Chapter 49

49.471(11)(a) (a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription.

49.471(11)(b) (b) Physicians’ services, including one annual routine physical examination, with a copayment of no more than $15 per visit.

49.471(11)(c) (c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.

49.471(11)(d) (d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75.

49.471(11)(e) (e) Laboratory and X-ray services, including mammography.

49.471(11)(f) (f) Home health services, limited to 60 visits per year.

49.471(11)(g) (g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

49.471(11)(h) (h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

49.471(11)(i) (i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

49.471(11)(j) (j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

49.471(11)(k) (k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).

49.471(11)(L) (L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.

49.471(11)(m) (m) Transportation to obtain medical care, as medically necessary, and, to the extent permitted under federal law, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

49.471(11)(n) (n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.

49.471(11)(o) (o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.

49.471(11)(p) (p) Early childhood developmental services, for children under 6 years of age.

49.471(11)(q) (q) Smoking cessation treatment, for pregnant women only.

49.471(11)(r) (r) Prenatal care coordination, for pregnant women at high risk only.

49.471(11)(s) (s) Early and periodic screening and diagnosis, and all services included in the definition of “medical assistance” under 42 USC 1396d (a) that are found necessary by this screening and diagnosis, for recipients under 21 years of age.

49.471(11m) (11m) Provider payments and requirements. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs.

49.471(11r) (11r) Alternate Benchmark plan benefits and copayments.

49.471(11r)(a) (a) If the department chooses to provide the alternate benchmark plan under this subsection, the department shall provide to the recipients described under sub. (4) (e) coverage for benefits similar to those in a commercial, major medical insurance policy.

49.471(11r)(b) (b) The department may charge copayments to recipients receiving coverage under the alternate benchmark plan under this subsection that are higher than copayments charged to recipients receiving coverage under the standard plan under s. 49.46 (2). The department may not charge to a recipient of coverage under the alternate benchmark plan under this subsection whose family income is at or below 150 percent of the poverty line a copayment that exceeds 5 percent of the individual’s family income for all members of the family.

49.471(11r)(c) (c)

49.471(11r)(c)1. 1. The department may only provide coverage under the alternate benchmark plan under this subsection to the extent the alternate benchmark plan is approved by the federal department of health and human services.

49.471(11r)(c)2. 2. If the department is providing coverage under the alternate benchmark plan under this subsection the department may discontinue coverage under the benchmark plan under sub. (11) for those individuals eligible for the alternate benchmark plan under this subsection.

49.471(11r)(c)3. 3. The department may provide services to individuals enrolled in the alternate benchmark plan under this subsection through a medical home initiative similar to an initiative described under s. 49.45 (24j).

49.471(12) (12) Rules; notice of effective date.

49.471(12)(a) (a)

49.471(12)(a)1. 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.

49.471(12)(a)2. 2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.

49.471(12)(b) (b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is substantially consistent with the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.

49.471 History History: 2007 a. 20; 2009 a. 28, 180, 219; 2011 a. 10, 32; 2013 a. 20; 2013 a. 116 ss. 4, 5, 29 to 31, 33; 2013 a. 117 ss. 2 to 5; 2015 a. 55; 2021 a. 58.

49.472 49.472 Medical assistance purchase plan.

49.472(1) (1) Definitions. In this section:

49.472(1)(a) (a) “Earned income” has the meaning given in 42 USC 1382a (a) (1).

49.472(1)(am) (am) “Family” means an individual, the individual’s spouse and any dependent child, as defined in s. 49.141 (1) (c), of the individual.

49.472(1)(b) (b) “Health insurance” means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.

49.472(1)(c) (c) “Independence account” means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which an individual began receiving medical assistance under this section.

49.472(1)(d) (d) “Medical assistance purchase plan” means medical assistance, eligibility for which is determined under this section.

49.472(1)(e) (e) “Unearned income” has the meaning given in 42 USC 1382a (a) (2).

49.472(2) (2) Waivers and amendments. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.

49.472(3) (3) Eligibility. Except as provided in sub. (6) (a), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:

49.472(3)(a) (a) The individual’s family’s net income is less than 250 percent of the poverty line for a family the size of the individual’s family. In calculating the net income, the department shall apply all of the exclusions specified under 42 USC 1382a (b) and to the extent approved by the federal government shall exclude medical and remedial expenditures and long-term care costs in excess of $500 per month that would be incurred by the individual in absence of coverage under the medical assistance purchase plan or a Medicaid long-term care program.

49.472(3)(b) (b) The individual’s assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under 42 USC 1382b (a), assets accumulated in an independence account, and, to the extent approved by the federal government, assets from retirement benefits accumulated from income or employer contributions while employed and receiving medical assistance under this section or state-funded benefits under s. 46.27, 2017 stats. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.

49.472(3)(c) (c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under 42 USC 1396d (q) (2) (B) and (D).

49.472(3)(e) (e) The individual is legally able to work in all employment settings without a permit under s. 103.70.

49.472(3)(f) (f) The individual maintains premium payments under sub. (4) (am) and, if applicable and to the extent approved by the federal government, premium payments calculated by the department in accordance with sub. (4) (bm), unless the individual is exempted from premium payments under sub. (4) (dm).

49.472(3)(g) (g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals. To the extent approved by the federal government, an individual shall prove gainful employment and earned income to the department by providing wage income or prove in-kind work income by federal tax filing documentation. To qualify as gainful income, the amount of in-kind income shall be equal to or greater than the minimum amount for which federal income tax reporting is required.

49.472(3)(h) (h) The individual meets all other requirements established by the department by rule.

49.472(4) (4) Premiums.

49.472(4)(am) (am) To the extent approved by the federal government and except as provided in pars. (dm) and (em), an individual who receives medical assistance under this section shall pay a monthly premium of $25 to the department.

49.472(4)(bm) (bm) To the extent approved by the federal government, in addition to the $25 monthly premium under par. (am), an individual who receives medical assistance under this section and whose individual income exceeds 100 percent of the poverty line for a single-person household shall pay 3 percent of his or her adjusted earned and unearned monthly income under par. (cm) that is in excess of 100 percent of the poverty line.

49.472(4)(cm) (cm) For the purposes of par. (bm), an individual’s adjusted earned and unearned monthly income is calculated by subtracting from the individual’s earned and unearned monthly income his or her actual out-of-pocket medical and remedial expenses, long-term care costs, and impairment-related work expenses.

49.472(4)(dm) (dm) The department shall temporarily waive an individual’s monthly premium under par. (am) and, if applicable, par. (bm) when the department determines that paying the premium would be an undue hardship on the individual.

49.472(4)(em) (em) If the department determines that a state plan amendment or waiver of federal Medicaid law is necessary to implement the premium methodology under this subsection and changes to the income and asset eligibility under sub. (3) and s. 49.47 (4) (c) 1., the department shall submit a state plan amendment or waiver request to the federal department of health and human services requesting those changes. If a state plan amendment or waiver is not necessary or if the federal department of health and human services does not disapprove the state plan amendment or waiver request, the department may implement subs. (3) and (4) and s. 49.47 (4) (c) 1. with any adjustments from the federal department of health and human services. If the federal department of health and human services disapproves the state plan amendment or waiver request in whole or in part, the department may implement the income and asset eligibility requirements and premium methodology under subs. (3) and (4), 2015 stats., and s. 49.47 (4) (c) 1., 2015 stats.

49.472(6) (6) Insured persons.

49.472(6)(a) (a) Notwithstanding sub. (4), from the appropriation accounts under s. 20.435 (4) (b), (gm), or (w), the department shall, on the part of an individual who is eligible for medical assistance under sub. (3), pay premiums for or purchase individual coverage offered by the individual’s employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.

49.472(6)(b) (b) If federal financial participation is available, from the appropriation accounts under s. 20.435 (4) (b), (gm), or (w), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under sub. (3).

49.472(7) (7) Department duties. The department shall do all of the following:

49.472(7)(a) (a) Determine eligibility, or contract with a county department, as defined in s. 49.45 (6c) (a) 3., or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with sub. (3).

49.472(7)(b) (b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.

49.472 History History: 1999 a. 9, 185; 2001 a. 16; 2003 a. 33; 2009 a. 2; 2011 a. 10, 32; 2015 a. 55; 2015 a. 197 s. 51; 2017 a. 59; 2019 a. 9.

49.472 Cross-reference Cross-reference: See also chs. DHS 103 and 107 and s. DHS 103.087, Wis. adm. code.

49.473 49.473 Medical assistance; women diagnosed with breast or cervical cancer or precancerous conditions.

49.473(1) (1) In this section:

49.473(1)(a) (a) “County department” means a county department under s. 46.215, 46.22, or 46.23.

49.473(1)(b) (b) “Qualified entity” has the meaning given in 42 USC 1396r-1b (b) (2).

49.473(2) (2) A woman is eligible for medical assistance as provided under sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:

49.473(2)(a) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.

49.473(2)(b) (b) The woman is under 65 years of age.

49.473(2)(c) (c) The woman is not eligible for health care coverage that qualifies as creditable coverage in 42 USC 300gg (c), excluding the coverage specified in 42 USC 300gg (c) (1) (F).

49.473(2)(d) (d) The woman has been screened for breast or cervical cancer under a breast and cervical cancer early detection program that is authorized under a grant received under 42 USC 300k.

49.473(2)(e) (e) The woman requires treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix.

49.473(3) (3) Prior to applying to the department or a county department for medical assistance, a woman is eligible for medical assistance as provided under sub. (5) beginning on the date on which a qualified entity determines, on the basis of preliminary information, that the woman meets the requirements specified in sub. (2) and ending on one of the following dates:

49.473(3)(a) (a) If the woman applies to the department or a county department for medical assistance within the time limit required under sub. (4), the day on which the department or county department determines whether the woman meets the requirements under sub. (2).

49.473(3)(b) (b) If the woman does not apply to the department or county department for medical assistance within the time limit required under sub. (4), the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.

49.473(4) (4) A woman who a qualified entity determines under sub. (3) is eligible for medical assistance shall apply to the department or county department no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.

49.473(5) (5) The department shall audit and pay, from the appropriation accounts under s. 20.435 (4) (b), (gm), and (o), allowable charges to a provider who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under sub. (2) for all benefits and services specified under s. 49.46 (2).

49.473(6) (6) A qualified entity that determines under sub. (3) that a woman is eligible for medical assistance as provided under sub. (5) shall do all of the following:

49.473(6)(a) (a) Notify the department of the determination no later than 5 days after the date on which the determination is made.

49.473(6)(b) (b) Inform the woman at the time of the determination that she is required to apply to the department or a county department for medical assistance no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.

49.473(7) (7) The department shall provide qualified entities with application forms for medical assistance and information on how to assist women in completing the form.

49.473 History History: 2001 a. 16, 104; 2003 a. 33; 2007 a. 20; 2009 a. 2; 2011 a. 10, 32.

49.475 49.475 Information about assistance program beneficiaries; electronic submission of claims.

49.475(1) (1) Definitions. In this section:

49.475(1)(ar) (ar) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

49.475(1)(b) (b) “Insurer” has the meaning given in s. 600.03 (27).

49.475(1)(c) (c) “Pharmacy benefits management” means the administration or management of prescription drug benefits provided by an insurer or other 3rd party, including the performance of any of the following services: