DHS 108.02(12)(a)4.
4. “Recipient” means a person who received services funded by medical assistance or the long-term community support program under s.
46.27 (7), 2017 Stats.
DHS 108.02(12)(a)5.
5. “Waiver applicant” means a beneficiary or heir of a decedent who requests the department to waive an estate claim filed by the department pursuant to s.
49.496 or
49.849, Stats, and s.
46.27 (7g), 2017 Stats.
DHS 108.02(12)(b)1.1. A beneficiary or heir of a decedent may apply to the department for a waiver of an estate claim filed by the department. The department shall review an application for a waiver under this subsection and shall determine whether the applicant meets the criterion under subd.
2. a.,
b. or
c. If the department determines that the criterion under subd.
2. a.,
b. or
c. is met, the department shall waive its claim as to that applicant.
DHS 108.02(12)(b)2.
2. Any of the following situations constitutes an undue hardship on the waiver applicant:
DHS 108.02(12)(b)2.a.
a. The waiver applicant would become or remain eligible for supplemental security income (SSI), food stamps under
7 USC 2011 to
2029, or medical assistance if the department pursued its claim.
DHS 108.02(12)(b)2.b.
b. A decedent's real property is used as part of the waiver applicant's business, which may be a working farm, and recovery by the department would affect the property and would result in the waiver applicant losing his or her means of livelihood.
DHS 108.02(12)(b)2.c.
c. The waiver applicant is receiving general relief, relief to needy Indian persons or veterans benefits based on need under s.
45.40 (1m), Stats.
DHS 108.02(12)(c)1.1. The department shall provide written notice of the hardship waiver provisions to the person handling the decedent's estate, if that person can be ascertained from the probate information provided to the department, or, if that person cannot be ascertained, the department shall include the notice with the copy of the claim it files with the probate court.
DHS 108.02(12)(c)2.
2. The person handling the decedent's estate shall be responsible for notifying the decedent's beneficiaries and heirs of the hardship waiver provisions.
DHS 108.02(12)(d)1.1. A waiver applicant shall mail his or her application for a waiver in writing to the department within 45 days after the date the department mailed its claim or affidavit pursuant to s.
49.496 or
49.849, Stats., or its notice under par.
(c), whichever is later. The application shall include the following information:
DHS 108.02(12)(d)1.a.
a. The relationship of the waiver applicant to the decedent and copies of documents establishing that relationship; and
DHS 108.02(12)(d)1.b.
b. The criterion under par.
(b) 2. a.,
b., or
c. which is the basis for the application and documentation supporting the waiver applicant's position.
DHS 108.02(12)(d)2.
2. The department shall review each application and issue a written decision within 90 days after the application was received by the department. The department shall consider all information received within 60 days following receipt of the application. The department's decision shall be based on information received within that time-period. The department's written decision shall include information regarding the waiver applicant's right to a hearing under par.
(e).
DHS 108.02(12)(e)1.1. If a waiver applicant wishes to contest the department's decision denying a waiver, the waiver applicant shall serve the department with a request for a hearing within 45 days of the date the department's decision was mailed. The hearing request shall be in writing and shall identify the basis for contesting the decision. The request shall be submitted to the department of administration's division of hearings and appeals. The date on which the division of hearings and appeals receives the request shall be the date of service.
DHS 108.02 Note
Note: The mailing address of the division of hearings and appeals is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 108.02(12)(e)2.
2. If a waiver applicant wishes to introduce information at the hearing that he or she did not submit to the department under par.
(d), the applicant shall provide the department with that information by mailing it to the department with a postmark of at least 7 working days prior to the hearing date.
DHS 108.02(12)(e)3.
3. The issue for hearing shall be whether the department's decision was correct based on the information submitted to the department by the waiver applicant within the time periods specified in par.
(d) 2. and subd.
2. No other information may be considered by the hearing examiner unless the hearing examiner finds that the applicant did not timely provide the information to the department for good cause. The hearing decision shall be the final decision of the department. The hearing shall be held in accordance with the provisions of ch.
227, Stats.
DHS 108.02(12)(f)
(f) Applicability. Heirs and beneficiaries may apply for a hardship waiver under this subsection from estate claims filed by the department pursuant to s.
49.496 or
49.849, Stats., in the estates of persons who die on or after April 1, 1995.
DHS 108.02(13)
(13)
BadgerCare buy-in to employer-provided health care coverage. DHS 108.02(13)(a)(a)
Authority. The department may purchase coverage under a group health insurance plan offered by the employer of a member of an eligible family if the department determines that purchasing that coverage would not be more costly than providing coverage under BadgerCare.
