DHS 103.085(1)(a)(a)
Authority. Subject to s.
49.471 (10) (b) 2., Stats., and this section, a child under the age of 19 eligible for BadgerCare Plus may be required to pay a premium.
DHS 103.085(1)(b)1.1. A child under age 19 eligible for BadgerCare Plus with budgetable income at or below 201% of the poverty line is not required to pay a premium toward the cost of the health care coverage.
DHS 103.085(1)(b)2.
2. Except as provided in subd.
3.,
4., or
5., a child under age 19 eligible for BadgerCare Plus with budgetable income above 201% of the poverty line shall pay a premium toward the cost of the health care coverage.
DHS 103.085(1)(b)3.
3. A BadgerCare Plus applicant group does not owe a premium for the first month of BadgerCare Plus unless a member of the BadgerCare Plus fiscal test group was an MA recipient in the previous month.
DHS 103.085(1)(b)4.
4. A BadgerCare Plus applicant group does not owe a premium for the first month of BadgerCare Plus unless a member of the BadgerCare Plus fiscal test group was a BadgerCare Plus recipient in the previous 12 months.
DHS 103.085(1)(b)5.
5. A child under the age of 19 shall not be required to pay a premium if any of the following apply:
DHS 103.085(1)(c)
(c) Amounts. A child eligible for BadgerCare Plus required under this subsection to pay a premium shall pay the amount indicated in the schedule provided in Table 103.085, except as provided under par.
(cm). Income for each child's BadgerCare Plus fiscal test group shall be determined according to s.
DHS 103.07. -
See PDF for table 
DHS 103.085(1)(cm)
(cm)
Caps on premiums. Families must pay either the combined premiums for all of the children required to pay or an amount equal to five percent of the family's countable monthly income, whichever is less.
DHS 103.085(1)(d)1.1. All children otherwise eligible for BadgerCare Plus in a family who are required to pay a premium under this section shall pay the premium amount in full to the agency before the agency may certify the children's initial eligibility for BadgerCare Plus.
DHS 103.085(1)(d)2.
2. Premiums are due by the 10th of the month prior to the month for which the premium is required.
DHS 103.085(1)(d)3.
3. If no payment is received by the end of the month for which the premium is required, the department shall terminate the group's eligibility for BadgerCare, effective at the end of the month.
DHS 103.085(1)(d)4.
4. The department shall allow a variety of premium payment methods. A group may choose one of the following methods for premium payment:
DHS 103.085(1)(e)
(e) Refunds. The department shall issue a refund for a premium which has been paid when the premium is for one of the following:
DHS 103.085(1)(e)2.
2. A month that the child's budgetable income drops to or below 200% of the poverty line and the change in income that brought the child's budgetable income to or below 200% of the poverty line was reported within 10 days of the date the change occurred.
DHS 103.085(1)(e)3.
3. A month which requires a lower premium amount due to a change in circumstances which was in effect for the entire month so long as the change was reported within 10 days of the date it occurred. In a case where the change was not reported within 10 days of the date it occurred, the effective date of the lower premium amount due is the first day of the month in which the change was reported.
DHS 103.085(1)(f)
(f)
Consequence of failure to pay BadgerCare premiums. A child required to pay a premium shall be ineligible for re-enrollment for the period specified in sub.
(3) when the group fails to pay its premium within the time specified in par.
(d).
DHS 103.085(3)(a)(a)
Period of ineligibility. A BadgerCare Plus group that fails to make a premium payment under sub.
(1) is not eligible for BadgerCare Plus for a period of at least 3 consecutive calendar months following the date that BadgerCare Plus eligibility ends, unless one of the circumstances in par.
(b) applies. Eligibility is restored as described in par.
(c). After 3 calendar months, the child shall be eligible for BadgerCare Plus if otherwise eligible.
DHS 103.085(3)(b)
(b)
Reasons restriction on re-enrollment may not apply. The restriction on re-enrollment under this section does not apply for any of the following reasons:
DHS 103.085(3)(b)1.
1. The failure to pay premiums was due to a circumstance beyond the group's control, provided that all past due premiums have been paid in full. A circumstance beyond the group's control includes any of the following:
DHS 103.085(3)(b)1.a.
a. A problem with an electronic funds transfer from a bank account to the BadgerCare Plus program.
DHS 103.085(3)(b)3.
3. Payment is received in full for all owed premiums before the end of the three-month restrictive re-enrollment period.
DHS 103.085(3)(b)4.
4. Any other circumstance affecting payment of the premium which the department determines is beyond the group's control, but not including insufficient funds.
DHS 103.085(3)(c)
(c)
Resuming BadgerCare eligibility. Eligibility for BadgerCare shall resume in the following manner for persons with a re-enrollment restriction that ended due to a reason described in par.
(b):
DHS 103.085(3)(c)1.
1. For a child with a reason under par.
(b) 1. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for any months that the group had been closed during the restriction period, provided that payment of any outstanding premiums owed is made and the child was otherwise eligible for BadgerCare Plus in those months.
DHS 103.085(3)(c)2.
2. For a child with a reason under par.
(b) 3. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for any calendar months that the child's BadgerCare Plus fiscal test group's income was at or below 201% of the poverty line and the child was otherwise eligible for BadgerCare Plus in those months.
DHS 103.085(3)(c)3.
3. For a child with a reason under par.
(b) 4. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for all months that the child had been ineligible during the restriction period, provided that payment of any outstanding premiums owed is made and the child is otherwise eligible for BadgerCare Plus in those months.
DHS 103.085 History
History: Emerg. cr. eff. 7-1-99; cr.
Register, March, 2000, No. 531, eff. 4-1-00; correction in (5) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 20-039: renum. (3) (b) (intro.) and 1. to (3) (b) (intro.) and am., r. (3) (b) 2., (6)
Register October 2021 No. 790, eff. 11-1-21;
CR 23-046: am. (title), (1) (a), (b) 1. to 4., cr. (1) (b) 5., am. (1) (c), r. and recr. Table 103.085, cr. (1) (cm), am. (1) (d) 1., r. (1) (d) 5., am. (1) (e) (intro.), r. (1) (e) 1., am. (1) (e) 2., (f), r. (2), am. (3) (a), (b) (intro.), r. and recr. (3) (b) 1. to 3., am. (3) (c) 1., r. and recr. (3) (c) 2. cr. (3) (c) 3., r. (4), (5) Register April 2024 No. 820, eff. 5-1-24; correction in (1) (c) made under s. 35.17, Stats., Register April 2024 No. 820. DHS 103.087
DHS 103.087 Conditions for continuation of eligibility. DHS 103.087(1)(a)(a)
Authority. Subject to this section and s.
49.472, Stats., a person eligible for the medicaid purchase plan shall pay a monthly premium.
DHS 103.087(1)(b)1.1. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is above 100% of the poverty line for the applicable household size shall pay a monthly premium and the applicant shall pay all retroactive premium amounts assessed or other premium payments due.
DHS 103.087(1)(b)2.
2. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is at or below 100% of the poverty line for the applicable household size pay does not owe a monthly premium.
DHS 103.087(1)(c)1.1. An applicant or recipient eligible for the medicaid purchase plan shall pay a monthly premium in accordance with this subsection.
DHS 103.087(1)(c)2.
2. The county agency shall determine the amount of the premium an applicant shall pay according to the guidelines described in this subsection at the time of application.
DHS 103.087(1)(c)3.
3. All earned and unearned sources of income available to the applicant or recipient, except for the interest, dividends or other gains accrued from a recipient's independence account, shall be used in the premium determination.
DHS 103.087(1)(d)
(d)
Calculating the monthly adjusted earned and unearned income. An applicant's or recipient's monthly adjusted income shall be calculated by subtracting applicant's or recipient's gross monthly countable earned and unearned income, their actual out-of-pocket medical and remedial expenses, long-term care costs, and impairment-related work expenses.
DHS 103.087(1)(f)1.
1. An applicant or recipient shall pay 3 percent of his or her adjusted earned and unearned monthly income under par.
(d) that is in excess of 100 percent of the poverty line plus $25.
DHS 103.087(1)(f)2.
2. The monthly premium shall be recalculated by the county agency to reflect any changes in earned or unearned income as reported by the recipient.
A recipient's premium amount may change for any of the following reasons:
DHS 103.087(1)(f)2.bm.
bm. A change in the SSI federal or state benefit payment rate, except that an annual cost of living adjustment to the SSI benefit payment rates will not affect the monthly premium amount until after the subsequent change in the poverty line.
DHS 103.087(1)(f)2.c.
c. Changes in income, impairment-related work expense costs or medical and remedial expense costs.
DHS 103.087(1)(f)2.e.
e. Other changes in personal or financial status that alter medical assistance eligibility.
DHS 103.087(1)(g)1.1. Before the county agency may certify an applicant as eligible for the medicaid purchase plan, the applicant who owes a premium under this subsection shall pay the premium amount. The premium amount owed shall include the premiums for all retroactive and current months in which the applicant owes a premium as of the date eligibility is determined.
DHS 103.087(1)(g)2.
2. An applicant may claim retroactive medicaid purchase plan eligibility for a period of up to 3 months prior to the month of application, but not prior to January 1, 2000. To be eligible for retroactive eligibility, an applicant shall pay the retroactive premium amount for each month claimed, in full, to the state's fiscal agent via the county agency, prior to the county agency certifying the applicant's eligibility for the medicaid purchase plan.
DHS 103.087(1)(g)3.
3. Based on arrangements made by the applicant or recipient, entities other than the applicant or recipient may pay monthly premiums on behalf of the applicant or recipient. The applicant or recipient shall be ultimately responsible for his or her monthly premium payment.
DHS 103.087(1)(g)4.
4. If the county agency does not receive payment by the last day of the calendar month for which the premium is owed, the department shall terminate the recipient's eligibility for the medicaid purchase plan, effective the last calendar day of the month.
DHS 103.087(1)(g)6.
6. If no premium is required and the applicant meets all other eligibility factors, the county agency shall approve the applicant for the medicaid purchase plan.
DHS 103.087(1)(h)1.
1. An applicant or recipient required to pay a monthly premium shall be ineligible for re-enrollment for the period specified in par.
(i) 2. when the applicant or recipient fails to pay his or her monthly premium within the time specified in par.
(g) 4. resulting in a finding of premium non-payment.
DHS 103.087(1)(h)2.
2. Premium non-payment shall include attempted payment with an instrument such as a check or direct deposit, that has been returned, refused or dishonored. A guaranteed form of payment such as a cashier's check or money order shall be required to replace a returned, refused or dishonored payment.
DHS 103.087(1)(h)3.
3. Failure to pay premiums due to circumstances beyond the recipient's control may not be considered non-payment, provided that all past due premiums are paid in full. Circumstances beyond the recipient's control are any of the following:
DHS 103.087(1)(h)3.a.
a. Problems with an electronic funds transfer or direct deposit from a financial institution to the medicaid purchase plan program.
DHS 103.087(1)(h)3.d.
d. Any other circumstances that may be found to be good cause as determined by the department on a case-by-case basis.
DHS 103.087(1)(h)3.e.
e. Approval for a temporary premium waiver because the department has determined that paying the premium would be an undue hardship on the individual.
DHS 103.087(1)(h)4.
4. At the time of application or anytime thereafter, an applicant or recipient may sign a release statement identifying an emergency contact to receive copies of the person's notice of decision letters.
DHS 103.087(1)(i)1.1. A person eligible for the medicaid purchase plan who fails to pay his or her monthly premium shall be terminated from the medicaid purchase plan and subject to restrictive re-enrollment as described under subd.
2. DHS 103.087(1)(i)2.
2. A medicaid purchase plan participant who fails to make his or her monthly premium payments in the medicaid purchase plan shall be ineligible for a period of 3 consecutive calendar months following the date that the medicaid purchase plan eligibility ends except for any month during that period when the recipient's individual income does not exceed 100 percent of the poverty line. During these 3 calendar months, the person shall be eligible for the medicaid purchase plan only if all past premiums due are paid in full or a hardship waiver has been granted for the months the past due premiums are owed or a combination of the two. After these three calendar months have passed, a medicaid purchase plan recipient can be eligible.
DHS 103.087(2)
(2)
Cooperation with buy-in to employer-provided health care coverage. DHS 103.087(2)(a)
(a) The applicant eligible for the medicaid purchase plan and the applicant's parent, if the applicant is a dependent child aged 18 or 19, shall cooperate when the department determines whether it is cost-effective to purchase coverage under the employer-provided health plan for the person under s.
DHS 108.02 (14). In this subsection, “cooperate" means provide necessary information in order to determine cost-effectiveness, sign up with the health plan when requested by the department and comply with any other requirements of the health plan.
DHS 103.087(2)(b)1.1. Except as provided in subd.
2., a person who fails or refuses to cooperate with the department's buy-in to employer-provided health care coverage is not eligible for the medicaid purchase plan.
DHS 103.087(2)(b)2.
2. An exception to subd.
1. shall be made in cases where a person who is otherwise eligible for medical assistance is unable to enroll in the group health plan on his or her own behalf.
An example of a person who is otherwise eligible for medical assistance but unable to enroll in the group health plan on his or her own behalf may be a child whose parent refuses to enroll the child or a spouse unable to enroll on his or her own behalf.
