Chapter DHS 103

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.

DHS 103.11(1e)(b) (b) Provide one or more of the following services:

DHS 103.11(1e)(b)1. 1. Outpatient hospital services.

DHS 103.11(1e)(b)2. 2. Rural health clinic services.

DHS 103.11(1e)(b)3. 3. Clinic services furnished by or under the direction of a physician.

DHS 103.11(1e)(c) (c) Receive funding or participate in a program under:

DHS 103.11(1e)(c)1. 1. The migrant health center or community health center programs under section 330 of the public health service act.

DHS 103.11(1e)(c)2. 2. The maternal and child health services block grant programs.

DHS 103.11(1e)(c)3. 3. The special supplemental food program for women, infants and children under section 17 of the child nutrition act of 1966, 42 USC 1786.

DHS 103.11(1e)(c)4. 4. The commodity supplemental food program under section 4 (a) of the agriculture and consumer protection act of 1973.

DHS 103.11(1e)(c)5. 5. A state prenatal program.

DHS 103.11(1e)(d) (d) Have been determined by the department to be a qualified provider under this section.

DHS 103.11(1m) (1m) Requirements for women diagnosed with breast or cervical cancer or precancerous conditions. Women may be determined presumptively eligible for MA on the basis of a diagnosis of breast or cervical cancer or precancerous conditions if they meet the requirements in s. 49.473 (2) (a) to (e), Stats.

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

DHS 103.11(1s)(a) (a) Be certified for MA as a general hospital under s. DHS 105.07.

DHS 103.11(1s)(b) (b) Notify the state Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures.

DHS 103.11(1s)(c) (c) Have not been disqualified by the department for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the department.

DHS 103.11(2) (2) Duties and responsibilities.

DHS 103.11(2)(a) (a) A qualified provider or hospital shall ascertain presumptive MA eligibility for a pregnant woman or a woman diagnosed with breast or cervical cancer or precancerous conditions by:

DHS 103.11(2)(a)1. 1. Determining on the basis of preliminary information that the applicant’s household or individual information meets the applicable non-financial requirements set by the department.

DHS 103.11(2)(a)2. 2. Determining on the basis of preliminary information that the applicant’s household or individual income meets the applicable income limits set by the department.

DHS 103.11(2)(b) (b) The provider or hospital shall inform the applicant, in writing, of the determination of presumptive eligibility.

DHS 103.11(2)(bm) (bm) In the event that the provider or hospital determines that the applicant is presumptively eligible, the provider or applicant shall explain to the applicant that the presumptive eligibility is for a temporary enrollment period and to file an application for MA eligibility with the county department of social services.

DHS 103.11(2)(c) (c) Within 5 working days following the date on which the determination was made, the provider or hospital shall in writing notify the department of the applicant’s presumptive eligibility.

DHS 103.11(2)(d) (d) In the event that the provider or hospital determines that the applicant is not presumptively eligible, the provider or hospital shall inform the applicant that he or she may file an application for MA eligibility at the county department of social services.

DHS 103.11 History History: Cr. Register, February, 1988, No. 386, 3-1-88; correction in (1) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 23-046: am. (title), (1) (title), renum. (1) (intro.) to (1) and am., renum. (1) (a) to (d) to be (1e) (a) to (d) and am., cr. (1e) (intro.), (1m), (1s), am. (2) (a), (b), cr. (2) (bm), am. (2) (c), (d); correction in (title) made under s. 13.92 (4) (b) 2., Stats., corrections in (1e) (b) (intro.), (c) (intro.), 5. made under s. 35.17, Stats., and corrections in (1e) (c) 1., 3., 4., (1m) made under s. 13.92 (4) (b) 7., Stats., Register April 2024 No. 820.