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. 49.155(1m)
(1m) Eligibility. A Wisconsin works agency shall determine eligibility for a child care subsidy under this section. Under this section, an individual may receive a subsidy for child care for a child who has not attained the age of 13 if the individual meets all of the following conditions:
49.155(1m)(a)
(a) The individual is a custodial parent of a child who is under the age of 13, or is a person who, under
s. 48.57 (3m), is providing care and maintenance for a child who is under the age of 13, and child care services for that child are needed in order for the individual to do any of the following:
49.155(1m)(a)2.
2. Work in an unsubsidized job, including training provided by an employer during the regular hours of employment.
49.155(1m)(a)4.
4. Participate in other employment skills training, including an English as a 2nd language course, if the Wisconsin works agency determines that the course would facilitate the individual's efforts to obtain employment; a course of study meeting the standards established by the secretary of education under
s. 115.29 (4) for the granting of a declaration of equivalency of high school graduation; a course of study at a technical college; or participation in educational courses that provide an employment skill, as determined by the department. An individual may receive aid under this subdivision for up to one year. An individual may not receive aid under this subdivision unless the individual meets at least one of the following conditions:
49.155(1m)(a)4.a.
a. The individual has been employed in unsubsidized employment for 9 consecutive months and continues to be so employed.
49.155(1m)(a)4.b.
b. The individual is a participant in a Wisconsin works employment position.
49.155(1m)(b)
(b) The individual meets the eligibility conditions under
s. 49.145 (2) (c) to
(g) and
(3) (a), except that an individual may be eligible for a child care subsidy under this section regardless of the number of days the individual has resided in this state prior to applying for the child care subsidy.
49.155(1m)(c)
(c) The gross income of the individual's family is at or below 165% of the poverty line for a family the size of the individual's family. In calculating the gross income of the family, the Wisconsin works agency shall include income described under
s. 49.145 (3) (b) 1. to
3.
49.155(1m)(d)
(d) The individual satisfies other eligibility criteria established by the department by rule.
49.155(3)(a)(a) A Wisconsin works agency shall refer an individual who has been determined eligible under
sub. (1m) to a county department under
s. 46.215,
46.22 or
46.23 for child care assistance.
49.155(3)(b)
(b) The county department under
s. 46.215,
46.22 or
46.23 shall administer child care assistance under this section. In administering child care assistance under this section, the county department under
s. 46.215,
46.22 or
46.23 shall do all of the following:
49.155(3)(b)2.
2. Provide a voucher to an eligible individual for the payment of child care services provided by a child care provider or otherwise reimburse child care providers.
49.155(3)(b)6.
6. Assist individuals who are eligible for child care subsidies under this section to identify available child care providers and select appropriate child care arrangements.
49.155(4)
(4) Choice of provider. An eligible individual shall choose whether the child care will be provided by a day care center licensed under
s. 48.65, a Level I certified family day care provider, a Level II certified family day care provider or a day care program provided or contracted for by a school board under
s. 120.13 (14).
49.155(5)
(5) Liability for payment. An individual is liable for the percentage of the cost of the child care that the department specified.
49.155(6)
(6) Child care rates and quality standards. 49.155(6)(a)(a) The department shall establish the maximum rate that a county department under
s. 46.215,
46.22 or
46.23 may pay for child care services provided under this section. The department shall set the rate so that at least 75% of the number of places for children within the licensed capacity of all child care providers in each county or in a multicounty area determined by the department can be purchased at or below that maximum rate.
49.155(6)(b)
(b) The department shall set a maximum rate that a county department under
s. 46.215,
46.22 or
46.23 may pay for Level I certified family day care providers for services provided to eligible individuals. The maximum rate set under this paragraph may not exceed 75% of the rate established under
par. (a).
49.155(6)(c)
(c) The department shall set a maximum rate that a county department under
s. 46.215,
46.22 or
46.23 may pay for Level II certified family day care providers for services provided to eligible individuals. The maximum rate set under this paragraph may not exceed 50% of the rate established under
par. (a).
49.155(6)(d)
(d) The department may establish a system of rates for child care programs that exceed the quality of care standards required for licensure under
s. 48.65 or for certification under
s. 48.651 (1) (a).
49.155(7)
(7) Refusal to pay child care providers. 49.155(7)(a)(a) The department or the county department under
s. 46.215,
46.22 or
46.23 may refuse to pay a child care provider for child care provided under this section if any of the following applies to the child care provider, employe or person living on the premises where child care is provided:
