Chapter 49

49.471(1)(k)5. 5. The unborn child and the mother of the unborn child meet all other applicable eligibility requirements under this chapter or established by the department by rule except for any of the following:

49.471(1)(k)5.a. a. The mother is not a U.S. citizen or an alien qualifying for Medicaid under 8 USC 1612.

49.471(1)(k)5.b. b. The mother is an inmate of a public institution.

49.471(1)(k)5.c. c. The mother does not provide a social security number, but only if subd. 5. a. applies.

49.471(2) (2) Waiver and state plan amendments. The department shall request a waiver from, and submit amendments to the state Medical Assistance plan to, the secretary of the federal department of health and human services to implement BadgerCare Plus. If the state plan amendments are approved and a waiver that is substantially consistent with the provisions of this section, excluding sub. (2m), is granted and in effect, the department shall implement BadgerCare Plus beginning on January 1, 2008, the effective date of the state plan amendments, or the effective date of the waiver, whichever is latest. If the state plan amendments are not approved or if a waiver that is substantially consistent with the provisions of this section, excluding sub. (2m), is not granted, BadgerCare Plus may not be implemented. If the state plan amendments are approved but approval is not continued or if a waiver that is substantially consistent with the provisions of this section, excluding sub. (2m), is granted but not continued in effect, BadgerCare Plus shall be discontinued.

49.471(2m) (2m) Approval to qualify as a health coverage tax credit plan. The department shall seek any necessary federal approvals to ensure that BadgerCare Plus is qualified health insurance under 26 USC 35 (e). Notwithstanding subs. (4) and (5), if BadgerCare Plus is determined to be qualified health insurance under 26 USC 35 (e), the department shall expand eligibility under BadgerCare Plus to include individuals who are eligible individuals under 26 USC 35 (c). Notwithstanding sub. (10) (a) and (b) 1. to 4., individuals who are eligible for coverage under BadgerCare Plus under this subsection shall pay premiums that are equal to the capitation payments that the department would make on behalf of similar individuals with coverage under BadgerCare Plus, or the full per member per month cost of coverage, whichever is appropriate.

49.471(3) (3) Ineligibility for other Medical Assistance benefits.

49.471(3)(a) (a)

49.471(3)(a)1. 1. Notwithstanding ss. 49.46 (1), 49.465, 49.47 (4), and 49.665 (4), if the amendments to the state plan under sub. (2) are approved and a waiver under sub. (2) that is substantially consistent with the provisions of this section, excluding sub. (2m), is granted and in effect, an individual described in sub. (4) (a) or (5) is not eligible under s. 49.46, 49.465, 49.47, or 49.665 for Medical Assistance or BadgerCare health program benefits. The eligibility of an individual described in sub. (4) (a) or (5) for Medical Assistance benefits shall be determined under this section.

49.471(3)(a)2. 2. Notwithstanding subd. 1., an individual who is eligible for medical assistance under s. 49.46 (1) (a) 3. or 4. may not receive benefits under this section.

49.471(3)(a)3. 3. Notwithstanding subd. 1., an individual described in sub. (4) (a) or (5) who is eligible for medical assistance under s. 49.46 (1) (a) 5., 6m., 14., 14m., or 15. or (d) or 49.47 (4) (a) or (as) may receive medical assistance benefits under this section or under s. 49.46 or 49.47.

49.471(3)(b) (b)

49.471(3)(b)1. 1. If an individual over 18 years of age who is eligible for and receiving Medical Assistance benefits under s. 49.46, 49.47, or 49.665 in the month before BadgerCare Plus is implemented loses that eligibility solely due to the implementation of BadgerCare Plus and, because of his or her income, is not eligible for BadgerCare Plus, the individual shall continue receiving for 12 consecutive months the medical assistance he or she was receiving before the implementation of BadgerCare Plus if all of the following are satisfied:

49.471(3)(b)1.a. a. The individual’s eligibility for the Medical Assistance benefits in the month before the implementation of BadgerCare Plus was based on an application filed before the implementation of BadgerCare Plus.

49.471(3)(b)1.b. b. The individual continues to pay any premium that he or she was required to pay for the Medical Assistance coverage in the same amount as the amount that was due in the month before the implementation of BadgerCare Plus.

