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)1.
1. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
49.471(4)(a)1g.
1g. A pregnant woman whose family income exceeds 200 percent but does not exceed 300 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)2m.
2m. A child who is under one year of age, whose mother was determined to be eligible under
subd. 1g., 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)3g.
3g. 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)(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 dependent 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 dependent 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. For purposes of this subdivision, a "dependent child" means an individual who is under the age of 18 or an individual who is age 18 and a full-time student in secondary school or equivalent vocational or technical training if before attaining the age of 19 the individual is reasonably expected to complete the school or training.
49.471(4)(a)4.b.
b. The individual's family income does not exceed 100 percent of the poverty line before application of the 5 percent income disregard under
42 CFR 435.603 (d).
49.471(4)(a)5.
5. An individual who, regardless of family income, was born on or after January 1, 1988, and who, on his or her 18th birthday, was in a foster care placement under the responsibility of this state, or at the option of the department, under the responsibility of another state, and enrolled in Medical Assistance under this subchapter or a Medicaid program, 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 26 years of age, unless he or she otherwise loses eligibility sooner.
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(4)(e)
(e) If the department obtains approval from the federal department of health and human services to provide an alternate benchmark plan under
sub. (11r), to the extent the federal department of health and human services approves, the department may enroll in the alternate benchmark plan under
sub. (11r) any individual whose family income exceeds 100 percent of the poverty line, who is either an adult who is not pregnant or a child, and who applies and is otherwise eligible to receive benefits under this section, except that the department shall enroll a child who has a parent who is enrolled in a plan under this section in the same plan as his or her parent.
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 any of the following and ending on the applicable day specified in
subd. 3., unless the federal department of health and human services approves the department's request to not extend eligibility to children during this period:
49.471(5)(b)2.a.
a. 150 percent of the poverty line for a child who is 6 years of age or older but has not yet attained the age of 19.
49.471(5)(b)2.b.
b. 185 percent of the poverty line for a child who is one year of age or older but has not yet attained the age of 6.
49.471(5)(b)2.c.
c. 300 percent of the poverty line for a child who is under one year of age.
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), except that a child who is not an unborn child is not eligible for benefits described in
s. 49.46 (2) (a) and
(b) during that time if the federal department of health and human services approves the department's request not to provide those benefits during that time.
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. Except as provided in
subd. 4., 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. Except as provided in
subd. 3. or
4., 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)(a)3.
3. Any individual described in
subd. 2. who is not disabled, not elderly, and not pregnant, who is an adult, and whose family income exceeds 133 percent of the federal poverty level is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.
49.471(6)(a)4.
4. To the extent allowed by the federal department of health and human services, any individual described in
subd. 1. or
2. who is not disabled is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.
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).
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)(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) (a) 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), or whose family income exceeds 300 percent of the poverty line, 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)(d)
(d) In addition to applying other income counting requirements the department shall do all of the following:
49.471(7)(d)1.
1. When calculating the family income of a member of a household who is not disabled, include the income of all adults residing in the home for at least 60 consecutive days but exclude the income of a grandparent in a household containing 3 generations, unless the grandparent applies for or receives benefits as a parent or caretaker relative under this section.
49.471(7)(d)2.
2. When determining the size of a family for purposes of determining income eligibility, exclude from family size an adult whose income is included in a calculation of family income solely under
subd. 1.
49.471(7)(d)3.
3. Apply this paragraph only to the extent the federal department of health and human services approves the income eligibility calculation methods, if approval is required.
49.471(7)(e)
(e) For the purpose of determining family income, the department shall apply the regulations defining a household under
42 CFR 435.603 (f). To determine the family size for a pregnant woman, the department shall include the pregnant woman and the number of babies she is expecting.
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),
(cg),
(cr),
(ct), 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.
