49.47(4)(c)3.
3. Except as provided in
par. (am), no person is eligible for medical assistance under this section if the person's income exceeds the maximum income levels that the U.S. department of health and human services sets for federal financial participation under
42 USC 1396b (f).
49.47(4)(cm)1.1. Except as provided in
subd. 2., any individual who is otherwise eligible under this subsection and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for medical assistance and if the department determines it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor's behalf.
49.47(4)(cm)2.
2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with
subd. 1., the failure does not affect the minor's eligibility under this subsection.
49.47(4)(cm)3.
3. An individual who is otherwise eligible under this subsection and who has set aside funds in an irrevocable burial trust under
s. 445.125 (1) (a) 2. shall, as a condition of eligibility for medical assistance, specify the state as a secondary beneficiary of the trust with respect to all funds in the trust that exceed the burial costs but do not exceed the amount of medical assistance paid on behalf of the individual.
49.47(4)(d)
(d) An individual is eligible for medical assistance under this section for 3 months prior to the month of application if the individual met the eligibility criteria under this section during those months.
49.47(4)(e)
(e) Temporary absence of a resident from the state shall not be grounds for denying the certificate or for the cancellation of an existing certificate.
49.47(4)(f)
(f) An individual determined to be eligible for benefits under
par. (am) 1. remains eligible for benefits under
par. (am) 1. for the balance of the pregnancy and to the last day of the first month which ends at least 60 days after the last day of the pregnancy without regard to any change in the individual's family income.
49.47(4)(g)
(g) If a child eligible for benefits under
par. (am) 2. is receiving inpatient services covered under
sub. (6) on the day before the birthday on which the child attains the age of 6 and, but for attaining that age, the child would remain eligible for benefits under
par. (am) 2., the child remains eligible for benefits until the end of the stay for which the inpatient services are furnished.
49.47(4)(h)
(h) For the purposes of
par. (am), "income" includes income that would be used in determining eligibility for aid to families with dependent children under
s. 49.19 and excludes income that would be excluded in determining eligibility for aid to families with dependent children under
s. 49.19.
49.47(4)(i)1.1. The department shall request a waiver from the secretary of the federal department of health and human services to permit the application of
subd. 2. The waiver shall request approval to implement the waiver on a statewide basis, unless the department of health and family services determines that statewide implementation of the waiver would present an obstacle to the approval of the waiver by the secretary of the federal department of health and human services, in which case the waiver shall request approval to implement the waiver in 48 pilot counties to be selected by the department of health and family services. Within 30 days after August 12, 1993, the department of regulation and licensing shall notify funeral directors licensed under
ch. 445, cemetery associations, as defined in
s. 157.061 (1r), and cemetery authorities, as defined in
s. 157.061 (2), of the terms of the waiver required to be requested under this subdivision. If the waiver is approved by the secretary of the federal department of health and human services and if the waiver remains in effect,
subd. 2. shall apply.
49.47(4)(i)2.
2. Notwithstanding
par. (b) 2r. and
3., a person who is described in
par. (a) 3. or
4. is not eligible for benefits under this section if any of the following criteria is met:
49.47(4)(i)2.a.
a. For the person or his or her spouse, the sum of the following, less the cash value of any life insurance excluded under
par. (b) 2w. that was obtained after July 1, 1993, exceeds $8,000: the value of any burial space or agreement described in
par. (b) 2r. that was acquired after July 1, 1993; the amount in any irrevocable burial trust under
s. 445.125 (1) (a) that was acquired after July 1, 1993; and any funds set aside after July 1, 1993, to meet the burial and related expenses under
par. (b) 3.
49.47(4)(i)2.b.
b. The value of any burial space or agreement described in
par. (b) 2r. that is held for any other member of the person's immediate family and that was acquired after July 1, 1993, exceeds $8,000.
49.47(4)(i)2.c.
c. For the person or his or her spouse, the value of amounts set aside under
par. (b) 3. for cemetery property and fees to open and close grave sites, including mausoleum spaces, exceeds $1,000.
49.47(4)(j)
(j) If the change in the approved state plan under
s. 49.46 (1) (am) 2. is denied, the department shall request a waiver from the secretary of the federal department of health and human services to allow the use of federal matching funds to provide medical assistance coverage under
par. (am) 1. and
2. to individuals whose family incomes do not exceed 185% of the poverty line in each state fiscal year after the 1994-95 state fiscal year.
49.47(5)
(5) Investigation by department. The department may make additional investigation of eligibility:
49.47(5)(a)
(a) When there is reasonable ground for belief that an applicant may not be eligible or that the beneficiary may have received benefits to which the beneficiary is not entitled; or
49.47(5)(b)
(b) Upon the request of the secretary of the U.S. department of health and human services.
49.47(6)(a)(a) The department shall audit and pay charges to certified providers for medical assistance on behalf of the following:
49.47(6)(a)6.a.a. In this subdivision,"
entitled to coverage under part A of medicare" means eligible for and enrolled in part A of medicare under
42 USC 1395c to
1395f.
49.47(6)(a)6.ag.
ag. In this subdivision,"entitled to coverage under part B of medicare" means eligible for and enrolled in part B of medicare under
42 USC 1395j to
1395L.
49.47(6)(a)6.ar.
ar. In this subdivision,"income limitation" means income that is equal to or less than 100% of the poverty line, as established under
42 USC 9902 (2).
49.47(6)(a)6.b.
b. An individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare, meets the eligibility criteria under
sub. (4) (a) and meets the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums payable under
42 USC 1395v; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.47(6)(a)6.c.
c. An individual who is only entitled to coverage under part A of medicare, meets the eligibility criteria under
sub. (4) (a) and meets the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which are not paid under
42 USC 1395 to
1395i, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare.
49.47(6)(a)6.d.
d. An individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare and meets the eligibility criteria for medical assistance under
sub. (4) (a) but does not meet the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.47(6)(a)6.e.
e. An individual who is only entitled to coverage under part A of medicare and meets the eligibility criteria for medical assistance under
sub. (4) (a), but does not meet the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i, including those services that are not included in the approved state plan for services under
42 USC 1396.
49.47(6)(a)6.f.
f. For an individual who is only entitled to coverage under part B of medicare and meets the eligibility criteria under
sub. (4), but does not meet the income limitation, medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395j to
1395w, including those medicare services that are not included in the approved state plan for services under
42 USC 1396. Payment of coinsurance for a service under part B of medicare, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.47(6)(a)6m.
6m. An individual who is entitled to coverage under part A of medicare, as defined in
subd. 6. a. is entitled to coverage under part B of medicare, as defined in
subd. 6. ag. and meets the eligibility criteria under
sub. (4) (a) and whose income is greater than 100% of the poverty line but less than 120% of the poverty line for the monthly premiums under
42 USC 1395r.
49.47(6)(a)7.
7. Beneficiaries eligible under
sub. (4) (ag) 2. or
(am) 1., for services under
s. 49.46 (2) (a) and
(b) that are related to pregnancy, including postpartum services and family planning services, as defined in
s. 253.07 (1) (b), or related to other conditions which may complicate pregnancy.
49.47(6)(b)
(b) In no event may payments be made for medical assistance rendered during a period when the beneficiary would not have been eligible for benefits under this section.
49.47(6)(c)
(c) Benefits shall not include any payment with respect to:
49.47(6)(c)1.
1. Care or services in any private or public institution, unless the institution has been approved by a standard-setting authority responsible by law for establishing and maintaining standards for such institution.
49.47(6)(c)2.
2. That part of any service otherwise authorized under this section which is payable through 3rd party liability or any federal, state, county, municipal or private benefit systems, to which the beneficiary may otherwise be entitled.
49.47(6)(c)3.
3. Care or services for an individual who is an inmate of a public institution, except as a patient in a medical institution or a resident in an intermediate care facility.
49.47(6)(c)4.
4. Services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this subdivision, the department shall define "convalescent leave" and "conditional release" by rule.
49.47(6)(d)
(d) No payment under this subsection may include care for services rendered earlier than 3 months preceding the month of application.
49.47(7)
(7) Reduction of benefits. If the funds appropriated become or are estimated to be insufficient to make full payment of benefits provided under this section, all charges for service so authorized shall be prorated on the basis of funds available or by limiting the benefits provided.
49.47(8)
(8) Enrollment fee. As long as an enrollment fee or premium is required for persons receiving benefits under Title XIX of the social security act, the department shall charge the minimum enrollment fee or premium required under federal law. The fee or premium so charged shall be related to the beneficiary's income, in accordance with guidelines established by the secretary of the U.S. department of health and human services.
49.47(9m)
(9m) Eligibility for long-term care insurance beneficiaries. 49.47(9m)(b)
(b) A person who meets the eligibility requirements for medical assistance under
sub. (4) except that the person has liquid assets in excess of the limits under
sub. (4) (b) is eligible for medical assistance under this section if all of the following conditions are satisfied:
49.47(9m)(b)2.
2. The person is the beneficiary of a long-term care insurance policy that is certified to meet the standards set by the department by rule.
49.47(9m)(b)3.
3. The long-term care insurance policy paid for institutional or community-based long-term care services, or both, up to the limits specified in the long-term care insurance policy.
49.47(9m)(b)4.
4. The person required the services paid for under the long-term care insurance policy because of a severe limitation in activities of daily living or because of medical necessity, as defined by the department by rule.
49.47(9m)(b)5.
5. The amount of liquid assets retained by the person does not exceed the amount paid under the policy or the actual charges, whichever is lower, for the following services provided to the beneficiary that are reimbursed under the medical assistance program:
49.47(9m)(c)
(c) A person who seeks benefits under this subsection shall apply to an office of the department designated by the department.
49.47(9m)(d)
(d) Paragraphs (b) and
(c) do not apply unless the federal department of health and human services approves a waiver of federal medical assistance eligibility limits that authorizes federal financial participation in providing medical assistance benefits to persons eligible under
par. (b). If a waiver is approved, the department shall implement
pars. (b) and
(c) no later than 3 months after the date on which it is notified of that approval.
49.47 History
History: 1971 c. 125;
1971 c. 213 s.
5;
1971 c. 215;
1973 c. 90,
147,
333;
1977 c. 29 ss.
593,
1656 (18);
1977 c. 105 s.
59;
1977 c. 273,
418;
1979 c. 34;
1981 c. 20,
93;
1981 c. 314 s.
144;
1983 a. 27,
245;
1985 a. 29;
1987 a. 27,
307,
399,
413;
1989 a. 9;
1989 a. 31 ss.
1462k to
1466d,
2909c to
2909i;
1989 a. 173,
336,
351;
1991 a. 39,
178,
269,
316;
1993 a. 16,
269,
277,
437;
1995 a. 27 ss.
3026 to
3028,
9126 (19);
1995 a. 225,
289,
295;
1997 a. 27;
1999 a. 9;
2001 a. 16.
49.47 Cross-reference
Cross Reference: See also chs.
HFS 102,
103, and
107, Wis. adm. code.
49.47 Annotation
Compliance of state spend-down requirements with federal requirements are discussed. Swanson v. DHSS,
105 Wis. 2d 78,
312 N.W.2d 833 (Ct. App. 1981).
49.47 Annotation
Evaluating disability claims requires determining whether the claimant: 1) is working; 2) has significant impairments that significantly limit physical or mental ability to work; 3) has impairments that are federal "listed impairments;" 4) does not have "listed impairments" and can return to prior work; 5) cannot return to prior work but can perform other work. Clauer v. DHSS,
174 Wis. 2d 344,
497 N.W.2d 738 (Ct. App. 1993).
49.47 Annotation
Section 49.46 (1) (b) and sub. (6) (d) limit retroactive medical assistance payments to services received not more than three months prior to the date the application was submitted. St. Paul Ramsey Medical Center v. DHSS,
186 Wis. 2d 37,
519 N.W.2d 706 (Ct. App. 1994).
49.47 Annotation
A regulation that "deemed" resources of one spouse to be "available" to the other was valid. Schweiker v. Gray Panthers,
453 U.S. 34 (1981).
49.472
49.472
Medical assistance purchase plan. 49.472(1)(am)
(am) "Family" means an individual, the individual's spouse and any dependent child, as defined in
s. 49.141 (1) (c), of the individual.
49.472(1)(b)
(b) "Health insurance" means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.
49.472(1)(c)
(c) "Independence account" means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which an individual began receiving medical assistance under this section.
49.472(1)(d)
(d) "Medical assistance purchase plan" means medical assistance, eligibility for which is determined under this section.
49.472(2)
(2) Waivers and amendments. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.
49.472(3)
(3) Eligibility. Except as provided in
sub. (6) (a), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:
49.472(3)(a)
(a) The individual's family's net income is less than 250% of the poverty line for a family the size of the individual's family. In calculating the net income, the department shall apply all of the exclusions specified under
42 USC 1382a (b).
49.472(3)(b)
(b) The individual's assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under
42 USC 1382b (a) or assets accumulated in an independence account. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.
49.472(3)(c)
(c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under
42 USC 1396d (q) (2) (B) and (D).
49.472(3)(e)
(e) The individual is legally able to work in all employment settings without a permit under
s. 103.70.
49.472(3)(f)
(f) The individual maintains premium payments calculated by the department in accordance with
sub. (4), unless the individual is exempted from premium payments under
sub. (4) (b) or
(5).
49.472(3)(g)
(g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals.
49.472(3)(h)
(h) The individual meets all other requirements established by the department by rule.
49.472(4)(a)(a) Except as provided in
par. (b) and
sub. (5), an individual who is eligible for medical assistance under
sub. (3) and receives medical assistance shall pay a monthly premium to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:
49.472(4)(a)1.
1. The premium for any individual may not exceed the sum of the following:
49.472(4)(a)1.a.
a. Three and one-half percent of the individual's earned income after the disregards specified in
subd. 2m.
49.472(4)(a)1.b.
b. One hundred percent of the individual's unearned income after the deductions specified in
subd. 2.
49.472(4)(a)2.
2. In determining an individual's unearned income under
subd. 1., the department shall disregard all of the following:
49.472(4)(a)2.a.
a. A maintenance allowance established by the department by rule. The maintenance allowance may not be less than the sum of $20, the federal supplemental security income payment level determined under
42 USC 1382 (b) and the state supplemental payment determined under
s. 49.77 (2m).