49.471(3)(b)1.c. c. The individual meets all nonfinancial eligibility requirements under this section.

49.471(3)(b)1.d. d. The individual continues to be ineligible for BadgerCare Plus because of his or her income.

49.471(3)(b)2. 2. Notwithstanding subd. 1., if at any time during an individual’s 12-month eligibility extension under subd. 1. any criterion under subd. 1. a. to d. is not satisfied, the individual’s eligibility for the extended coverage is terminated and any time remaining in the eligibility period is lost.

49.471(4) (4) General eligibility criteria; applicable benefits.

49.471(4)(a) (a) Except as otherwise provided in this section, all of the following individuals are eligible for the benefits described in s. 49.46 (2) (a) and (b), subject to sub. (6) (k) and s. 49.45 (24j):

49.471(4)(a)1. 1. A pregnant woman whose family income does not exceed 200 percent of the poverty line.

49.471(4)(a)1g. 1g. A pregnant woman whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line.

49.471(4)(a)1m. 1m. A pregnant woman who obtains eligibility under sub. (7) (b) 1.

49.471(4)(a)2. 2. A child who is under one year of age, whose mother was, on the day the child was born, eligible for and receiving medical assistance under subd. 1. or 5. or s. 49.46 or 49.47, and who lives with his or her mother in this state.

49.471(4)(a)2m. 2m. A child who is under one year of age, whose mother was determined to be eligible under subd. 1g., and who lives with his or her mother in this state.

49.471(4)(a)3. 3. A child whose family income does not exceed 200 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care.

49.471(4)(a)3g. 3g. A child whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care.

49.471(4)(a)3m. 3m. A child who obtains eligibility under sub. (7) (b) 2.

49.471(4)(a)4. 4. An individual who satisfies all of the following criteria:

49.471(4)(a)4.a. a. The individual is a parent or caretaker relative of a dependent child who is living in the home with the parent or caretaker relative or who is temporarily absent from the home for not more than 6 months or, if the dependent child has been removed from the home for more than 6 months, the parent or caretaker relative is working toward unifying the family by complying with a permanency plan under s. 48.38 or 938.38. For purposes of this subdivision, a “dependent child” means an individual who is under the age of 18 or an individual who is age 18 and a full-time student in secondary school or equivalent vocational or technical training if before attaining the age of 19 the individual is reasonably expected to complete the school or training.

49.471(4)(a)4.b. b. The individual’s family income does not exceed 100 percent of the poverty line before application of the 5 percent income disregard under 42 CFR 435.603 (d).

49.471(4)(a)5. 5. An individual who, regardless of family income, was born on or after January 1, 1988, and who, on his or her 18th birthday, was in a foster care placement under the responsibility of this state, or at the option of the department, under the responsibility of another state, and enrolled in Medical Assistance under this subchapter or a Medicaid program, as determined by the department. The coverage for an individual under this subdivision ends on the last day of the month in which the individual becomes 26 years of age, unless he or she otherwise loses eligibility sooner.

49.471(4)(a)6. 6. Migrant workers and their dependents who are determined eligible under sub. (6) (f).

49.471(4)(a)7. 7. Individuals who qualify for a medical assistance eligibility extension under s. 49.46 (1) (c) or (cg) when their income increases above the poverty line, except as provided in s. 49.46 (1) (cr).

49.471(4)(d) (d) An individual is eligible to purchase coverage of the benefits described in sub. (11) for himself or herself and for his or her spouse and dependent children, at the full per member per month cost of coverage, if all of the following apply:

49.471(4)(d)1. 1. The individual lost his or her employer-sponsored health care coverage as a result of his or her employer’s or former employer’s bankruptcy.

49.471(4)(d)2. 2. After losing his or her employer-sponsored health care coverage, the individual received health care coverage through a voluntary employment benefit association that was established before August 2006.

49.471(4)(d)3. 3. The individual is not otherwise eligible for coverage under this section.

49.471(4)(d)4. 4. The individual is under 65 years of age.

49.471(4)(e) (e) If the department obtains approval from the federal department of health and human services to provide an alternate benchmark plan under sub. (11r), to the extent the federal department of health and human services approves, the department may enroll in the alternate benchmark plan under sub. (11r) any individual whose family income exceeds 100 percent of the poverty line, who is either an adult who is not pregnant or a child, and who applies and is otherwise eligible to receive benefits under this section, except that the department shall enroll a child who has a parent who is enrolled in a plan under this section in the same plan as his or her parent.

