49.471(11m)
(11m) Provider payments and requirements. The provider of a service or equipment under
sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under
sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under
sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under
sub. (11) to a recipient who is unable to share costs as specified in
sub. (11), the recipient is not relieved of liability for those costs.
49.471(12)(a)1.1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.
49.471(12)(a)2.
2. The department may promulgate emergency rules under
s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under
subd. 1., but not to exceed the period authorized under
s. 227.24 (1) (c) and
(2). Notwithstanding
s. 227.24 (1) (a),
(2) (b), and
(3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.
49.471(12)(b)
(b) If the amendments to the state plan submitted under
sub. (2) are approved and a waiver that is substantially consistent with the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.
49.471 History
History: 2007 a. 20;
2009 a. 28,
180,
219.
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).
49.472(4)(a)2.b.
b. Medical and remedial expenses and impairment-related work expenses.
49.472(4)(a)2m.
2m. If the disregards under
subd. 2. exceed the unearned income against which they are applied, the department shall disregard the remainder in calculating the individual's earned income.
49.472(4)(a)3.
3. The department may reduce the premium by 25% for an individual who is covered by private health insurance.
49.472(4)(b)
(b) The department may waive monthly premiums that are calculated to be below $10 per month. The department may not assess a monthly premium for any individual whose income level, after adding the individual's earned income and unearned income, is below 150% of the poverty line.
49.472(5)
(5) Community options participants. From the appropriation under
s. 20.435 (7) (bd), the department may pay all or a portion of the monthly premium calculated under
sub. (4) (a) for an individual who is a participant in the community options program under
s. 46.27 (11).
49.472(6)(a)(a) Notwithstanding
sub. (4) (a) 3., from the appropriation account under
s. 20.435 (4) (b) or
(w), the department shall, on the part of an individual who is eligible for medical assistance under
sub. (3), pay premiums for or purchase individual coverage offered by the individual's employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.
49.472(6)(b)
(b) If federal financial participation is available, from the appropriation account under
s. 20.435 (4) (b) or
(w), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under
sub. (3).
49.472(7)
(7) Department duties. The department shall do all of the following:
49.472(7)(a)
(a) Determine eligibility, or contract with a county department, as defined in 49.45 (6c) (a) 3., or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with
sub. (3).
49.472(7)(b)
(b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.
49.472 Cross-reference
Cross-reference: See also chs.
DHS 103 and
107 and s.
DHS 103.087, Wis. adm. code.
49.473
49.473
Medical assistance; women diagnosed with breast or cervical cancer or precancerous conditions. 49.473(2)
(2) A woman is eligible for medical assistance as provided under
sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:
49.473(2)(c)
(c) The woman is not eligible for health care coverage that qualifies as creditable coverage in
42 USC 300gg (c), excluding the coverage specified in
42 USC 300gg (c) (1) (F).
49.473(2)(d)
(d) The woman has been screened for breast or cervical cancer under a breast and cervical cancer early detection program that is authorized under a grant received under
42 USC 300k.
49.473(2)(e)
(e) The woman requires treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix.
49.473(3)
(3) Prior to applying to the department or a county department for medical assistance, a woman is eligible for medical assistance as provided under
sub. (5) beginning on the date on which a qualified entity determines, on the basis of preliminary information, that the woman meets the requirements specified in
sub. (2) and ending on one of the following dates:
49.473(3)(a)
(a) If the woman applies to the department or a county department for medical assistance within the time limit required under
sub. (4), the day on which the department or county department determines whether the woman meets the requirements under
sub. (2).
49.473(3)(b)
(b) If the woman does not apply to the department or county department for medical assistance within the time limit required under
sub. (4), the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(4)
(4) A woman who a qualified entity determines under
sub. (3) is eligible for medical assistance shall apply to the department or county department no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(5)
(5) The department shall audit and pay, from the appropriation accounts under
s. 20.435 (4) (b) and
(o), allowable charges to a provider who is certified under
s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under
sub. (2) for all benefits and services specified under
s. 49.46 (2).
49.473(6)
(6) A qualified entity that determines under
sub. (3) that a woman is eligible for medical assistance as provided under
sub. (5) shall do all of the following:
49.473(6)(a)
(a) Notify the department of the determination no later than 5 days after the date on which the determination is made.
49.473(6)(b)
(b) Inform the woman at the time of the determination that she is required to apply to the department or a county department for medical assistance no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(7)
(7) The department shall provide qualified entities with application forms for medical assistance and information on how to assist women in completing the form.
49.475
49.475
Information about medical assistance beneficiaries. 49.475(1)(ag)
(ag) "Covered entity" means any of the following that is not an insurer:
49.475(1)(ag)2.
2. An employer, as defined in
s. 101.01 (4), labor union, or other group of persons organized in this state if the employer, labor union, or other group provides prescription drug coverage to covered individuals who reside or are employed in this state.
49.475(1)(ag)3.
3. A comprehensive or limited health care benefits program administered by the state that provides prescription drug coverage.
49.475(1)(am)
(am) "Covered individual" means an individual who is a member, participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary of a covered entity, or a dependent of the individual, and who receives prescription drug coverage from or through the covered entity.
49.475(1)(c)
(c) "Pharmacy benefits management" means the procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals; or any of the following services provided in the administration of pharmacy benefits:
49.475(1)(c)2.
2. Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals.
49.475(1)(c)3.
3. Clinical formulary development and management services.
49.475(1)(c)5.
5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.
49.475(1)(d)
(d) "Pharmacy benefits manager" means a person that performs pharmacy benefits management functions.
49.475(1)(e)
(e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:
49.475(1)(e)1.
1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.
49.475(1)(e)5.
5. A participant in the program of prescription drug assistance for elderly persons under
s. 49.688.
49.475(1)(f)
(f) "Third party" means an entity that by statute, rule, or contract is responsible for payment of a claim for a health care item or service. "Third party" includes all of the following:
