Chapter DHS 103

DHS 103.10   Redetermination of eligibility.

DHS 103.11   Presumptive eligibility for pregnant women and women diagnosed with breast or cervical cancer or precancerous conditions.

Ch. DHS 103 Note Note: Chapter HSS 103 as it existed on February 28, 1986, was repealed and a new chapter HSS 103 was created effective March 1, 1986. Chapter HSS 103 was renumbered Chapter HFS 103 under s. 13.93, Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1997, No. 493. Chapter HFS 103 was renumbered to chapter DHS 103 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 103.01 DHS 103.01 Introduction.

DHS 103.01(1) (1) Persons eligible.

DHS 103.01(1)(a) (a) Eligibility for medical assistance shall be determined pursuant to ss. 49.453, 49.454, 49.455, 49.46 (1), 49.468, 49.47 (4), 49.471, 49.472 and 49.473, Stats., and this chapter, except that medical assistance shall be provided without eligibility determination to persons receiving SSI.

DHS 103.01(1)(b) (b) Presumptive eligibility for pregnant women shall be determined under s. 49.465, Stats., and this chapter.

DHS 103.01(1)(c) (c) Presumptive eligibility for children shall be determined under s. 49.471 (5) (b) 2., Stats., and this chapter.

DHS 103.01(1)(d) (d) Presumptive eligibility for women diagnosed with breast or cervical cancer or precancerous conditions shall be determined under s. 49.473 (3), Stats., and this chapter.

DHS 103.01(2) (2) Singular enrollment. No person may be certified eligible in more than one MA case.

DHS 103.01(3) (3) Definition. In this chapter, “modified adjusted gross income” or “MAGI” has the meaning under 42 USC 435.603.

DHS 103.01 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; renum. (1) to be (1) (a) and cr. (1) (b), Register, February, 1988, No. 386, eff. 3-1-88; am. (1) (a), Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1) (a), eff. 7-1-99; am. (1) (a), Register, March, 2000, No. 531, eff. 4-1-00; am. (1) (a), Register, November, 2000, No. 539, eff. 12-1-00; CR 23-046: am. (1) (a), cr. (1) (c), (d), (3) Register April 2024 No. 820, eff. 5-1-24.

DHS 103.03 DHS 103.03 Non-financial conditions for eligibility. In order to be eligible for MA, a person shall meet both non-financial conditions for eligibility in this section and financial conditions for eligibility under s. DHS 103.04. The non-financial conditions for eligibility are:

DHS 103.03(1) (1) BadgerCare Plus-relatedness or SSI-relatedness.

DHS 103.03(1)(a) (a) Requirement. To be non-financially eligible for MA, an applicant shall be BadgerCare Plus-related or SSI-related.

DHS 103.03(1)(b) (b) BadgerCare Plus-related persons. In this subsection, “BadgerCare Plus-related” means a person who meets one of the following conditions:

DHS 103.03(1)(b)1. 1. The person is pregnant and meets the conditions specified in s. 49.471 (4) (a) 1., 1g., or 1m., Stats.

DHS 103.03(1)(b)2. 2. The person is a child under age 19 who meets the conditions specified in s. 49.471 (4) (a) 3., 3g., 3m. or 7., Stats., and under par. (f).

DHS 103.03(1)(b)2m. 2m. The person is an unborn child as defined in s. 49.471 (1) (k), Stats., and meets the conditions under par. (f).

DHS 103.03(1)(b)3. 3. The person is a caretaker relative or a caretaker relative’s spouse if the spouse resides with the caretaker relative’s child who meets the conditions specified in s. 49.471 (4) (a) 4. or 7., Stats.

DHS 103.03(1)(b)4. 4. The person is a foster child under 19 years of age living in a foster home licensed under s. 48.62, Stats., or a group home licensed under s. 48.625, Stats., is a child under the care of a subsidized guardianship under s. 48.623, Stats., or is a child in an adoption assistance placement under s. 48.975, Stats.

DHS 103.03(1)(b)5. 5. The person is a former foster care recipient and meets the conditions specified under s. 49.471 (4) (a) 5, Stats.

DHS 103.03(1)(b)6. 6. The person meets the conditions to receive family planning services under s. 49.45 (24s), Stats.

DHS 103.03(1)(b)7. 7. The person is diagnosed with tuberculosis and meets the conditions under s. 49.46 (1) (a) 15., Stats.

DHS 103.03(1)(b)8. 8. The person is at least 19, but under 21 years of age and resides in an intermediate care facility, skilled nursing facility, or inpatient psychiatric hospital and meets the conditions under s. 49.47 (4), Stats.

DHS 103.03(1)(c) (c) SSI-related persons. In this subsection, “SSI-related person” means a person who meets one of the following conditions:

DHS 103.03(1)(c)1. 1. The person is age 65 or over; or

DHS 103.03(1)(c)2. 2. The person is blind or disabled.

DHS 103.03(1)(d) (d) Verification of blindness or disability. Except as provided under par. (e), the blindness or disability claimed under par. (c) 2. shall be verified in one of the following ways:

DHS 103.03(1)(d)1. 1. By presentation of a current old age and survivors disability insurance (OASDI) disability award notice;

DHS 103.03(1)(d)2. 2. By presentation of a current medicare card indicating blindness or disability; or

DHS 103.03(1)(d)3. 3. By receipt of a disability determination made by the department’s bureau of social security disability insurance, along with current medical reports.

DHS 103.03(1)(e) (e) Presumption of disability in an emergency.

DHS 103.03(1)(e)1. 1. Under emergency circumstances, a person may be presumed disabled for purposes of demonstrating SSI-relatedness and be eligible for MA without the verification required under par. (d).

DHS 103.03(1)(e)2. 2. When an emergency need for MA exists, the department shall make a preliminary disability determination within 7 days of the date a completed disability determination form is received.

DHS 103.03(1)(e)3. 3. An emergency need for MA shall exist when the applicant is:

DHS 103.03(1)(e)3.a. a. A patient in a hospital;

DHS 103.03(1)(e)3.b. b. Seriously impaired and the attending physician states the applicant will be unable to work or return to normal functioning for at least 12 months;

DHS 103.03(1)(e)3.c. c. In need of long-term care and the nursing home will not admit the applicant until MA benefits are in effect; or

DHS 103.03(1)(e)3.d. d. Unable to return home from a nursing home unless in-home service or equipment is available and this cannot be obtained without MA benefits.

DHS 103.03 Note Note: Copies of the disability determination form may be obtained from the county or tribal income maintenance agency.

DHS 103.03(1)(f) (f) BadgerCare Plus eligibility. To be non-financially eligible for BadgerCare Plus, a person shall meet all of the following conditions:

DHS 103.03(1)(f)1. 1. The person meets one of the conditions in par. (b).

DHS 103.03(1)(f)2. 2. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and does not have health insurance coverage that meets both of the following criteria:

DHS 103.03(1)(f)2.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is provided under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)2.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)2m. 2m. The person is an unborn child and the unborn child’s mother does not have health insurance coverage that covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)3. 3. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and the person does not have access to coverage under a group health insurance plan that meets all of the following criteria:

DHS 103.03(1)(f)3.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)3.b. b. The health insurance coverage would begin within 3 calendar months following the BadgerCare Plus application filing date, the BadgerCare Plus annual renewal month, or the start date of the employment through which the child can access the health insurance coverage.

DHS 103.03(1)(f)3.c. c. The employer of the person’s parent, step-parent or other caretaker relative residing with the person, when the person is under 19 years of age.

DHS 103.03(1)(f)3.cm. cm. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)3.d. d. The health insurance policy is through the child’s employer, the employer of the child’s spouse when the spouse is residing with the child, or the employer of the child’s parent, step-parent or other caretaker relative residing with the child.

DHS 103.03(1)(f)3m. 3m. If the person is an unborn child, the unborn child’s mother does not have access to coverage under a group health insurance plan that meets all of the following criteria:

DHS 103.03(1)(f)3m.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)3m.b. b. The health insurance coverage would begin within 3 calendar months following the BadgerCare Plus application filing date, the BadgerCare Plus annual renewal month, or the start date of the employment through which the mother can access the health insurance coverage.

DHS 103.03(1)(f)3m.c. c. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)3m.d. d. The health insurance policy is through the mother’s employer or the employer of the mother’s spouse when the spouse is residing with the mother.

DHS 103.03(1)(f)3m.e. e. When the mother is under 19 years old, the health insurance coverage is through the employer of the mother’s parent, step-parent, or other caretaker relative residing with the mother.

DHS 103.03(1)(f)4. 4. Except as provided in subd. 5. or 5m., if the person did not, at any time in the 12 months immediately preceding application for BadgerCare Plus, have access to employer-subsidized health care coverage or a state employee health plan and is any of the following:

DHS 103.03(1)(f)4.a. a. A child ages 1 through 5 with household income over 191% of the federal poverty level.

DHS 103.03(1)(f)4.b. b. A child ages 6 through 18 with household income over 156% of the federal poverty line.