49.471(5) (5) Presumptive eligibility.

49.471(5)(a) (a) In this subsection:

49.471(5)(a)1. 1. “Qualified entity” means an entity that satisfies the requirements under 42 USC 1396r-1a (b) (3) (A), as determined by the department.

49.471(5)(a)2. 2. “Qualified provider” means a provider that satisfies the requirements under 42 USC 1396r-1 (b) (2), as determined by the department.

49.471(5)(b) (b)

49.471(5)(b)1. 1. Except as provided in sub. (6) (a) 1., a pregnant woman is eligible for the benefits specified in par. (c) during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman’s family income does not exceed 300 percent of the poverty line and ending on the applicable day specified in subd. 3.

49.471(5)(b)2. 2. Except as provided in sub. (6) (a) 2., a child who is not an unborn child is eligible for the benefits described in s. 49.46 (2) (a) and (b) during the period beginning on the day on which a qualified entity determines, on the basis of preliminary information, that the child’s family income does not exceed any of the following and ending on the applicable day specified in subd. 3., unless the federal department of health and human services approves the department’s request to not extend eligibility to children during this period:

49.471(5)(b)2.a. a. 150 percent of the poverty line for a child who is 6 years of age or older but has not yet attained the age of 19.

49.471(5)(b)2.b. b. 185 percent of the poverty line for a child who is one year of age or older but has not yet attained the age of 6.

49.471(5)(b)2.c. c. 300 percent of the poverty line for a child who is under one year of age.

49.471(5)(b)3. 3.

49.471(5)(b)3.a. a. If the woman or child applies for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the day on which the department or the county department under s. 46.215, 46.22, or 46.23 determines whether the woman or child is eligible for benefits under sub. (4), except that a child who is not an unborn child is not eligible for benefits described in s. 49.46 (2) (a) and (b) during that time if the federal department of health and human services approves the department’s request not to provide those benefits during that time.

49.471(5)(b)3.b. b. If the woman or child does not apply for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the last day of the month following the month in which the provider or entity makes the determination under this paragraph.

49.471(5)(c) (c)

49.471(5)(c)1. 1. On behalf of a woman under par. (b) 1. whose family income does not exceed 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits described in s. 49.46 (2) (a) and (b).

49.471(5)(c)2. 2. On behalf of a woman under par. (b) 1. whose family income exceeds 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits under sub. (11).

49.471(5)(d) (d) A woman or child who is determined to be eligible under par. (b) shall apply for benefits under sub. (4) on or before the last day of the month following the month in which the qualified provider or entity makes the eligibility determination.

49.471(5)(e) (e) A qualified provider or entity that determines that a woman or child is eligible under par. (b) shall do all of the following:

49.471(5)(e)1. 1. Notify the department of that determination within 5 working days after the day on which the determination is made.

49.471(5)(e)2. 2. Notify the woman or child of the requirement under par. (d) at the time of the determination.

49.471(5)(f) (f) The department shall provide qualified providers and qualified entities with application forms for the benefits under sub. (4) and information on how to assist women and children in completing the forms.

49.471(6) (6) Miscellaneous eligibility and benefit provisions.

49.471(6)(a) (a)

49.471(6)(a)1. 1. Except as provided in subd. 4., any pregnant woman, including a pregnant woman under sub. (5) (b) 1., is eligible for medical assistance under this section for any of the 3 months prior to the month of application if she met the eligibility criteria under this section in that month.

49.471(6)(a)2. 2. Except as provided in subd. 3. or 4., any child who is not an unborn child, including a child under sub. (5) (b) 2., parent, or caretaker relative whose family income is less than 150 percent of the poverty line is eligible for medical assistance under this section for any of the 3 months prior to the month of application if the individual met the eligibility criteria under this section and had a family income of less than 150 percent of the poverty line in that month.

49.471(6)(a)3. 3. Any individual described in subd. 2. who is not disabled, not elderly, and not pregnant, who is an adult, and whose family income exceeds 133 percent of the federal poverty level is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.

