Chapter DHS 103

DHS 103.085(3)(b)1.b. b. A problem with an employer’s wage withholding.

DHS 103.085(3)(b)1.c. c. An administrative error in processing the premium.

DHS 103.085(3)(b)1.d. d. A fair hearing decision.

DHS 103.085(3)(b)2. 2. The child’s income decreases to at or below 201% of the poverty line.

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) (1) Premiums.

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) (b) Applicability.

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) (c) Premium amounts.

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)(c)4. 4. The applicant’s or recipient’s monthly premium shall be at least $25.

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) (f) Calculating the total monthly premium.

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.a. a. Termination of the recipient from the medicaid purchase plan.

DHS 103.087(1)(f)2.b. b. A change in the poverty line.

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.d. d. Contributions to a recipient’s independence account greater than an amount equal to 50% of earned income as described in s. DHS 103.06 (15).

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) (g) Monthly payments.

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)5. 5. The applicant or recipient shall pay monthly premium amounts in full.

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) (h) Non-payment of medicaid purchase plan premiums.

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.b. b. Problems with an employer’s wage withholding.

DHS 103.087(1)(h)3.c. c. Administrative error in processing the premium.

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) (i) Consequences of premium non-payment.

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) (b)

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.

DHS 103.087 History History: Cr. Register, November, 2000, No. 539, eff. 12-1-00; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 21-067: cr. (1) (h) 5. Register March 2022 No 795, eff. 4-1-22, r. (1) (h) 5. eff. the first day of the month after the last day of the quarter or on the first day of the calendar month following the month in which the emergency period, as defined in 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends, whichever occurs later; correction in (1) (h) 5. made under s. 35.17, Stats., Register March 2022 No. 795; CR 23-046: am. (1) (b) 1., 2., r. (1) (b) 3., am. (1) (c) 1., 4., renum. (1) (d) 1. (intro.) to (1) (d) 1. and am., r. (1) (d) 1. a. to c., 2., (e), r. and recr. (1) (f) 1., am. (1) (f) 2. b., cr. (1) (f) 2. bm., am. (1) (g) 5., cr. (1) (h) 3. e., am. (1) (i) 2., r. Table 103.087 Register April 2024 No. 820, eff. 5-1-24.

DHS 103.09 DHS 103.09 Termination of medical assistance.

DHS 103.09(1) (1) Final month coverage. When eligibility ends, except in the case of death of the recipient, the MA benefits shall continue until the end of the calendar month.

DHS 103.09(2) (2) Four-month continuation of eligibility.

DHS 103.09(2)(a) (a) When a parent, caretaker, or pregnant person eligible for BadgerCare Plus has an increase in MAGI-based countable monthly income under s. DHS 103.04 (7) (d) that exceeds 100% of the federal poverty line, BadgerCare Plus eligibility for the persons identified in par. (c) will continue for four months when the conditions in par. (b) are met. Eligibility shall be discontinued when the person is no longer a resident of Wisconsin.

DHS 103.09(2)(b) (b) To receive a four-month continuation of BadgerCare Plus eligibility, all of the following conditions must be met by the parent, caretaker or pregnant person:

DHS 103.09(2)(b)1. 1. The monthly income increase which caused the countable income to exceed 100% of the poverty line must be due solely to one of the following:

DHS 103.09(2)(b)1.a. a. Increased spousal support income.

DHS 103.09(2)(b)1.b. b. Increased spousal support income along with other unearned income.

DHS 103.09(2)(b)2. 2. There has been no increase in earned income.

DHS 103.09(2)(b)3. 3. The person receiving the spousal support is eligible for BadgerCare Plus with monthly income at or below 100% of the poverty line at the time the income increased to over 100% of the poverty line.

DHS 103.09(2)(b)4. 4. The person must have been enrolled in BadgerCare Plus with monthly income that was at or below 100% of the poverty line for at least three of the six months immediately preceding the month in which the monthly income went above 100% of the poverty line.

DHS 103.09(2)(b)5. 5. The person must otherwise meet the BadgerCare Plus eligibility criteria for persons with monthly income below 100% of the poverty line.

DHS 103.09(2)(c) (c) When a parent, caretaker, or pregnant person eligible for BadgerCare Plus meets the condition in par. (b), any of the following persons in the home, who otherwise meet the BadgerCare Plus eligibility criteria are eligible for BadgerCare Plus for four months past the month in which income exceeded 100% of the poverty line:

DHS 103.09(2)(c)1. 1. The parent, caretaker or pregnant person who received the spousal support.

