applies for and the month in which an individual applies for BadgerCare Plus.
AB40,578,65 b. The 3 months after the last day of the month in which the individual applies
6for BadgerCare Plus.
AB40,578,87 c. The month including the date of the annual determination of the individual's
8eligibility for Medical Assistance.
AB40,578,109 3. The individual does not have as a reason for not obtaining health insurance
10any of the good cause reasons under par. (d) 2. a. to e.
AB40,1128 11Section 1128. 49.471 (8) (cr) of the statutes is created to read:
AB40,578,1412 49.471 (8) (cr) 1. Subject to subd. 4., an individual who is any of the following
13is not eligible for BadgerCare Plus if the criteria under par. (cg) 1. and 2. apply to that
14individual:
AB40,578,1715 a. An individual who is not disabled and who is a child, or unborn child, of an
16individual whose family income is at a level determined by the department but no
17lower than 133 percent of the poverty line.
AB40,578,2018 b. A parent or caretaker relative who is not disabled, not pregnant, and an adult
19and whose family income is at a level determined by the department but no lower
20than 100 percent of the poverty line.
AB40,578,2421 c. An adult, including a pregnant individual, who is not disabled, who is under
2226 years of age; who is eligible to be covered under coverage a parent receives from
23an employer; and whose family income is at a level determined by the department
24but no lower than 100 percent of the poverty line.
AB40,579,3
12. An individual under subd. 1. is not ineligible if any of the good cause reasons
2described in par. (d) 2. a. to e. is the reason that the individual did not obtain health
3insurance coverage.
AB40,579,54 3. An individual under subd. 1. c. is not ineligible if any of the following good
5cause reasons is the reason the individual did not obtain health insurance coverage:
AB40,579,86 a. The parent of the individual is no longer employed by the employer through
7which the parent was eligible for coverage, and the parent does not have current
8coverage.
AB40,579,109 b. The employer of the parent of the individual discontinued providing health
10benefits to all employees.
AB40,579,1311 4. The department may apply this paragraph to eligibility determinations for
12BadgerCare Plus only if the federal department of health and human services
13approves of the conditions to make that individual ineligible, if approval is required.
AB40,1129 14Section 1129. 49.471 (8) (ct) of the statutes is created to read:
AB40,579,2115 49.471 (8) (ct) 1. If the federal department of health and human services
16approves the department's request to add private major medical insurance as a type
17of coverage which causes ineligibility, an individual who is not disabled and not
18pregnant, who is over 18 years of age, whose family income exceeds 133 percent of
19the poverty line, and who has coverage provided by private major medical insurance
20in which the monthly premium does not exceed 9.5 percent of the family's monthly
21income is not eligible for BadgerCare Plus.
AB40,579,2522 2. If the federal department of health and human services approves of the
23conditions to make that individual ineligible for BadgerCare Plus, an individual who
24is any of the following is not eligible for BadgerCare Plus if he or she has the major
25medical insurance coverage described under subd. 1.:
AB40,580,3
1a. An individual who is not disabled and who is a child, or unborn child, of an
2individual whose family income is at a level determined by the department but no
3lower than 133 percent of the poverty line.
AB40,580,64 b. A parent or caretaker relative who is not disabled, not pregnant, and an adult
5and whose family income is at a level determined by the department but no lower
6than 100 percent of the poverty line.
AB40,1130 7Section 1130. 49.471 (8) (d) 1. a. of the statutes is amended to read:
AB40,580,98 49.471 (8) (d) 1. a. A pregnant woman, except as provided in pars. (cr) 1. c. and
9(fm) 4
.
AB40,1131 10Section 1131. 49.471 (8) (d) 1. b. of the statutes is amended to read:
AB40,580,1111 49.471 (8) (d) 1. b. A child described in sub. (4) (a) 2. or (b) 2.
AB40,1132 12Section 1132. 49.471 (8) (d) 1. g. of the statutes is created to read:
AB40,580,1313 49.471 (8) (d) 1. g. An adult who is disabled.
AB40,1133 14Section 1133. 49.471 (8) (d) 2. dg. of the statutes is created to read:
AB40,580,1615 49.471 (8) (d) 2. dg. The insurance is owned by someone not residing with the
16family and continuation of the coverage is beyond the family's control.