49.471(6)(a)4. 4. To the extent allowed by the federal department of health and human services, any individual described in subd. 1. or 2. who is not disabled is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.

49.471(6)(b) (b) A pregnant woman who is determined to be eligible for benefits under sub. (4) remains eligible for benefits under sub. (4) for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 90th day after the last day of the pregnancy falls without regard to any change in the woman’s family income.

49.471(6)(c) (c) If a child who is eligible for benefits under sub. (4) is receiving inpatient services covered under sub. (4) on the day before his or her 19th birthday and, but for attaining 19 years of age, the child would remain eligible for benefits under sub. (4), the child remains eligible for benefits until the end of the stay for which the inpatient services are being furnished.

49.471(6)(d) (d) If an application under this section shows that an individual is an essential person, the individual shall be provided the benefits specified under sub. (4) (a).

49.471(6)(f) (f) The medical assistance eligibility provisions for migrant workers and their dependents under s. 49.47 (4) (av) apply to BadgerCare Plus.

49.471(6)(g) (g)

49.471(6)(g)1. 1. Except as provided in subd. 2., as a condition of eligibility for coverage under this section, an individual with income shall provide verification, as determined by the department, of that income.

49.471(6)(g)2. 2. Subdivision 1. does not apply to an individual under sub. (4) (a) 5. or a child under the age of 18.

49.471(6)(h) (h) Within 10 days after the change occurs, a recipient shall report to the department any change that might affect his or her eligibility or any change that might require premium payment by a recipient who was not required to pay premiums before the change.

49.471(6)(i) (i) For purposes of determining eligibility and family income, the department shall include a family member who is temporarily absent from the home for not more than 6 months, as determined by the department.

49.471(6)(j) (j) All of the following apply to BadgerCare Plus in the same respect as they apply under s. 49.46:

49.471(6)(j)1. 1. Section 49.46 (2) (c) and (cm), relating to benefits for individuals who are eligible for Medicare.

49.471(6)(j)2. 2. Section 49.46 (2) (d), relating to prohibiting payments for any part of any service payable through 3rd-party liability or any governmental or private benefit system.

49.471(6)(j)3. 3. Section 49.46 (2) (dm), relating to prohibiting payment for services to residents of institutions for mental diseases.

49.471(6)(j)4. 4. Section 49.46 (2) (f), relating to prohibiting payment for gastric bypass or stapling surgery.

49.471(6)(k) (k) For an individual who is eligible for medical assistance under this section and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under sub. (11) (a) or s. 49.46 (2) (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug.

49.471(6)(L) (L) The department shall request from the federal department of health and human services approval of a state plan amendment or a waiver of federal law to implement subs. (6) (b) and (7) (b) 1. and ss. 49.46 (1) (a) 1m. and (j) and 49.47 (4) (ag) 2.

49.471(7) (7) Special income provisions.

49.471(7)(b) (b)

49.471(7)(b)1. 1. A pregnant woman whose family income exceeds 300 percent of the poverty line may become eligible for coverage under this section if the difference between the pregnant woman’s family income and the applicable income limit under sub. (4) (a) is obligated or expended for any member of the pregnant woman’s family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision continues without regard to any change in family income for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 90th day after the last day of the woman’s pregnancy falls. Eligibility obtained by a pregnant woman under this subdivision extends to all pregnant women in the pregnant woman’s family.

49.471(7)(b)2. 2. A child who is not an unborn child, whose family income exceeds 150 percent of the poverty line, and who is ineligible under this section solely because of sub. (8) (b), or whose family income exceeds 300 percent of the poverty line, may obtain eligibility under this section if the difference between the child’s family income and 150 percent of the poverty line is obligated or expended on behalf of the child or any member of the child’s family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision during any 6-month period, as determined by the department, continues for the remainder of the 6-month period and extends to all children in the family.

49.471(7)(b)3. 3. For a pregnant woman to obtain eligibility under subd. 1., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the pregnant woman’s monthly family income and the monthly family income that is 300 percent of the poverty line. For a child to obtain eligibility under subd. 2., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the child’s monthly family income and the monthly family income that is 150 percent of the poverty line.

49.471(7)(d) (d) In addition to applying other income counting requirements the department shall do all of the following: