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.
49.471(9)(b)
(b) An employer that receives a request from the department for insurance coverage and access to coverage information shall supply the information requested by the department in the format specified by the department within 30 calendar days after receiving the request.
49.471(9)(c)1.1. Subject to
subds. 2. and
3., an employer that does not comply with the requirements under
par. (b) shall be required to pay, within 45 days after the requested information was due, a penalty equal to the full per member per month cost of coverage under BadgerCare Plus for the individual about whom the information is requested, and for each of the individual's family members with coverage under BadgerCare Plus, for each month in which the individual and the individual's family members are covered before the employer provides the information.
49.471(9)(c)2.
2. An employer with fewer than 250 employees may not be required to pay more than $1,000 in penalties under this paragraph that are attributable to any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in penalties under this paragraph that are attributable to any 6-month period.
49.471(9)(c)3.
3. Notwithstanding
subd. 1., an employer shall not be subject to any penalties if the employer, at least once per year, timely provides to the department, in the manner and format specified by the department, information from which the department may determine whether the employer provides its employees with access to health insurance coverage.
49.471(9)(d)
(d) An employer may contest a penalty assessment under
par. (c) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by
ch. 227.
49.471(10)(b)1.1. Except as provided in
subds. 1m. and
4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income.
49.471(10)(b)1m.
1m. Except as provided in
subd. 4., a recipient who is an adult parent or adult caretaker relative; who is not disabled, pregnant, or American Indian; and whose family income exceeds 133 percent of the federal poverty line shall pay a premium for coverage under BadgerCare Plus in an amount determined by the department that is based on a formula in which costs decrease for those with lower family incomes and that is no less than 3 percent of family income but no greater than 9.5 percent of family income. If the recipient has self-employment income and is eligible under
sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted. If the department intends to impose a premium under this subdivision after December 31, 2013, the department shall request from the federal department of health and human services any necessary approval to continue imposing premiums under this subdivision.
49.471(10)(b)2.
2. Except as provided in
subds. 3m. and
4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in
sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.
49.471(10)(b)3m.
3m. A recipient who is a child, who is not disabled, and whose family income is at a level determined by the department that is at least 150 percent of the poverty line shall pay a premium in an amount determined by the department. The department may apply this subdivision only to the extent the federal department of health and human services approves applying a premium to those individuals, if approval is required.
49.471(10)(b)4.
4. None of the following shall pay a premium, except as provided in
subd. 3m.:
49.471(10)(b)4.a.
a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line.
49.471(10)(b)4.c.
c. A child whose family income does not exceed 200 percent of the poverty line.
49.471(10)(b)4.d.
d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
49.471(10)(b)5.
5. If a recipient who is required to pay a premium under this paragraph or under
sub. (2m) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient's coverage terminates. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 12 consecutive calendar months following the date on which the recipient's coverage terminated, except for any month during that 12-month period when the recipient's family income does not exceed 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient's coverage terminated, except for any month during that period when the recipient's family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums.
49.471(11)
(11) Benchmark plan benefits and copayments. Except as provided in
sub. (11r) and
s. 49.45 (24j), recipients who are not eligible for the benefits described in
s. 49.46 (2) (a) and
(b) shall have coverage of the following benefits and pay the following copayments:
49.471(11)(a)
(a) Subject to
sub. (6) (k), prescription drugs bearing only a generic name, as defined in
s. 450.12 (1) (b), with a copayment of no more than $5 per prescription.
49.471(11)(b)
(b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.
49.471(11)(c)
(c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.
49.471(11)(d)
(d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in
s. 632.85 (1) (a), shall require a copayment of no more than $75.
49.471(11)(e)
(e) Laboratory and X-ray services, including mammography.
49.471(11)(f)
(f) Home health services, limited to 60 visits per year.
49.471(11)(g)
(g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(h)
(h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(i)
(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
49.471(11)(j)
(j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under
s. 49.46 (2) for the services provided.
