49.47(4)(b)
(b) Eligibility exists if the applicant's property, subject to the exclusion of any amounts under the Long-Term Care Partnership Program established under
s. 49.45 (31), any amounts in an independence account, as defined in
s. 49.472 (1) (c), or any retirement assets that accrued from employment while the applicant was eligible for the community options program under
s. 46.27 (11), or any other Medical Assistance program, including deferred compensation or the value of retirement accounts in the Wisconsin Retirement System or under the federal Social Security Act, does not exceed the following:
49.47(4)(b)1.
1. Subject to
par. (bc), a home and the land used and operated in connection therewith or in lieu thereof a manufactured home or mobile home if the home, manufactured home, or mobile home is used as the person's or his or her family's place of abode.
49.47(4)(b)2m.
2m. One or more motor vehicles as specified in this subdivision.
49.47(4)(b)2m.a.
a. For persons who are eligible under
par. (a) 1., one vehicle is exempt from consideration as an asset. A 2nd vehicle is exempt from consideration as an asset only if the department determines that it is necessary for the purpose of employment or to obtain medical care. The equity value of any nonexempt vehicles owned by the applicant is an asset for the purposes of determining eligibility for medical assistance under this section.
49.47(4)(b)2r.
2r. For a person who is eligible under
par. (a) 3. or
4., the value of any burial space or agreement representing the purchase of a burial space held for the purpose of providing a place for the burial of the person or any member of his or her immediate family.
49.47(4)(b)2w.
2w. For a person who is eligible under
par. (a) 3. or
4., life insurance with cash surrender values if the total face value of all life insurance policies, including riders and other attachments, is not more than $1,500.
49.47(4)(b)3.
3. For a person who is eligible under
par. (a) 3. or
4., funds set aside to meet the burial and related expenses of the person and his or her spouse in an amount not to exceed $1,500 each, minus the sum of the cash value of any life insurance excluded under
subd. 2w. and the amount in any irrevocable burial trust under
s. 445.125 (1) (a).
49.47(4)(b)3r.
3r. Liquid assets limited to $300 for each legal dependent in addition to a family of 2.
49.47(4)(b)4.
4. Additional tangible personal property of reasonable value, considering the number of members in the family group, used in the production of income.
49.47(4)(bc)1.1. Subject to
subd. 2., a person shall be ineligible under this section for medical assistance for nursing facility services or other long-term care services described in s. 49. 453 (2) if the equity in his or her home and the land used and operated in connection with the home exceeds $750,000. This subdivision does not apply if any of the following persons lawfully resides in the home:
49.47(4)(bc)2.a.
a. At the time of application, to a person who applies for medical assistance for nursing facility services or other long-term care services described in
s. 49.453 (2) after February 1, 2008.
49.47(4)(bc)2.b.
b. At the time of the person's first recertification after February 1, 2008, to a person not specified in
subd. 2. a. who applied for medical assistance for nursing facility services or other long-term care services described in
s. 49.453 (2) on or after January 1, 2006, and who was eligible for medical assistance for those services on February 1, 2008.
49.47(4)(bm)
(bm) For purposes of determining eligibility or benefits amount for a person described in
par. (a) 3. or
4. who resides in a continuing care retirement community or a life care community, any entrance fee paid on admission to the community shall be considered a resource available to the person to the extent that all of the following apply:
49.47(4)(bm)1.
1. The person has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care if the person's other resources or income are insufficient to pay for the care.
49.47(4)(bm)2.
2. The person is eligible for a refund of any remaining entrance fee when the person dies or terminates the continuing care retirement community or life care community contract and leaves the community.
49.47(4)(bm)3.
3. The entrance fee does not confer an ownership interest in the continuing care retirement community or life care community.
49.47(4)(c)1.1. Except as provided in
par. (am), eligibility exists if income does not exceed 133 1/3% of the maximum aid to families with dependent children payment under
s. 49.19 (11) for the applicant's family size or the combined benefit amount available under supplemental security income under
42 USC 1381 to
1383c and state supplemental aid under
s. 49.77 whichever is lower. In this subdivision "income" includes earned or unearned income that would be included in determining eligibility for the individual or family under
s. 49.19 or
49.77, or for the aged, blind or disabled under
42 USC 1381 to
1385. "Income" does not include earned or unearned income which would be excluded in determining eligibility for the individual or family under
s. 49.19 or
49.77, or for the aged, blind or disabled individual under
42 USC 1381 to
1385.
49.47(4)(c)2.
2. Whenever an applicant has excess income under
subd. 1. or
par. (am), no certification may be issued until the excess income above the applicable limits has been obligated or expended for medical care or for any other type of remedial care recognized under state law or for personal health insurance premiums or both.
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)(cr)1.1. As a condition of receiving medical assistance for long-term care services described in
s. 49.453 (2) (a), an applicant for or recipient of the long-term care services shall disclose on the application or recertification form a description of any interest the individual or his or her community spouse, as defined in
s. 49.453 (1) (ar), has in an annuity, regardless of whether the annuity is irrevocable or is treated as an asset. The application or recertification form shall include a statement that the state becomes a remainder beneficiary under any annuity in which the individual or his or her spouse has an interest by virtue of the provision of the medical assistance. The applicant or recipient shall, no later than 30 days after the department receives the application or recertification form, take any action required by the annuity issuer to make the state a remainder beneficiary.
49.47(4)(cr)2.
2. The department shall notify the issuer of an annuity disclosed under
subd. 1. of the state's right as a remainder beneficiary and shall request that the issuer notify the department of any changes to or payments made under the annuity contract.
49.47(4)(cr)3.b.
b. Annuities purchased before February 8, 2006, for which a transaction, as defined in
s. 49.453 (4) (ac), has occurred on or after February 8, 2006.
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 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 services. Within 30 days after August 12, 1993, the department of safety and professional services 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(4)(k)
(k) Notwithstanding
par. (b) 3. and
s. 445.125 (1) (a), no later than 60 days after July 1, 2013, the department shall seek approval from the federal Centers for Medicare and Medicaid Services to permit any individual receiving medical assistance under this section to contribute funds to an irrevocable burial trust for the individual, up to a total irrevocable trust amount of $4,500, without the individual losing eligibility for medical assistance under this section. If the federal Centers for Medicare and Medicaid Services approves the request, the department shall implement the change under this section within 60 days after receiving approval.
49.47(5)
(5) Investigation by department. The department may make additional investigation of eligibility at any of the following times:
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.
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 that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare 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 that 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. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.
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 that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare 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. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.
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 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;
2011 a. 10,
32;
2013 a. 20;
2013 a. 116 ss.
29,
30;
2013 a. 117 s.
2,
3.
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).