AB40,1134 17Section 1134. 49.471 (8) (d) 2. dr. of the statutes is created to read:
AB40,580,1918 49.471 (8) (d) 2. dr. The insurance only covers services provided in a service
19area that is beyond a reasonable driving distance.
AB40,1135 20Section 1135. 49.471 (8) (e) of the statutes is repealed.
AB40,1136 21Section 1136. 49.471 (8) (f) of the statutes is amended to read:
AB40,581,522 49.471 (8) (f) If an individual with a family income that exceeds 150 percent
23of the poverty line had the health insurance coverage specified in par. (b) 1. but no
24longer has the coverage, or if an individual who is an unborn child or an unborn
25child's mother, regardless of family income, had health insurance coverage but no

1longer has the coverage, or if a pregnant woman specified in par. (e) has health
2insurance coverage and does not maintain the coverage
, the individual or pregnant
3woman
is not eligible for BadgerCare Plus for the 3 calendar months following the
4month in which the insurance coverage ended without a good cause reason specified
5in par. (g).
AB40,1137 6Section 1137. 49.471 (8) (fm) of the statutes is created to read:
AB40,581,117 49.471 (8) (fm) If an individual who is one of the following individuals had the
8health insurance coverage specified in par. (cg) 1. or (ct) but no longer has the
9coverage, the individual is not eligible for BadgerCare Plus for the 3 calendar months
10following the month in which the insurance coverage ended without a good cause
11reason specified in par. (g):
AB40,581,1312 1. An individual who is not disabled and not pregnant, who is over 18 years of
13age, and whose family income exceeds 133 percent of the poverty line.
AB40,581,1714 2. If the federal department of health and human services approves of the
15department's request to make such an individual ineligible, an individual who is not
16disabled and who is a child of an individual whose family income is at a level
17determined by the department but no lower than 133 percent of the poverty line.
AB40,581,2218 3. If the federal department of health and human services approves of the
19department's request to make such an individual ineligible, a parent or caretaker
20relative who is not disabled, not pregnant, and an adult and whose family income is
21at a level determined by the department but no lower than 100 percent of the poverty
22line.
AB40,582,323 4. If the federal department of health and human services approves of the
24department's request to make such an individual ineligible, an adult, including a
25pregnant individual, who is not disabled, who is under 26 years of age; who is eligible

1to be covered under coverage a parent receives from an employer; and whose family
2income is at a level determined by the department but no lower than 100 percent of
3the poverty line.
AB40,1138 4Section 1138. 49.471 (8) (g) (intro.), 1., 2., 3., 4. and 5. of the statutes are
5amended to read:
AB40,582,76 49.471 (8) (g) (intro.) Any of the following is a good cause reason for purposes
7of par. pars. (f) and (fm):
AB40,582,128 1. The individual or pregnant woman was covered by a group health plan that
9was provided by a subscriber through his or her employer, and the subscriber's
10employment ended for a reason other than voluntary termination, unless the
11voluntary termination was a result of the incapacitation of the subscriber or because
12of an immediate family member's health condition.
AB40,582,1513 2. The individual or pregnant woman was covered by a group health plan that
14was provided by a subscriber through his or her employer, the subscriber changed
15employers, and the new employer does not offer health insurance coverage.
AB40,582,1816 3. The individual or pregnant woman was covered by a group health plan that
17was provided by a subscriber through his or her employer, and the subscriber's
18employer discontinued health plan coverage for all employees.
AB40,582,2019 4. The pregnant woman's individual's coverage was continuation coverage and
20the continuation coverage was exhausted in accordance with 29 CFR 2590.701-2 (4).
AB40,582,2221 5. The individual's or pregnant woman's coverage terminated due to the death
22or change in marital status of the subscriber.
AB40,1139 23Section 1139. 49.471 (8) (g) 5g. of the statutes is created to read:
AB40,582,2524 49.471 (8) (g) 5g. The insurance coverage is owned by someone not residing
25with the family and continuation of the coverage is beyond the family's control.
AB40,1140
1Section 1140. 49.471 (8) (g) 5r. of the statutes is created to read:
AB40,583,32 49.471 (8) (g) 5r. The insurance coverage only covers services provided in a
3service area that is beyond a reasonable driving distance.
AB40,1141 4Section 1141. 49.471 (9) (a) 2. b. of the statutes is amended to read:
AB40,583,55 49.471 (9) (a) 2. b. A child described in sub. (4) (a) 2. or (b) 2.
