49.153(1)(a)
(a) "Employer-subsidized health care coverage" means a health care plan, which provides coverage of health care costs, offered by the employer for which the employer pays at least 50% of the cost of the plan for the employe, including dependent coverage and excluding any deductibles or copayments that may be required under the plan.
49.153(1)(b)
(b) "Unsubsidized employer-offered health care coverage" means a health care plan, which provides coverage of health care costs, offered by the employer for which the employer pays less than 50% of the cost of coverage for the employe, including dependent coverage and excluding any deductibles or copayments that may be required under the plan.
49.153(2)
(2) Administration. The department of health and family services shall provide health services and benefits under
sub. (4) to individuals who have been determined by a Wisconsin works agency to be eligible under
subs. (3) to
(3p) for such services and benefits. The Wisconsin works agency shall maintain a list of eligible individuals and shall make the list available to the department of health and family services upon request.
49.153(3)(a)1.1. A Wisconsin works agency shall determine eligibility for benefits and services under this section, in accordance with rules promulgated by the department of health and family services in consultation with the department of industry, labor and job development. The Wisconsin works agency shall make the eligibility determination after the date on which the agency receives a completed application from the individual for services and benefits under this section and shall immediately notify the department of health and family services of that determination. An individual who applies for and receives benefits and services under this section is considered to have assigned to the state any rights to medical support or other payment of medical expenses from any other person, including rights to unpaid amounts accrued at the time of application for benefits and services under this section and any rights to support accruing during the time for which benefits and services under this section are provided. Eligibility for benefits and services under this section begins on the day on which the department of health and family services or the provider issues a health plan membership card. The department of health and family services or the provider shall issue the health plan membership card to an individual after the date on which the Wisconsin works agency notifies the department of health and family services that the individual is eligible.
49.153(3)(a)2.a.a. Except as provided in
subd. 3. and
pars. (em) and
(f), an individual who is eligible for the health care coverage under this section remains eligible under this section for 12 consecutive months or until the individual has access to unsubsidized employer-offered health care coverage, whichever is later.
49.153(3)(a)2.b.
b. Notwithstanding
subd. 2. a., an individual who is described under
par. (f) 1. a.,
b.,
c. or
d. who is eligible for health care coverage under this section remains eligible until the individual no longer meets eligibility criteria, as provided in
subd. 3.
49.153(3)(a)3.
3. A Wisconsin works agency shall, within the period of an individual's eligibility, as specified under
subd. 2., periodically review an individual's eligibility. The individual remains eligible for benefits and services under this section until any of the following applies:
49.153(3)(a)3.a.
a. The assets of the individual or, if the individual is a member of a Wisconsin works group, the assets of the Wisconsin works group of which the individual is a member, exceed the asset limits for at least 2 months.
49.153(3)(a)3.b.
b. The income of the individual, or, if the individual is a member of a Wisconsin works group, the income of the Wisconsin works group of which the individual is a member, is expected to exceed the income limits for at least 2 consecutive months.
49.153(3)(e)
(e)
Access to employer-subsidized health care coverage. An individual is eligible for health care coverage under this section only if the individual has not had access to employer-subsidized health care coverage within the 18 months immediately preceding application for health care coverage under this section. This paragraph does not apply to any of the following:
49.153(3)(e)1.
1. An individual who has lost access to employer-subsidized health care coverage within the 18 months immediately preceding application for health care coverage under this subsection because of the termination by the employer of the employment relationship for a reason other than misconduct on the part of the employe and who has not had access to employer-subsidized health care coverage since the termination.
49.153(3)(e)2.
2. An individual who has lost access to employer-subsidized health care coverage within the 18 months immediately preceding application for health care coverage under this subsection because of the termination by the employe of the employment relationship for just cause.
49.153(3)(e)3.
3. A dependent child who has lost eligibility for employer-subsidized health care coverage for any reason.
49.153(3)(e)3m.
3m. A pregnant woman with an income equal to or less than 165% of the poverty line who has lost eligibility for employer-subsidized health care coverage for any reason.
49.153(3)(e)4.
4. A participant in a Wisconsin works employment position.
49.153(3)(em)
(em)
Continuous coverage requirement. An individual who withdraws from health care coverage under this section while the individual is still eligible for health care coverage under this section is ineligible for health care coverage under this section for a period of 6 months following the withdrawal.
49.153(3)(f)
(f)
Ineligibility. No individual is eligible for health care coverage under this section in a month in which any of the following applies:
49.153(3)(f)1.
1. The individual is eligible for employer-subsidized health care coverage. This subdivision does not apply to any of the following:
49.153(3)(f)1.a.
a. A pregnant woman in a Wisconsin works group with an income that is equal to or less than 165% of the poverty line.
49.153(3)(f)1.b.
b. A child who has not attained the age of 6 in a Wisconsin works group with an income equal to or less than 165% of the poverty line.
49.153(3)(f)1.c.
c. A child who has attained the age of 6 and has not attained the age of 12 in a Wisconsin works group with an income that is equal to or less than 100% of the poverty line.
49.153(3)(f)1.d.
d. A child who has attained the age of 6 and has not attained the age of 12 in a Wisconsin works group with an income in excess of 100% of the poverty line if the total amount obligated or expended for medical care or other type of remedial care and for health insurance premiums, when subtracted from the Wisconsin works group's income, places the Wisconsin works group at or below 100% of the poverty line.
49.153(3)(f)2.
2. The individual fails to pay the established premium in a timely manner, as defined by the department of industry, labor and job development by rule.
49.153(3g)
(3g) Eligible groups. Subject to the requirements under
sub. (3), the following individuals are eligible for benefits and services under this section:
49.153(3g)(a)
(a)
Wisconsin works groups. Except as provided in
par. (c), an individual who is a member of a Wisconsin works group, if all of the following conditions apply:
49.153(3g)(a)3.
3. The gross income of the Wisconsin works group is at or below 165% of the poverty line, or, for a Wisconsin works group that is already receiving health care coverage under this section, the gross income is at or below 200% of the poverty line. In calculating the gross income of the Wisconsin works group, the Wisconsin works agency shall include income described under
s. 49.145 (3) (b) 1. to
3.
49.153(3g)(b)
(b)
Pregnant women. A pregnant woman whose pregnancy has been medically verified and who has no dependent children, if she meets all of the following conditions:
49.153(3g)(b)3.
3. The gross income of the woman is at or below 165% of the poverty line. In calculating gross income under this subdivision, the Wisconsin works agency shall include income described under
s. 49.145 (3) (b) 1. and
3.
49.153(3g)(c)
(c)
Minor parents. An individual who is a custodial parent and who is under the age of 18, and any dependent children with respect to whom the individual is a custodial parent, only if the individual meets one of the following conditions:
49.153(3g)(c)1.
1. The individual resides with his or her custodial parent and the gross income of the Wisconsin works group of which the individual is a member does not exceed 165% of the poverty line. In calculating the gross income of the Wisconsin works group, the Wisconsin works agency shall include income described under
s. 49.145 (3) (b) 1. to
3.
49.153(3g)(c)2.
2. The individual is in an independent living arrangement supervised by an adult and the gross income of the individual does not exceed 165% of the poverty line. In calculating the gross income of the individual, the Wisconsin works agency shall include income described under
s. 49.145 (3) (b) 1. to
3.
49.153(3m)(am)(am) Notwithstanding
sub. (3) (a) 2. a.,
(e) and
(f) 1., if the individual is a pregnant woman or a child who has not attained the age of 6, and the individual meets all of the requirements of
sub. (3g) (a),
(b) or
(c), except that the income calculated for the individual under
sub. (3g) (a) 3.,
(b) 3. or
(c) 1. or
2. exceeds the applicable income limit under
sub. (3g) (a) 3.,
(b) 3. or
(c) 1. or
2., the individual is eligible for benefits and services under this section if all of the excess income above the applicable limit has been obligated or expended for medical care or other type of remedial care or for personal health insurance premiums.
49.153(3m)(as)
(as) Notwithstanding
sub. (3) (a) 2. a., if the individual is a child who has attained the age of 6 and has not attained the age of 12, and the individual meets all of the requirements of
sub. (3g) (a) except that the income calculated for the individual under
sub. (3g) (a) 3. exceeds the income level under
sub. (3g) (a) 3., the individual is eligible for benefits and services under this section if the total amount obligated or expended for medical care or other type of remedial care and for health insurance premiums, when subtracted from the Wisconsin works group's income, places the Wisconsin works group at 100% of the poverty line.
49.153(3m)(b)
(b) In determining the income for an individual under this subsection for purposes of determining the premium amount under
sub. (4) (d), the Wisconsin works agency shall exclude the excess income specified under
par. (am) or
(as).
49.153(3p)
(3p) Presumptive eligibility for pregnant women. 49.153(3p)(a)(a) Notwithstanding
sub. (3g) (a),
(b) and
(c), a pregnant woman is eligible under this subsection for ambulatory prenatal care services under this section during the period beginning on the day on which an authorized health care provider under contract under
sub. (4) (a) determines, on the basis of preliminary information, that the woman's family income does not exceed 165% of the poverty line and that the woman's family's assets do not exceed the asset limits under
s. 49.145 (3) (a). Eligibility under this subsection ends as follows:
49.153(3p)(a)1.
1. If the woman applies under
sub. (3g) (a),
(b) or
(c) for benefits and services under this section within the time required under
par. (c), on the day on which the Wisconsin works agency determines whether the woman is eligible for benefits and services under
sub. (3g) (a),
(b) or
(c).
49.153(3p)(a)2.
2. If the woman does not apply under
sub. (3g) (a),
(b) or
(c) for benefits and services under this section within the time required under
par. (c), on the last day of the month following the month in which the health care provider makes the determination under this paragraph.
49.153(3p)(c)
(c) A woman who is determined to be eligible under this subsection shall apply under
sub. (3g) (a),
(b) or
(c) for benefits and services under this section within 14 days after the date on which the health care provider makes that determination.
49.153(3p)(cm)
(cm) A woman who receives services under this subsection is liable for a monthly premium payable in the amount and in the manner prescribed under
sub. (4) (d) beginning with the first month in which she receives those services.
49.153(3p)(d)
(d) A health care provider under contract under
sub. (4) (a) that determines that a woman is eligible under this subsection for benefits and services under this section shall do all of the following:
49.153(3p)(d)1.
1. Notify the Wisconsin works agency of that determination within 5 working days after the day on which the determination is made.
49.153(3p)(e)
(e) The Wisconsin works agency shall provide health care providers under contract under
sub. (4) (a) with application forms for benefits and services under this section and information on how to assist women in completing the forms.
49.153(3p)(f)
(f) No provider may make more than one eligibility determination under this subsection with respect to an individual.
49.153(4)(a)(a)
Health maintenance organization contract. The department of health and family services shall contract with health maintenance organizations or other health care providers, including federally qualified health centers, to provide health care services under this subsection. A health maintenance organization or other health care provider that contracts under this subsection shall meet the certification criteria established by the department of health and family services under
s. 49.45 (2) (a) 11.
49.153(4)(b)1.1. Except as provided in
subd. 2., the Wisconsin works health plan shall cover the care and services specified under
s. 49.46 (2).
49.153(4)(b)1m.
1m. The Wisconsin works health plan shall cover in-home psychotherapy for individuals who are under the age of 21 if the in-home psychotherapy is prescribed pursuant to a physical examination under
42 USC 1396 (r) (1).
49.153(4)(b)1s.
1s. The Wisconsin works health plan shall cover insulin if it is prescribed by a physician.
49.153(4)(b)2.
2. Except as otherwise required under a federal waiver received under
42 USC 1315, the Wisconsin works health plan shall not cover the following goods and services:
49.153(4)(b)2.d.
d. Treatment of alcoholism or other drug abuse problems in excess of the minimum coverage required under
s. 632.89 (2).
49.153(4)(bm)1.a.
a. "Abortion" means the intentional destruction of the life of an unborn child.
49.153(4)(bm)1.b.
b. "Unborn child" means a human being from the time of conception until it is born alive.
49.153(4)(bm)2.
2. Except as provided in
subd. 3., each contract that is entered into under
par. (a) shall explicitly provide that it does not include coverage for the performance of an abortion.
49.153(4)(bm)3.a.
a. The performance by a physician of an abortion which is directly and medically necessary to save the life of the woman or in a case of sexual assault or incest, provided that prior thereto the physician signs a certification which so states, and provided that, in the case of sexual assault or incest the crime has been reported to the law enforcement authorities. The certification shall be affixed to the claim form or invoice when submitted to any agency or fiscal intermediary of the state for payment or when submitted by an individual health care provider to the coverage provider for payment or for submittal to any agency or fiscal intermediary of the state for payment, and shall specify and attest to the direct medical necessity of the abortion upon the best clinical judgment of the physician or attest to his or her belief that sexual assault or incest has occurred.
49.153(4)(bm)3.b.
b. The performance by a physician of an abortion if, due to a medical condition existing prior to the abortion, the physician determines that the abortion is directly and medically necessary to prevent grave, long-lasting physical health damage to the woman, provided that prior thereto the physician signs a certification which so states. The certification shall be affixed to the claim form or invoice when submitted to any agency or fiscal intermediary of the state for payment or when submitted by an individual health care provider to the coverage provider for payment or for submittal to any agency or fiscal intermediary of the state for payment, and shall specify and attest to the direct medical necessity of the abortion upon the best clinical judgment of the physician.
49.153(4)(bm)3.c.
c. The authorization or payment of funds to a physician or surgeon or a hospital, clinic or medical facility for or in connection with the prescription of a drug or the insertion of a device to prevent the implantation of a fertilized ovum.
49.153(4)(bm)4.
4. Quarterly, as determined by the department of health and family services, following any annual quarter in which health care services have been provided under coverage that is affected by this paragraph, the coverage provider shall submit a written report to the agency which contracted for the services of the provider. The report shall specify the number of abortions provided in the previous quarter by the provider to individuals who have coverage for the abortion under this subsection, as permitted under
subd. 3. a. or
b., the reason for each abortion, and the total cost of each abortion.
49.153(4)(bm)5.
5. A copy of each report submitted under
subd. 4. shall be forwarded to the department of health and family services, which shall review the data for compliance with this paragraph and annually publish a summary of the information obtained under this subdivision.
49.153(4)(c)
(c)
Distribution of payments. From the appropriations under
s. 20.435 (1) (b) and
(o), the department of health and family services shall make payments to a health maintenance organization or other health care provider with which the department of health and family services has contracted under
par. (a) in accordance with a payment schedule established by contract.
49.153(4)(d)1.1. An individual who receives the Wisconsin works health plan shall pay, in the manner prescribed in
subd. 3., the monthly premium that the department of health and family services specified.
49.153(4)(d)3.a.
a. For a participant in a trial job, the Wisconsin works agency shall deduct the premium from the subsidy that is paid to the employer under
s. 49.147 (3) (a). The employer shall deduct the premium from the trial job participant's wages.
49.153(4)(d)3.b.
b. For a participant in a community service job or transitional placement, the Wisconsin works agency shall deduct the premium from the participant's monthly grant amount under
s. 49.148 (1) (b) or
(c).
49.153(4)(d)3.c.
c. For an individual not specified under
subd. 3. a. or
b., the individual shall pay the premium directly to the Wisconsin works agency, or, if the individual and his or her employer agree, the individual's employer may deduct the premium from the individual's payroll and pay the premium to the Wisconsin works agency.
49.153(4)(d)4.
4. The Wisconsin works agency shall remit to the department of industry, labor and job development in the manner prescribed by the department of industry, labor and job development all premium payments that the Wisconsin works agency receives under this paragraph.
49.153 History
History: 1995 a. 289.
49.155
49.155
Wisconsin works; child care subsidy.
