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.
49.471(7)(a)1.1. In the calculation of family income, if an adult member of the family has self-employment income, the department shall count the net self-employment earnings. Net self-employment earnings shall be determined by subtracting from gross self-employment income all self-employment expenses that are allowed under federal and state tax law, except for depreciation.
49.471(7)(a)2.
2. If a parent's or caretaker relative's family income includes self-employment income and, without deducting depreciation, does not exceed 200 percent of the poverty line, the parent or caretaker relative is eligible under
sub. (4) (a) 4.
49.471(7)(a)3.
3. If a parent's or caretaker relative's family income includes self-employment income and, without deducting depreciation, exceeds 200 percent of the poverty line, the parent or caretaker relative is eligible under
sub. (4) (b) 4. if his or her family income does not exceed 200 percent of the poverty line after depreciation is deducted.
49.471(7)(b)1.1. A pregnant woman whose family income exceeds 300 percent of the poverty line may become eligible for coverage under this section if the difference between the pregnant woman's family income and the applicable income limit under
sub. (4) (b) is obligated or expended for any member of the pregnant woman's family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision continues without regard to any change in family income 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 woman's pregnancy falls. Eligibility obtained by a pregnant woman under this subdivision extends to all pregnant women in the pregnant woman's family.
49.471(7)(b)2.
2. A child who is not an unborn child, whose family income exceeds 150 percent of the poverty line, and who is ineligible under this section solely because of
sub. (8) (b) may obtain eligibility under this section if the difference between the child's family income and 150 percent of the poverty line is obligated or expended on behalf of the child or any member of the child's family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision during any 6-month period, as determined by the department, continues for the remainder of the 6-month period and extends to all children in the family.
49.471(7)(b)3.
3. For a pregnant woman to obtain eligibility under
subd. 1., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the pregnant woman's monthly family income and the monthly family income that is 300 percent of the poverty line. For a child to obtain eligibility under
subd. 2., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the child's monthly family income and the monthly family income that is 150 percent of the poverty line.
49.471(7)(c)
(c) When calculating an individual's family income, the department shall do all of the following:
49.471(7)(c)1.
1. Deduct from the individual's income, up to the amount of the individual's income, any amount the individual is obligated to pay for court-ordered child or family support or maintenance.
49.471(7)(c)2.
2. Disregard earnings of children under 18 years of age.
49.471(7)(c)3.
3. Determine separately the family incomes of caretaker relatives and the children for whom they are caring and not legally responsible.
49.471(7)(c)4.
4. Not include in the calculation any income of an individual receiving benefits under
s. 49.77 or federal Title XVI.
49.471(8)
(8) Health insurance coverage and eligibility. 49.471(8)(a)1.1. Except as provided in
subd. 2., any individual who is otherwise eligible under this section and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for BadgerCare Plus and if the department determines that 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.
49.471(8)(a)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 section.
49.471(8)(b)
(b) Except as provided in
pars. (c) and
(d), an individual whose family income exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of the following applies:
49.471(8)(b)1.
1. The individual has individual or family health insurance coverage that is any of the following:
49.471(8)(b)1.a.
a. Coverage provided by an employer and for which the employer pays at least 80 percent of the premium.
49.471(8)(b)2.
2. The individual, in the 12 months before applying, had access to the health insurance coverage specified in
subd. 1.
49.471(8)(b)3.
3. The individual could be covered under the health insurance coverage specified in
subd. 1. if the coverage is applied for, and the coverage could become available to the individual in the month in which the individual applies for benefits under this section or in any of the next 3 calendar months.
49.471(8)(c)
(c) An unborn child, regardless of family income, is not eligible for BadgerCare Plus if any of the following applies:
49.471(8)(c)1.
1. The unborn child or the unborn child's mother has individual or family health insurance coverage.
49.471(8)(c)2.
2. The unborn child or the unborn child's mother, in the 12 months before applying, had access to the health insurance coverage specified in
par. (b) 1.
49.471(8)(c)3.
3. The unborn child or the unborn child's mother could be covered under individual or family health insurance coverage if the coverage is applied for, and the coverage could become available to the unborn child or the unborn child's mother in the month in which the unborn child applies for benefits under this section or in any of the next 3 calendar months.
49.471(8)(d)1.1. None of the following is ineligible for BadgerCare Plus by reason of having health insurance coverage or access to health insurance coverage:
49.471(8)(d)1.c.
c. Except as provided in
par. (c), a child who has health insurance coverage, or access to health insurance coverage, as a dependent of an absent parent but who resides outside of the service area of the absent parent's plan.
49.471(8)(d)2.
2. An individual under
par. (b) 2., or an individual who is an unborn child or an unborn child's mother under
par. (c) 2., is not ineligible if any of the following good cause reasons is the reason that the individual did not obtain the health insurance coverage under
par. (b) 1. to which they had access:
49.471(8)(d)2.b.
b. The individual's employer discontinued health insurance coverage for all employees.
49.471(8)(d)2.c.
c. One or more members of the individual's family were eligible for other health insurance coverage or Medical Assistance under
s. 49.46 or
49.47 at the time the employee failed to enroll in the health insurance coverage under
par. (b) 1. and no member of the family was eligible for coverage under this section at that time or, if one or more members of the individual's family were eligible for coverage under this section at that time, family income did not exceed 150 percent of the poverty line or the individual qualified for a medical assistance eligibility extension as provided in
sub. (4) (a) 7.
49.471(8)(d)2.d.
d. The individual's access to health insurance coverage has ended due to the death or change in marital status of the subscriber.
49.471(8)(d)2.e.
e. Any other reason that the department determines is a good cause reason.
49.471(8)(e)
(e) If a pregnant woman has health insurance coverage and her family income exceeds 200 percent of the poverty line, the woman is required, as a condition of eligibility, to maintain the health insurance coverage.
49.471(8)(f)
(f) If an individual with a family income that exceeds 150 percent of the poverty line had the health insurance coverage specified in
par. (b) 1. but no longer has the coverage, if an individual who is an unborn child or an unborn child's mother, regardless of family income, had health insurance coverage but no longer has the coverage, or if a pregnant woman specified in
par. (e) has health insurance coverage and does not maintain the coverage, the individual or pregnant woman is not eligible for BadgerCare Plus for the 3 calendar months following the month in which the insurance coverage ended without a good cause reason specified in
par. (g).
49.471(8)(g)
(g) Any of the following is a good cause reason for purposes of
par. (f):
49.471(8)(g)1.
1. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employment ended for a reason other than voluntary termination, unless the voluntary termination was a result of the incapacitation of the subscriber or because of an immediate family member's health condition.
49.471(8)(g)2.
2. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, the subscriber changed employers, and the new employer does not offer health insurance coverage.
49.471(8)(g)3.
3. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.
49.471(8)(g)4.
4. The pregnant woman's coverage was continuation coverage and the continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
49.471(8)(g)5.
5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.
49.471(8)(g)6.
6. Any other reason determined by the department to be a good cause reason.
49.471(9)
(9) Employer verification of insurance coverage. 49.471(9)(a)1.1. Except as provided in
subd. 2., for an applicant or recipient with a family income that exceeds 150 percent of the poverty line, the department shall verify insurance coverage and access information directly with the employer through which the applicant or recipient may have health insurance coverage or access to coverage.
