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 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;
2005 a. 25,
253;
2007 a. 11, a.
20 ss.
1596 to
1604,
9121 (6) (a);
2009 a. 28,
180.
49.47 Cross-reference
Cross-reference: See also chs.
DHS 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).
49.471
49.471
BadgerCare Plus. 49.471(1)(1)
Definitions. In this section, unless the context requires otherwise:
49.471(1)(a)
(a) "BadgerCare Plus" means the Medical Assistance program described in this section.
49.471(1)(b)
(b) "Caretaker relative" means an individual who is maintaining a residence as a child's home, who exercises primary responsibility for the child's care and control, including making plans for the child, and who is any of the following with respect to the child:
49.471(1)(b)1.
1. A blood relative, including those of half-blood, and including first cousins, nephews, nieces, and individuals of preceding generations as denoted by prefixes of grand, great, or great-great.
49.471(1)(b)2.
2. A stepfather, stepmother, stepbrother, or stepsister.
49.471(1)(b)3.
3. An individual who is the adoptive parent of the child's parent, a natural or legally adopted child of such individual, or a relative of an adoptive parent.
49.471(1)(b)4.
4. A spouse of any individual named in this paragraph even if the marriage is terminated by death or divorce.
49.471(1)(c)
(c) "Child" means an individual who is under the age of 19 years. "Child" includes an unborn child.
49.471(1)(d)
(d) "Essential person" means an individual who satisfies all of the following:
49.471(1)(d)1.
1. Is related to an individual receiving benefits under this section.
49.471(1)(d)2.
2. Is otherwise nonfinancially eligible, except that the individual need not have a minor child under his or her care.
49.471(1)(d)3.
3. Provides at least one of the following to an individual receiving benefits under this section:
49.471(1)(d)3.a.
a. Child care that enables a caretaker to work outside the home for at least 30 hours per week for pay, to receive training for at least 30 hours per week, or to attend, on a full-time basis as defined by the school, high school or a course of study meeting the standards established by the state superintendent of public instruction for the granting of a declaration of equivalency of high school graduation under
s. 115.29 (4).
49.471(1)(e)
(e) "Family" means all children for whom assistance is requested, their minor siblings, including half brothers, half sisters, stepbrothers, and stepsisters, and any parents of these minors and their spouses.
49.471(1)(f)
(f) "Family income" means the total gross earned and unearned income received by all members of a family.
49.471(1)(h)
(h) "Health insurance coverage" has the meaning given in
42 USC 300gg-91 (b) (1), and also includes any arrangement under which a 3rd party agrees to pay for the health care costs of the individual.
49.471(1)(j)
(j) "Recipient" means an individual receiving benefits under this section.
49.471(1)(k)
(k) "Unborn child" means an individual from conception until he or she is born alive for whom all of the following requirements are met:
49.471(1)(k)1.
1. The unborn child's mother is not eligible for medical assistance under this subchapter, except that she may be eligible for benefits under
s. 49.45 (27).
49.471(1)(k)2.
2. The income of the unborn child's mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 300 percent of the poverty line.
49.471(1)(k)3.
3. Each of the following applicable persons who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings:
49.471(1)(k)4.
4. The unborn child's mother provides medical verification of her pregnancy, in the manner specified by the department. An unborn child's eligibility for coverage under this section does not begin before the first day of the month in which the unborn child's mother provides the medical verification.
49.471(1)(k)5.
5. The unborn child and the mother of the unborn child meet all other applicable eligibility requirements under this chapter or established by the department by rule except for any of the following:
49.471(1)(k)5.c.
c. The mother does not provide a social security number, but only if
subd. 5. a. applies.
49.471(2)
(2) Waiver and state plan amendments. The department shall request a waiver from, and submit amendments to the state Medical Assistance plan to, the secretary of the federal department of health and human services to implement BadgerCare Plus. If the state plan amendments are approved and a waiver that is substantially consistent with the provisions of this section, excluding
sub. (2m), is granted and in effect, the department shall implement BadgerCare Plus beginning on January 1, 2008, the effective date of the state plan amendments, or the effective date of the waiver, whichever is latest. If the state plan amendments are approved but the terms of approval do not allow for federal funding of the cost of benefits for all or any part of one or more of the eligibility categories under
sub. (4) (b), the department may at its discretion pay for the cost of benefits for all or any part of any group for which federal funding was denied exclusively with moneys from the appropriation under
s. 20.435 (4) (b). If the state plan amendments are not approved or if a waiver that is substantially consistent with the provisions of this section, excluding
sub. (2m), is not granted, BadgerCare Plus may not be implemented. If the state plan amendments are approved but approval is not continued or if a waiver that is substantially consistent with the provisions of this section, excluding
sub. (2m), is granted but not continued in effect, BadgerCare Plus shall be discontinued.
49.471(2m)
(2m) Approval to qualify as a health coverage tax credit plan. The department shall seek any necessary federal approvals to ensure that BadgerCare Plus is qualified health insurance under
26 USC 35 (e). Notwithstanding
subs. (4) and
(5), if BadgerCare Plus is determined to be qualified health insurance under
26 USC 35 (e), the department shall expand eligibility under BadgerCare Plus to include individuals who are eligible individuals under
26 USC 35 (c). Notwithstanding
sub. (10) (a) and
(b) 1. to
4., individuals who are eligible for coverage under BadgerCare Plus under this subsection shall pay premiums that are equal to the capitation payments that the department would make on behalf of similar individuals with coverage under BadgerCare Plus, or the full per member per month cost of coverage, whichever is appropriate.
49.471(3)
(3) Ineligibility for other Medical Assistance benefits. 49.471(3)(a)1.1. Notwithstanding
ss. 49.46 (1),
49.465,
49.47 (4), and
49.665 (4), if the amendments to the state plan under
sub. (2) are approved and a waiver under
sub. (2) that is substantially consistent with the provisions of this section, excluding
sub. (2m), is granted and in effect, an individual described in
sub. (4) (a) or
(b) or
(5) is not eligible under
s. 49.46,
49.465,
49.47, or
49.665 for Medical Assistance or BadgerCare health program benefits. The eligibility of an individual described in
sub. (4) (a) or
(b) or
(5) for Medical Assistance benefits shall be determined under this section.
49.471(3)(a)2.
2. Notwithstanding
subd. 1., an individual who is eligible for medical assistance under
s. 49.46 (1) (a) 3. or
4. may not receive benefits under this section.
49.471(3)(b)1.1. If an individual over 18 years of age who is eligible for and receiving Medical Assistance benefits under
s. 49.46,
49.47, or
49.665 in the month before BadgerCare Plus is implemented loses that eligibility solely due to the implementation of BadgerCare Plus and, because of his or her income, is not eligible for BadgerCare Plus, the individual shall continue receiving for 12 consecutive months the medical assistance he or she was receiving before the implementation of BadgerCare Plus if all of the following are satisfied:
49.471(3)(b)1.a.
a. The individual's eligibility for the Medical Assistance benefits in the month before the implementation of BadgerCare Plus was based on an application filed before the implementation of BadgerCare Plus.
49.471(3)(b)1.b.
b. The individual continues to pay any premium that he or she was required to pay for the Medical Assistance coverage in the same amount as the amount that was due in the month before the implementation of BadgerCare Plus.
49.471(3)(b)1.c.
c. The individual meets all nonfinancial eligibility requirements under this section.
49.471(3)(b)1.d.
d. The individual continues to be ineligible for BadgerCare Plus because of his or her income.
49.471(3)(b)2.
2. Notwithstanding
subd. 1., if at any time during an individual's 12-month eligibility extension under
subd. 1. any criterion under
subd. 1. a. to
d. is not satisfied, the individual's eligibility for the extended coverage is terminated and any time remaining in the eligibility period is lost.
49.471(4)
(4) General eligibility criteria; applicable benefits. 49.471(4)(a)(a) Except as otherwise provided in this section, all of the following individuals are eligible for the benefits described in
s. 49.46 (2) (a) and
(b), subject to
sub. (6) (k):
49.471(4)(a)1.
1. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
49.471(4)(a)2.
2. A child who is under one year of age, whose mother was, on the day the child was born, eligible for and receiving medical assistance under
subd. 1. or
5. or
s. 49.46 or
49.47, and who lives with his or her mother in this state.
49.471(4)(a)3.
3. A child whose family income does not exceed 200 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care.
49.471(4)(a)4.
4. An individual who satisfies all of the following criteria:
49.471(4)(a)4.a.
a. The individual is a parent or caretaker relative of a child who is living in the home with the parent or caretaker relative or who is temporarily absent from the home for not more than 6 months or, if the child has been removed from the home for more than 6 months, the parent or caretaker relative is working toward unifying the family by complying with a permanency plan under
s. 48.38 or
938.38.
49.471(4)(a)4.b.
b. Except as provided in
subd. 4. c., the individual's family income does not exceed 200 percent of the poverty line and does not include self-employment income.
49.471(4)(a)4.c.
c. If the individual's family income includes self-employment income, the individual's family income does not exceed 200 percent of the poverty line as calculated under
sub. (7) (a) 2.
49.471(4)(a)5.
5. An individual who, regardless of family income, was born on or after January 1, 1990, and who, on his or her 18th birthday, was in a foster care or treatment foster care placement under the responsibility of a state, as determined by the department. The coverage for an individual under this subdivision ends on the last day of the month in which the individual becomes 21 years of age, unless he or she otherwise loses eligibility sooner.
Effective date note
NOTE: Subd. 5. is amended by
2009 Wis. Act 28 eff. the date stated in the notice provided by the secretary of children and families and published in the Wisconsin Administrative Register under s. 48.62 (9) to read:
Effective date text
5. An individual who, regardless of family income, was born on or after January 1, 1990, and who, on his or her 18th birthday, was in a foster care placement under the responsibility of a state, as determined by the department. The coverage for an individual under this subdivision ends on the last day of the month in which the individual becomes 21 years of age, unless he or she otherwise loses eligibility sooner.
49.471(4)(a)7.
7. Individuals who qualify for a medical assistance eligibility extension under
s. 49.46 (1) (c),
(cg), or
(co) when their income increases above the poverty line.
49.471(4)(b)
(b) Except as otherwise provided in this section, all of the following individuals are eligible for the benefits described in
sub. (11):
49.471(4)(b)1.
1. A pregnant woman whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line.
49.471(4)(b)2.
2. A child who is under one year of age, whose mother was determined to be eligible under
subd. 1., and who lives with his or her mother in this state.
49.471(4)(b)3.
3. A child whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care.
49.471(4)(b)4.
4. An individual who satisfies all of the following criteria:
49.471(4)(b)4.a.
a. The individual is a parent or caretaker relative of a child who is living in the home with the parent or caretaker relative or who is temporarily absent from the home for not more than 6 months or, if the child has been removed from the home for more than 6 months, the parent or caretaker relative is working toward unifying the family by complying with a permanency plan under
s. 48.38 or
938.38.