DHS 103.09(2)(c)2. 2. All children whose parent or caretaker relative qualify for four months of continued eligibility under this subsection is eligible for the same four months of continued eligibility, provided that they are eligible for BadgerCare Plus in the month prior to the increase in countable income and one of the following applies:

DHS 103.09(2)(c)2.a. a. The child is under age one, and the parent or caretaker had MAGI-based countable income at or below 306% of the poverty line and is not eligible under ss. 49.471 (4) (a) 2. or 2m, Stats.

DHS 103.09(2)(c)2.b. b. The child is age one through five and the parent or caretaker had MAGI-based countable income at or below 191% of the poverty line.

DHS 103.09(2)(c)2.c. c. The child is age six through 18 and the parent or caretaker had MAGI-based countable income at or below 156% of the poverty line.

DHS 103.09(3) (3) Twelve-month continuation of eligibility.

DHS 103.09(3)(b) (b) When a parent or caretaker relative in a BadgerCare Plus group becomes ineligible due to an increase in earned income, eligibility for BadgerCare Plus shall continue for 12 months from the date that eligibility was terminated if all of the following conditions are satisfied:

DHS 103.09(3)(b)1. 1. At least one member of the BadgerCare Plus group received BadgerCare Plus for at least 3 of the 6 months immediately preceding the month in which BadgerCare Plus was discontinued.

DHS 103.09(3)(b)2. 2. at least one member of the BadgerCare Plus group is continuously employed during that period

DHS 103.09(3)(c) (c) When a parent or caretaker relative in a BadgerCare Plus group becomes ineligible for BadgerCare Plus due to an increase in earned income, or to a combination of an increase in earned income and in increase in spousal support payments, and has received BadgerCare Plus in at least 3 of the 6 months immediately preceding the month in which ineligibility begins, eligibility for BadgerCare Plus shall continue for 12 months from the date that BadgerCare Plus eligibility was terminated. The 6 months preceding the month in which ineligibility begins includes the month in which the BadgerCare Plus group became ineligible for BadgerCare Plus if the group was eligible for and received BadgerCare Plus for that month.

DHS 103.09(4) (4) Timely notice. The agency shall give the recipient timely advance notice and explanation of the agency’s intention to terminate MA. This notice shall be in writing and shall be mailed to the recipient at least 10 calendar days before the effective date of the proposed action. The notice shall clearly state what action the agency intends to take and the specific regulation supporting that action, and shall explain the right to appeal the proposed action and the circumstances under which MA is continued if a fair hearing is requested.

DHS 103.09 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (3) (a), r. (2) (a), renum. (2) (b) to be (2) and am., r. and recr. (3) (b), cr. (3) (c), Register, March, 1993, No. 447, eff. 4-1-93; CR 21-067: am. (2), (3) Register March 2022 No 795, eff. 4-1-22, am. (2), (3) eff. the first day of the month after the emergency period, as defined in 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; CR 23-046: r. and recr. (2), r. (3) (a), renum. (3) (b) to (3) (b) (intro.) and am., cr. (3) (b) 1., 2., am. (3) (c) Register April 2024 No. 820, eff. 5-1-24; corrections in (2) (a), (c) (intro.), 1., 2. a. made under s. 35.17, Stats., Register April 2024 No. 820.

DHS 103.10 DHS 103.10 Redetermination of eligibility. The agency shall give the recipient timely advance notice of the date on which the recipient’s eligibility will be redetermined. This notice shall be in writing and mailed to the recipient at least 15 calendar days but no more than 30 calendar days before the redetermination date. The requirement for timely advance notice of eligibility redetermination does not apply to spend-down cases in which the period of certification is less than 60 days.

DHS 103.10 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

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

DHS 103.11(1) (1) Requirements for pregnant women. Pregnant women may be determined presumptively eligible for MA on the basis of a statement of pregnancy, and preliminary household and financial information provided by the applicant. That determination shall be made by providers or hospitals designated by the department who are qualified in accordance with this section.

DHS 103.11(1e) (1e) Provider requirements. A provider qualified to make determinations of presumptive eligibility for pregnant women, and women diagnosed with breast or cervical cancer or precancerous conditions shall meet the following requirements:

DHS 103.11(1e)(a) (a) Be certified as an MA provider under ch. DHS 105.