DHS 103.03(1)(f)4g. 4g. The child under subd. 4. is ineligible for BadgerCare Plus the first day of the month that the employer’s plan would have provided coverage for the child if the family had been enrolled in the plan. The child remains ineligible for each month that coverage would have been available up to 18 12 months from the month the failure to enroll in the plan occurred if the health insurance plan meets all of the following criteria:

DHS 103.03(1)(f)4g.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)4g.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)4g.c. c. The health insurance policy is through the child’s employer, the employer of the child’s spouse when the spouse is residing with the child, or the employer of the child’s parent, step-parent or other caretaker relative residing with the child.

DHS 103.03(1)(f)4r. 4r. Except as provided in subd. 5., if the person is an unborn child, the unborn child’s mother did not, at any time in the 12 months immediately preceding application for BadgerCare Plus, have access to employer-subsidized health care coverage, or a state employee’s health plan. The unborn child is ineligible for BadgerCare Plus the first day of the month that the employer’s plan would have provided coverage for the unborn child’s mother if the family had been enrolled in the plan. The unborn child remains ineligible for each month that coverage would have been available up to 12 months from the month the failure to enroll in the plan occurred if the health insurance plan meets all of the following criteria:

DHS 103.03(1)(f)4r.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)4r.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

DHS 103.03(1)(f)4r.c. c. The health insurance policy is provided through the mother’s employer, the employer of the mother’s spouse when the spouse is residing with the mother, or the employer of the mother’s parent, step-parent or other caretaker relative residing with the child, if the mother is under 19 years of age.

DHS 103.03(1)(f)5. 5. The 12 month period in subds. 4. and 4m. does not apply if one of the following statements is true about access to employer-subsidized health care coverage:

DHS 103.03(1)(f)5.a. a. The employment ended.

DHS 103.03(1)(f)5.b. b. The person’s employer discontinued health care coverage for all employees.

DHS 103.03(1)(f)5.c. c. A member or members of the family were eligible for other health insurance coverage or MA at the time the employee failed to enroll in the employer-subsidized health care coverage and no member of the group was eligible at that time for BadgerCare Plus with an assistance group income above 156% of the federal poverty line.

DHS 103.03(1)(f)5.e. e. Any other reason determined by the department to be a good cause reason.

DHS 103.03(1)(f)6. 6. The person is not eligible for MA under BadgerCare Plus-related or SSI-related criteria in this chapter.

DHS 103.03(1)(f)7. 7. A person required to pay a premium under s. DHS 103.085 (1) has made the first payment.

DHS 103.03(1)(f)8. 8. A person has not chosen to receive BadgerCare Plus-related or SSI-related MA through a spend-down, as described in s. DHS 103.08 (2) (a), or has chosen to end a spend-down period at any time prior to the date at which the expenditure or obligation of excess income has been achieved.

DHS 103.03(1)(fm) (fm) Exemption from health insurance coverage requirements. A child is exempt from the health insurance coverage requirements in sub. (1) (f) 2., 3., and 4., if they meet any of the following criteria:

DHS 103.03(1)(fm)1. 1. The child is younger than 19 years old, has met a deductible, and is in the deductible period.

DHS 103.03(1)(fm)2. 2. The child is in an extension.

DHS 103.03(1)(fm)3. 3. The person is age 18 and was in foster care, subsidized guardianship, or court-ordered kinship care on the date they turned 18 years old.

DHS 103.03(1)(fm)4. 4. The child is pregnant.

DHS 103.03(1)(g) (g) Medicaid purchase plan non-financial eligibility. To be non-financially eligible for the medicaid purchase plan a person shall meet the conditions described in par. (c) for SSI-related persons and shall be age 18 or older and the person shall meet any of the following conditions:

DHS 103.03(1)(g)1. 1.

DHS 103.03(1)(g)1.a. a. The person shall be employed.

DHS 103.03(1)(g)1.b. b. The person shall be enrolled in a department-certified health and employment counseling program.

DHS 103.03(1)(g)1.c. c. The health of the person participating in the medicaid purchase plan for at least 6 months shall have deteriorated to the point that he or she is unable to participate under subd. 1. a. or b. and the county agency has waived the requirement for a period up to 6 calendar months. The county agency may waive the requirement if the person is hospitalized, injured or suffers any other health setback. The county agency may waive the requirement as long as it had not granted a waiver of the requirement twice within the 36 months immediately preceding the current waiver request. The waiver periods shall be non-consecutive. The person shall supply proof of health difficulties. In addition to the discretion the county agency has to grant a waiver, the department may grant a temporary waiver of the work requirement upon a showing of good cause.