AB40,1142 6Section 1142. 49.471 (10) (b) 1. of the statutes is amended to read:
AB40,583,137 49.471 (10) (b) 1. Except as provided in subd. subds. 1m. and 4., a recipient who
8is an adult, who is not a pregnant woman, and whose family income is greater than
9150 percent but not greater than 200 percent of the poverty line shall pay a premium
10for coverage under BadgerCare Plus that does not exceed 5 percent of his or her
11family income. If the recipient has self-employment income and is eligible under
12sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated
13before depreciation was deducted.
AB40,1143 14Section 1143 . 49.471 (10) (b) 1. of the statutes, as affected by 2013 Wisconsin
15Act .... (this act), is amended to read:
AB40,583,2216 49.471 (10) (b) 1. Except as provided in subds. 1m. and 4., a recipient who is
17an adult, who is not a pregnant woman, and whose family income is greater than 150
18percent but not greater than 200 percent of the poverty line shall pay a premium for
19coverage under BadgerCare Plus that does not exceed 5 percent of his or her family
20income. If the recipient has self-employment income and is eligible under sub. (4)
21(b) 4., the premium may not exceed 5 percent of family income calculated before
22depreciation was deducted.
AB40,1144 23Section 1144. 49.471 (10) (b) 1m. of the statutes is created to read:
AB40,584,724 49.471 (10) (b) 1m. Except as provided in subd. 4., a recipient who is an adult
25parent or adult caretaker relative; who is not disabled, pregnant, or American

1Indian; and whose family income exceeds 133 percent of the federal poverty line shall
2pay a premium for coverage under BadgerCare Plus in an amount determined by the
3department that is based on a formula in which costs decrease for those with lower
4family incomes and that is no less than 3 percent of family income but no greater than
59.5 percent of family income. If the recipient has self-employment income and is
6eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income
7calculated before depreciation was deducted.
AB40,1145 8Section 1145 . 49.471 (10) (b) 1m. of the statutes, as affected by 2013 Wisconsin
9Act .... (this act), is repealed.
AB40,1146 10Section 1146. 49.471 (10) (b) 2. of the statutes is amended to read:
AB40,584,1511 49.471 (10) (b) 2. Except as provided in subds. 3. 3m. and 4., a recipient who
12is a child whose family income is greater than 200 percent of the poverty line shall
13pay a premium for coverage of the benefits described in sub. (11) that does not exceed
14the full per member per month cost of coverage for a child with a family income of
15300 percent of the poverty line.
AB40,1147 16Section 1147. 49.471 (10) (b) 3. of the statutes is repealed.
AB40,1148 17Section 1148. 49.471 (10) (b) 3m. of the statutes is created to read:
AB40,584,2318 49.471 (10) (b) 3m. A recipient who is a child, who is not disabled, and whose
19family income is at a level determined by the department that is at least 150 percent
20of the poverty line shall pay a premium in an amount determined by the department.
21The department may apply this subdivision only to the extent the federal
22department of health and human services approves applying a premium to those
23individuals, if approval is required.
AB40,1149 24Section 1149. 49.471 (10) (b) 4. (intro.) of the statutes is amended to read:
AB40,585,2
149.471 (10) (b) 4. (intro.) None of the following shall pay a premium, except as
2provided in subd. 3m.
:
AB40,1150 3Section 1150. 49.471 (10) (b) 4. b. of the statutes is amended to read:
AB40,585,44 49.471 (10) (b) 4. b. A child who is eligible under sub. (4) (a) 2. or (b) 2.
AB40,1151 5Section 1151. 49.471 (10) (b) 5. of the statutes is amended to read:
AB40,585,186 49.471 (10) (b) 5. If a recipient who is required to pay a premium under this
7paragraph or under sub. (2m) or (4) (c) either does not pay a premium when due or
8requests that his or her coverage under this section be terminated, the recipient's
9coverage terminates and. If the recipient is an adult, the recipient is not eligible for
10BadgerCare Plus for 6 12 consecutive calendar months following the date on which
11the recipient's coverage terminated, except for any month during that 6-month
1212-month period when the recipient's family income does not exceed 150 133 percent
13of the poverty line. If the recipient is a child, the recipient is not eligible for
14BadgerCare Plus for 6 consecutive calendar months, or 12 consecutive calendar
15months if the federal department of health and human services approves, following
16the date on which the recipient's coverage terminated, except for any month during
17that period when the recipient's family income does not exceed 150 percent of the
18poverty line.
