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(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.
49.471(11)(k)
(k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under
s. 40.51 (6).
49.471(11)(L)
(L) Durable medical equipment, limited to $2,500 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 articles provided.
49.471(11)(m)
(m) Transportation to obtain medical care, as medically necessary, and, to the extent permitted under federal law, 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)(n)
(n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.
49.471(11)(o)
(o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.
49.471(11)(p)
(p) Early childhood developmental services, for children under 6 years of age.
49.471(11)(q)
(q) Smoking cessation treatment, for pregnant women only.
49.471(11)(r)
(r) Prenatal care coordination, for pregnant women at high risk only.
49.471(11)(s)
(s) Early and periodic screening and diagnosis, and all services included in the definition of “medical assistance" under
42 USC 1396d (a) that are found necessary by this screening and diagnosis, for recipients under 21 years of age.
49.471(11m)
(11m) Provider payments and requirements. The provider of a service or equipment under
sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under
sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under
sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under
sub. (11) to a recipient who is unable to share costs as specified in
sub. (11), the recipient is not relieved of liability for those costs.
49.471(11r)
(11r) Alternate Benchmark plan benefits and copayments. 49.471(11r)(a)(a) If the department chooses to provide the alternate benchmark plan under this subsection, the department shall provide to the recipients described under
sub. (4) (e) coverage for benefits similar to those in a commercial, major medical insurance policy.
49.471(11r)(b)
(b) The department may charge copayments to recipients receiving coverage under the alternate benchmark plan under this subsection that are higher than copayments charged to recipients receiving coverage under the standard plan under
s. 49.46 (2). The department may not charge to a recipient of coverage under the alternate benchmark plan under this subsection whose family income is at or below 150 percent of the poverty line a copayment that exceeds 5 percent of the individual's family income for all members of the family.
49.471(11r)(c)1.1. The department may only provide coverage under the alternate benchmark plan under this subsection to the extent the alternate benchmark plan is approved by the federal department of health and human services.
49.471(11r)(c)2.
2. If the department is providing coverage under the alternate benchmark plan under this subsection the department may discontinue coverage under the benchmark plan under
sub. (11) for those individuals eligible for the alternate benchmark plan under this subsection.
49.471(11r)(c)3.
3. The department may provide services to individuals enrolled in the alternate benchmark plan under this subsection through a medical home initiative similar to an initiative described under
s. 49.45 (24j).
49.471(12)(a)1.1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.
49.471(12)(a)2.
2. The department may promulgate emergency rules under
s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under
subd. 1., but not to exceed the period authorized under
s. 227.24 (1) (c) and
(2). Notwithstanding
s. 227.24 (1) (a),
(2) (b), and
(3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.
49.471(12)(b)
(b) If the amendments to the state plan submitted under
sub. (2) are approved and a waiver that is substantially consistent with the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.
49.472
49.472
Medical assistance purchase plan. 49.472(1)(am)
(am) “Family" means an individual, the individual's spouse and any dependent child, as defined in
s. 49.141 (1) (c), of the individual.
49.472(1)(b)
(b) “Health insurance" means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.
49.472(1)(c)
(c) “Independence account" means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which an individual began receiving medical assistance under this section.
49.472(1)(d)
(d) “Medical assistance purchase plan" means medical assistance, eligibility for which is determined under this section.
49.472(2)
(2) Waivers and amendments. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.
49.472(3)
(3) Eligibility. Except as provided in
sub. (6) (a), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:
49.472(3)(a)
(a) The individual's family's net income is less than 250 percent of the poverty line for a family the size of the individual's family. In calculating the net income, the department shall apply all of the exclusions specified under
42 USC 1382a (b).
49.472(3)(b)
(b) The individual's assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under
42 USC 1382b (a) or assets accumulated in an independence account. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.
49.472(3)(c)
(c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under
42 USC 1396d (q) (2) (B) and (D).
49.472(3)(e)
(e) The individual is legally able to work in all employment settings without a permit under
s. 103.70.
49.472(3)(f)
(f) The individual maintains premium payments calculated by the department in accordance with
sub. (4), unless the individual is exempted from premium payments under
sub. (4) (b) or
(5).
49.472(3)(g)
(g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals.
49.472(3)(h)
(h) The individual meets all other requirements established by the department by rule.
49.472(4)(a)(a) Except as provided in
par. (b) and
sub. (5), an individual who is eligible for medical assistance under
sub. (3) and receives medical assistance shall pay a monthly premium to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:
