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.
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)(cg)
(cg) An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line is not eligible for BadgerCare Plus if all of the following apply:
49.471(8)(cg)1.a.
a. Access to individual or family health coverage provided by an employer in which the monthly premium that an employee would pay for an employee-only policy does not exceed 9.5 percent of the family's monthly income.
49.471(8)(cg)1.b.
b. Access to individual or family health coverage under the state employee health plan.
49.471(8)(cg)2.
2. The individual has access to any coverage described in
subd. 1. during any of the following times:
49.471(8)(cg)2.a.
a. The 12 months before the first day of the month in which an individual applies for and the month in which an individual applies for BadgerCare Plus.
49.471(8)(cg)2.b.
b. The 3 months after the last day of the month in which the individual applies for BadgerCare Plus.
49.471(8)(cg)2.c.
c. The month including the date of the annual determination of the individual's eligibility for Medical Assistance.
49.471(8)(cg)3.
3. The individual does not have as a reason for not obtaining health insurance any of the good cause reasons under
par. (d) 2. a. to
e.
49.471(8)(cr)1.1. Subject to
subd. 4., an individual who is any of the following is not eligible for BadgerCare Plus if the criteria under
par. (cg) 1. and
2. apply to that individual:
49.471(8)(cr)1.a.
a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
49.471(8)(cr)1.b.
b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
49.471(8)(cr)1.c.
c. An adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
49.471(8)(cr)2.
2. An individual under
subd. 1. is not ineligible if any of the good cause reasons described in
par. (d) 2. a. to
e. is the reason that the individual did not obtain health insurance coverage.
49.471(8)(cr)3.
3. An individual under
subd. 1. c. is not ineligible if any of the following good cause reasons is the reason the individual did not obtain health insurance coverage:
49.471(8)(cr)3.a.
a. The parent of the individual is no longer employed by the employer through which the parent was eligible for coverage, and the parent does not have current coverage.
49.471(8)(cr)3.b.
b. The employer of the parent of the individual discontinued providing health benefits to all employees.
49.471(8)(cr)4.
4. The department may apply this paragraph to eligibility determinations for BadgerCare Plus only if the federal department of health and human services approves of the conditions to make that individual ineligible, if approval is required.
49.471(8)(ct)1.1. If the federal department of health and human services approves the department's request to add private major medical insurance as a type of coverage which causes ineligibility, an individual who is not disabled and not pregnant, who is over 18 years of age, whose family income exceeds 133 percent of the poverty line, and who has coverage provided by private major medical insurance in which the monthly premium does not exceed 9.5 percent of the family's monthly income is not eligible for BadgerCare Plus.
49.471(8)(ct)2.
2. If the federal department of health and human services approves of the conditions to make that individual ineligible for BadgerCare Plus, an individual who is any of the following is not eligible for BadgerCare Plus if he or she has the major medical insurance coverage described under
subd. 1.:
49.471(8)(ct)2.a.
a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
49.471(8)(ct)2.b.
b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
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.dg.
dg. The insurance is owned by someone not residing with the family and continuation of the coverage is beyond the family's control.
49.471(8)(d)2.dr.
dr. The insurance only covers services provided in a service area that is beyond a reasonable driving distance.
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)(fm)
(fm) If an individual who is one of the following individuals had the health insurance coverage specified in
par. (cg) 1. or
(ct) but no longer has the coverage, the individual 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)(fm)1.
1. An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line.
49.471(8)(fm)2.
2. If the federal department of health and human services approves of the department's request to make such an individual ineligible, an individual who is not disabled and who is a child of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.
49.471(8)(fm)3.
3. If the federal department of health and human services approves of the department's request to make such an individual ineligible, a parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
49.471(8)(fm)4.
4. If the federal department of health and human services approves of the department's request to make such an individual ineligible, an adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.
49.471(8)(g)
(g) Any of the following is a good cause reason for purposes of
pars. (f) and
(fm):
49.471(8)(g)1.
1. The individual 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 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 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 individual'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 coverage terminated due to the death or change in marital status of the subscriber.
49.471(8)(g)5g.
5g. The insurance coverage is owned by someone not residing with the family and continuation of the coverage is beyond the family's control.
49.471(8)(g)5r.
5r. The insurance coverage only covers services provided in a service area that is beyond a reasonable driving distance.
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.