AB40,1152 19Section 1152 . 49.471 (10) (b) 5. of the statutes, as affected by 2013 Wisconsin
20Act .... (this act), is amended to read:
AB40,586,721 49.471 (10) (b) 5. If a recipient who is required to pay a premium under this
22paragraph or under sub. (2m) or (4) (c) either does not pay a premium when due or
23requests that his or her coverage under this section be terminated, the recipient's
24coverage terminates. If the recipient is an adult, the recipient is not eligible for
25BadgerCare Plus for 12 consecutive calendar months following the date on which the

1recipient's coverage terminated, except for any month during that 12-month period
2when the recipient's family income does not exceed 133 percent of the poverty line.
3If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 6
4consecutive calendar months, or 12 consecutive calendar months if the federal
5department of health and human services approves, following the date on which the
6recipient's coverage terminated, except for any month during that period when the
7recipient's family income does not exceed 150 percent of the poverty line.
AB40,1153 8Section 1153. 49.471 (11) (intro.) of the statutes is amended to read:
AB40,586,129 49.471 (11) Benchmark plan benefits and copayments. (intro.) Recipients
10Except as provided in sub. (11r) and s. 49.45 (24j), recipients who are not eligible for
11the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following
12benefits and pay the following copayments:
AB40,1154 13Section 1154. 49.471 (11) (a) of the statutes is amended to read:
AB40,586,1614 49.471 (11) (a) Subject to sub. (6) (k), prescription drugs bearing only a generic
15name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per
16prescription, and subject to the Badger Rx Gold program discounts.
AB40,1155 17Section 1155. 49.471 (11r) of the statutes is created to read:
AB40,586,2118 49.471 (11r) Alternate Benchmark plan benefits and copayments. (a) If the
19department chooses to provide the alternate benchmark plan under this subsection,
20the department shall provide to the recipients described under sub. (4) (e) coverage
21for benefits similar to those in a commercial, major medical insurance policy.
AB40,587,322 (b) The department may charge copayments to recipients receiving coverage
23under the alternate benchmark plan under this subsection that are higher than
24copayments charged to recipients receiving coverage under the standard plan under
25s. 49.46 (2). The department may not charge to a recipient of coverage under the

1alternate benchmark plan under this subsection whose family income is at or below
2150 percent of the poverty line a copayment that exceeds 5 percent of the individual's
3family income for all members of the family.
AB40,587,64 (c) 1. The department may only provide coverage under the alternate
5benchmark plan under this subsection to the extent the alternate benchmark plan
6is approved by the federal department of health and human services.
AB40,587,107 2. If the department is providing coverage under the alternate benchmark plan
8under this subsection the department may discontinue coverage under the
9benchmark plan under sub. (11) for those individuals eligible for the alternate
10benchmark plan under this subsection.
AB40,587,1311 3. The department may provide services to individuals enrolled in the alternate
12benchmark plan under this subsection through a medical home initiative similar to
13an initiative described under s. 49.45 (24j).
AB40,1156 14Section 1156. 49.472 (1) (c) of the statutes is amended to read:
AB40,587,1815 49.472 (1) (c) "Independence account" means an account approved by the
16department that consists solely of savings, and dividends or other gains derived from
17those savings, from income earned from paid employment after the initial date on
18which
while an individual began is receiving medical assistance under this section.
AB40,1157 19Section 1157. 49.472 (3) (a) of the statutes is amended to read:
AB40,588,220 49.472 (3) (a) The individual's family's and his or her spouse's total net income
21is less than 250% of the poverty line for a family the size of the individual's family.
22In For purposes of calculating the net income under this paragraph, the department
23shall apply all of the exclusions specified under 42 USC 1382a (b) , except that
24exclusions applied under 42 USC 1382a (b) (4) to earned income shall be applied to
25earned and unearned income combined, and shall exclude up to $500 per month of

1the individual's out-of-pocket medical and remedial expenses and long-term care
2costs, if any
.
AB40,1158 3Section 1158. 49.472 (3) (b) of the statutes is amended to read:
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