DHS 108.02(13)(b)1.1. The department may not buy in to a group health insurance plan when any member of a family has been covered by a group health insurance plan offered by the employer of a member of an eligible family in the 6 months prior to the buy-in decision.
DHS 108.02(13)(b)2.
2. Children in a family are not eligible for buy-in to a group health insurance plan if the family had health care coverage through the employer of a member of the family for these children within the previous 6 months.
DHS 108.02(13)(b)3.
3. The employer shall pay at least 60% of the cost of the premiums for the group health insurance plan, but not more than 80% of the cost, for the department to purchase coverage under a group health insurance plan.
DHS 108.02(13)(c)
(c) Buy-in method. The department shall purchase coverage by making payment to one of the following:
DHS 108.02(13)(c)2.
2. The insurance company that provides the group health insurance plan offered by the employer.
DHS 108.02(13)(c)3.
3. If it is not practical or feasible for the department to purchase coverage by making payment to those specified in subd.
1. or
2., and if requested by the employer or the insurance company offering the group health insurance plan, directly to the employee as reimbursement for premiums paid by the employee.
DHS 108.02(14)
(14)
Medicaid purchase plan buy-in to employer-provided health care coverage. DHS 108.02(14)(a)
(a)
Authority. The department may purchase a group health plan offered by the employer of an eligible person or non-eligible family member if the department determines that purchasing that coverage and the associated administrative expense would not be more costly than providing the medical assistance coverage described under this chapter.
DHS 108.02(14)(b)1.1. The department shall pay on behalf of the recipient all deductibles, coinsurance and other cost sharing obligations under the group health plan that are for services covered under the state plan, except for the nominal cost sharing amounts otherwise permitted under section 1916 of the social security act that are the responsibility of the recipient.
DHS 108.02(14)(b)2.
2. The department shall purchase coverage by making payment to one of the following:
DHS 108.02(14)(b)2.b.
b. The insurance company that provides the health care coverage offered by the employer.
DHS 108.02(14)(b)3.
3. If a non-medical assistance eligible family member is enrolled in the group health plan in order to obtain coverage for the medical assistance eligible family member, the department shall pay for premiums only and not other cost sharing expenses for the non-medical assistance eligible family member. Premium payments for non-eligible members shall be included in the determination of cost-effectiveness under par.
(c).
DHS 108.02(14)(b)4.
4. If a person's group health plan offers more services than are covered under the state plan, the department may not pay any deductibles, coinsurance or other cost sharing obligations for non-covered services.
DHS 108.02(14)(b)5.
5. Medicaid purchase plan eligible persons enrolled in a group health plan under this section shall be eligible for wrap-around coverage as described in ch.
DHS 101.
DHS 108.02(14)(c)
(c)
Cost-effectiveness determination. A person's enrollment in a group health plan shall be cost-effective when the amount the department pays for premiums, coinsurance, deductibles, other cost sharing obligations, wrap-around costs and additional administrative cost is likely to be less than or equal to the medical assistance expenditures for an equivalent set of services.
DHS 108.02(15)(b)
(b) Amounts recovered in estate recovery from a recipient of the medicaid purchase plan shall be reduced by the total amount of monthly premiums paid by the recipient as a condition of eligibility for the medicaid purchase plan.
DHS 108.02 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (4), cr. (8) and (9), eff. 7-1-92; am. (4), cr. (8) and (9),
Register, February, 1993, No. 446, eff. 3-1-93; correction in (6) (a) made under s. 13.93 (2m) (b) 7., Stats.,
Register, June, 1994, No. 462; cr. (10) to (12),
Register, June, 1995, No. 474, eff. 7-1-95; am. (10) (intro.), (b), (c) (intro.), 3. to 6., (11) (a), (b) 1. (intro.), c., 2. (intro.), c., (12) (a) 2., 4. and 5., cr. (10) (d) and (12) (f) 2., renum. (12) (f) to be (12) (f) 1.,
Register, April, 1996, No. 484, eff. 5-1-96; correction in (9) (e) made under s. 13.93 (2m) (b) 6., Stats.,
Register, April, 1999, No. 520; emerg. cr. (13), eff. 7-1-99; emerg. cr. (9) (f), eff. 12-23-99; cr
. (13),
Register, March, 2000, No. 531, eff. 4-1-00; cr. (14) and (15),
Register, November, 2000, No. 539, eff. 12-1-00;
corrections in (2), (4), (9) (d) 1., (10) (b), (c) 1., 2., 4. to 6., (12) (b) 2. c. and (14) (b) 5. made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
correction in (12) (b) 2. c. made under s. 13.92 (4) (b) 7., Stats.,
Register May 2010 No. 653; corrections in (10) (intro.), (11) (a), (12) (a) 2., 5., (d) 1. (intro.), (f) 1., 2., (15) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2013 No. 696;
CR 23-046: am. (9) (d) (title), 1., 2. (intro.), a. to d., 3. (intro.), a., r. (9) (d) 3. b., am. (9) (d) 3. c., cr. (9) (d) 4. to 8., am. (10) (intro.), (a), (b), (c) 1. a. to c., 2. to 6., (d), (11) (a), (12) (a) 2., 4., 5., (b) 2. a. to c., r. (12) (f) 2., am. (15) (a) Register April 2024 No.820, eff. 5-1-24; correction in (10) (c) (intro.), (12) (a) 2. made under s. 35.17, Stats., (12) (f) 1. renumbered (12) (f) under s. 13.92 (4) (b) 1., Stats., Register April 2024 No. 820. DHS 108.03(1)(1)
Determination of eligibility. Agencies shall be responsible for determination of eligibility for MA. These determinations shall comply with standards for eligibility found in ss.
49.46 (1),
49.47 (4), and
49.665 (4), Stats., and ch.
DHS 103.
DHS 108.03(2)
(2)
Informing recipients of rights and duties. Agencies shall inform recipients of the recipients' rights and duties under the program, including those rights enumerated in s.
DHS 106.04 (3).
DHS 108.03(3)(a)
(a) Agencies shall begin recovery action, as provided by statute for civil liabilities, on behalf of the department against any MA recipient to whom or on whose behalf an incorrect payment was made.
DHS 108.03(3)(b)
(b) The incorrect payment shall have resulted from a misstatement or omission of fact by the person supplying information during an application for MA benefits, or failure by the recipient, or any other person responsible for giving information on the recipient's behalf, to report income or assets in an amount which would affect the recipient's eligibility for benefits.
DHS 108.03(3)(c)
(c) The amount of recovery may not exceed the amount of the MA benefits incorrectly provided.
DHS 108.03(3)(d)
(d) Records of payment for the period of ineligibility, provided to the agency by the MA fiscal agent, shall be evidence of the amounts paid on behalf of the recipient.
DHS 108.03(3)(e)
(e) The agency shall notify the recipient or the recipient's representative of the period of ineligibility and the amounts incorrectly paid, and shall request arrangement of repayment within a specified period of time.
DHS 108.03(3)(f)
(f) If the effort to recover incorrect payments under par.
(e) is not successful, the agency shall refer cases of possible recovery to the district attorney or corporation counsel for investigation and the district attorney or corporation counsel may bring whatever action may be appropriate for prosecution for fraud or collection under civil liability statutes. Judgments obtained in these actions shall be filed as liens against property in any county in which the recipient is known to possess assets, if not satisfied at the time the judgment or order for restitution is rendered. Execution may be taken on the judgments as otherwise provided in statute.
DHS 108.03(3)(g)
(g) The agency may seek recovery through an order for restitution by the court of jurisdiction in which the recipient or former recipient is being prosecuted for fraud.
DHS 108.03(3)(h)
(h) The agency's decision concerning ineligibility and amounts owed may be appealed pursuant to ch.
HA 3. During the appeal process the agency may take no further recovery actions pending a decision. Benefits shall be continued pending the decision on the appeal. When the hearing decision is subsequently adverse to the client the benefits paid pending a decision on the appeal shall be collectable as incorrect payments.
DHS 108.03(3)(i)
(i) The agency shall immediately deposit monies collected under this subsection to a designated bank account. The collection shall be reported to the department in the manner and on forms designated by the department within 30 days following the end of the month in which the collection is made, and shall be transmitted to the state in accordance with departmental instructions.
DHS 108.03 History
History: Cr.
Register, December, 1979, No. 288, eff. 2-1-80; renum. from HSS 108.02 and am.
Register, February, 1986, No. 362, eff. 3-1-86; cr. (6),
Register, December, 1988, No. 396, eff. 1-1-89; r. (4), renum. (5) and (6) to be (4) and (5),
Register, September, 1991, No. 429, eff. 10-1-91; correction in (5) made under s. 13.93 (am) (b) 7., Stats.,
Register, September, 1991, No. 429; correction in (3) (h) made under s. 13.93 (2m) (b) 7., Stats.,
Register, May, 1995, No. 473; emerg. am. (1), eff. 7-1-99
; am. (1),
Register, March, 2000, No. 531, eff. 4-1-00;
corrections in (3) (h) and (4) made under s. 13.93 (2m) (b) 7., Stats.,
Register February 2002 No. 554; corrections in (1), (2) and (4) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 18-046: r. (5)
Register January 2019 No. 757, eff. 2-1-19;
CR 23-046: r. (4) Register April 2024 No. 820, eff. 5-1-24.
