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.
49.471(4)(b)4.b.
b. The individual's family income includes self-employment income and does not exceed 200 percent of the poverty line as calculated under
sub. (7) (a) 3.
49.471(4)(c)
(c) Except as otherwise provided in this section, a child who is not an unborn child and whose family income exceeds 300 percent of the poverty line is eligible to purchase coverage of the benefits described in
sub. (11), at the full per member per month cost of the coverage.
49.471(4)(d)
(d) An individual is eligible to purchase coverage of the benefits described in
sub. (11) for himself or herself and for his or her spouse and dependent children, at the full per member per month cost of coverage, if all of the following apply:
49.471(4)(d)1.
1. The individual lost his or her employer-sponsored health care coverage as a result of his or her employer's or former employer's bankruptcy.
49.471(4)(d)2.
2. After losing his or her employer-sponsored health care coverage, the individual received health care coverage through a voluntary employment benefit association that was established before August 2006.
49.471(4)(d)3.
3. The individual is not otherwise eligible for coverage under this section.
49.471(5)(a)1.
1. "Qualified entity" means an entity that satisfies the requirements under
42 USC 1396r-1a (b) (3) (A), as determined by the department.
49.471(5)(a)2.
2. "Qualified provider" means a provider that satisfies the requirements under
42 USC 1396r-1 (b) (2), as determined by the department.
49.471(5)(b)1.1. Except as provided in
sub. (6) (a) 1., a pregnant woman is eligible for the benefits specified in
par. (c) during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman's family income does not exceed 300 percent of the poverty line and ending on the applicable day specified in
subd. 3.
49.471(5)(b)2.
2. Except as provided in
sub. (6) (a) 2., a child who is not an unborn child is eligible for the benefits described in
s. 49.46 (2) (a) and
(b) during the period beginning on the day on which a qualified entity determines, on the basis of preliminary information, that the child's family income does not exceed 150 percent of the poverty line and ending on the applicable day specified in
subd. 3.
49.471(5)(b)3.a.a. If the woman or child applies for benefits under
sub. (4) within the time required under
par. (d), the benefits specified in
subd. 1. or
2., whichever is applicable, end on the day on which the department or the county department under
s. 46.215,
46.22, or
46.23 determines whether the woman or child is eligible for benefits under
sub. (4).
49.471(5)(b)3.b.
b. If the woman or child does not apply for benefits under
sub. (4) within the time required under
par. (d), the benefits specified in
subd. 1. or
2., whichever is applicable, end on the last day of the month following the month in which the provider or entity makes the determination under this paragraph.
49.471(5)(c)1.1. On behalf of a woman under
par. (b) 1. whose family income does not exceed 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under
s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits described in
s. 49.46 (2) (a) and
(b).
49.471(5)(c)2.
2. On behalf of a woman under
par. (b) 1. whose family income exceeds 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under
s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits under
sub. (11).
49.471(5)(d)
(d) A woman or child who is determined to be eligible under
par. (b) shall apply for benefits under
sub. (4) on or before the last day of the month following the month in which the qualified provider or entity makes the eligibility determination.
49.471(5)(e)
(e) A qualified provider or entity that determines that a woman or child is eligible under
par. (b) shall do all of the following:
49.471(5)(e)1.
1. Notify the department of that determination within 5 working days after the day on which the determination is made.
49.471(5)(e)2.
2. Notify the woman or child of the requirement under
par. (d) at the time of the determination.
49.471(5)(f)
(f) The department shall provide qualified providers and qualified entities with application forms for the benefits under
sub. (4) and information on how to assist women and children in completing the forms.
49.471(6)
(6) Miscellaneous eligibility and benefit provisions. 49.471(6)(a)1.1. Any pregnant woman, including a pregnant woman under
sub. (5) (b) 1., is eligible for medical assistance under this section for any of the 3 months prior to the month of application if she met the eligibility criteria under this section in that month.
49.471(6)(a)2.
2. Any child who is not an unborn child, including a child under
sub. (5) (b) 2., parent, or caretaker relative whose family income is less than 150 percent of the poverty line is eligible for medical assistance under this section for any of the 3 months prior to the month of application if the individual met the eligibility criteria under this section and had a family income of less than 150 percent of the poverty line in that month.
49.471(6)(b)
(b) A pregnant woman who is determined to be eligible for benefits under
sub. (4) remains eligible for benefits under
sub. (4) for the balance of the pregnancy and to the last day of the month in which the 60th day after the last day of the pregnancy falls without regard to any change in the woman's family income.
49.471(6)(c)
(c) If a child who is eligible for benefits under
sub. (4) is receiving inpatient services covered under
sub. (4) on the day before his or her 19th birthday and, but for attaining 19 years of age, the child would remain eligible for benefits under
sub. (4), the child remains eligible for benefits until the end of the stay for which the inpatient services are being furnished.
49.471(6)(d)
(d) If an application under this section shows that an individual is an essential person, the individual shall be provided the benefits specified under
sub. (4) (a) or
(b).
49.471(6)(f)
(f) The medical assistance eligibility provisions for migrant workers and their dependents under
s. 49.47 (4) (av) apply to BadgerCare Plus.
49.471(6)(g)1.1. Except as provided in
subd. 2., as a condition of eligibility for coverage under this section, an individual with income shall provide verification, as determined by the department, of that income.
49.471(6)(h)
(h) Within 10 days after the change occurs, a recipient shall report to the department any change that might affect his or her eligibility or any change that might require premium payment by a recipient who was not required to pay premiums before the change.
49.471(6)(i)
(i) For purposes of determining eligibility and family income, the department shall include a family member who is temporarily absent from the home for not more than 6 months, as determined by the department.
49.471(6)(j)
(j) All of the following apply to BadgerCare Plus in the same respect as they apply under
s. 49.46:
49.471(6)(j)2.
2. Section 49.46 (2) (d), relating to prohibiting payments for any part of any service payable through 3rd-party liability or any governmental or private benefit system.
49.471(6)(k)
(k) For an individual who is eligible for medical assistance under this section and who is eligible for coverage under Part D of Medicare under
42 USC 1395w-101 et seq., benefits under
sub. (11) (a) or
s. 49.46 (2) (b) 6. h. do not include payment for any Part D drug, as defined in
42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in
42 CFR 423.4, covers the Part D drug.
