Chapter 49

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:

49.471(7)(d)1. 1. When calculating the family income of a member of a household who is not disabled, include the income of all adults residing in the home for at least 60 consecutive days but exclude the income of a grandparent in a household containing 3 generations, unless the grandparent applies for or receives benefits as a parent or caretaker relative under this section.

49.471(7)(d)2. 2. When determining the size of a family for purposes of determining income eligibility, exclude from family size an adult whose income is included in a calculation of family income solely under subd. 1.

49.471(7)(d)3. 3. Apply this paragraph only to the extent the federal department of health and human services approves the income eligibility calculation methods, if approval is required.

49.471(7)(e) (e) For the purpose of determining family income, the department shall apply the regulations defining a household under 42 CFR 435.603 (f). To determine the family size for a pregnant woman, the department shall include the pregnant woman and the number of babies she is expecting.

49.471(8) (8) Health insurance coverage and eligibility.

49.471(8)(a) (a)

49.471(8)(a)1. 1. Except as provided in subd. 2., any individual who is otherwise eligible under this section and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for BadgerCare Plus and if the department determines that it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor’s behalf.

49.471(8)(a)2. 2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with subd. 1., the failure does not affect the minor’s eligibility under this section.

49.471(8)(b) (b) Except as provided in pars. (c), (cg), (cr), (ct), and (d), an individual whose family income exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of the following applies:

49.471(8)(b)1. 1. The individual has individual or family health insurance coverage that is any of the following:

49.471(8)(b)1.a. a. Coverage provided by an employer and for which the employer pays at least 80 percent of the premium.

49.471(8)(b)1.b. b. Coverage under the state employee health plan under s. 40.51 (6).

49.471(8)(b)2. 2. The individual, in the 12 months before applying, had access to the health insurance coverage specified in subd. 1.

49.471(8)(b)3. 3. The individual could be covered under the health insurance coverage specified in subd. 1. if the coverage is applied for, and the coverage could become available to the individual in the month in which the individual applies for benefits under this section or in any of the next 3 calendar months.

49.471(8)(c) (c) An unborn child, regardless of family income, is not eligible for BadgerCare Plus if any of the following applies:

49.471(8)(c)1. 1. The unborn child or the unborn child’s mother has individual or family health insurance coverage.

49.471(8)(c)2. 2. The unborn child or the unborn child’s mother, in the 12 months before applying, had access to the health insurance coverage specified in par. (b) 1.

49.471(8)(c)3. 3. The unborn child or the unborn child’s mother could be covered under individual or family health insurance coverage if the coverage is applied for, and the coverage could become available to the unborn child or the unborn child’s mother in the month in which the unborn child applies for benefits under this section or in any of the next 3 calendar months.

49.471(8)(cg) (cg) An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line is not eligible for BadgerCare Plus if all of the following apply:

49.471(8)(cg)1. 1. The individual has any of the following:

49.471(8)(cg)1.a. a. Access to individual or family health coverage provided by an employer in which the monthly premium that an employee would pay for an employee-only policy does not exceed 9.5 percent of the family’s monthly income.

49.471(8)(cg)1.b. b. Access to individual or family health coverage under the state employee health plan.

49.471(8)(cg)2. 2. The individual has access to any coverage described in subd. 1. during any of the following times:

49.471(8)(cg)2.a. a. The 12 months before the first day of the month in which an individual applies for and the month in which an individual applies for BadgerCare Plus.

49.471(8)(cg)2.b. b. The 3 months after the last day of the month in which the individual applies for BadgerCare Plus.

49.471(8)(cg)2.c. c. The month including the date of the annual determination of the individual’s eligibility for Medical Assistance.

49.471(8)(cg)3. 3. The individual does not have as a reason for not obtaining health insurance any of the good cause reasons under par. (d) 2. a. to e.

49.471(8)(cr) (cr)

49.471(8)(cr)1. 1. Subject to subd. 4., an individual who is any of the following is not eligible for BadgerCare Plus if the criteria under par. (cg) 1. and 2. apply to that individual:

49.471(8)(cr)1.a. a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.

49.471(8)(cr)1.b. b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.

49.471(8)(cr)1.c. c. An adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.

49.471(8)(cr)2. 2. An individual under subd. 1. is not ineligible if any of the good cause reasons described in par. (d) 2. a. to e. is the reason that the individual did not obtain health insurance coverage.

49.471(8)(cr)3. 3. An individual under subd. 1. c. is not ineligible if any of the following good cause reasons is the reason the individual did not obtain health insurance coverage:

49.471(8)(cr)3.a. a. The parent of the individual is no longer employed by the employer through which the parent was eligible for coverage, and the parent does not have current coverage.

49.471(8)(cr)3.b. b. The employer of the parent of the individual discontinued providing health benefits to all employees.

49.471(8)(cr)4. 4. The department may apply this paragraph to eligibility determinations for BadgerCare Plus only if the federal department of health and human services approves of the conditions to make that individual ineligible, if approval is required.

49.471(8)(ct) (ct)

49.471(8)(ct)1. 1. If the federal department of health and human services approves the department’s request to add private major medical insurance as a type of coverage which causes ineligibility, an individual who is not disabled and not pregnant, who is over 18 years of age, whose family income exceeds 133 percent of the poverty line, and who has coverage provided by private major medical insurance in which the monthly premium does not exceed 9.5 percent of the family’s monthly income is not eligible for BadgerCare Plus.

49.471(8)(ct)2. 2. If the federal department of health and human services approves of the conditions to make that individual ineligible for BadgerCare Plus, an individual who is any of the following is not eligible for BadgerCare Plus if he or she has the major medical insurance coverage described under subd. 1.:

49.471(8)(ct)2.a. a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.

49.471(8)(ct)2.b. b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.

49.471(8)(d) (d)

49.471(8)(d)1. 1. None of the following is ineligible for BadgerCare Plus by reason of having health insurance coverage or access to health insurance coverage:

49.471(8)(d)1.a. a. A pregnant woman, except as provided in par. (cr) 1. c.

49.471(8)(d)1.b. b. A child described in sub. (4) (a) 2. or 2m.

49.471(8)(d)1.c. c. Except as provided in par. (c), a child who has health insurance coverage, or access to health insurance coverage, as a dependent of an absent parent but who resides outside of the service area of the absent parent’s plan.

49.471(8)(d)1.d. d. An individual described in sub. (4) (a) 5.

49.471(8)(d)1.e. e. A child who obtains eligibility under sub. (7) (b) 2., but only for the remainder of the child’s eligibility period under sub. (7) (b) 2.

49.471(8)(d)1.f. f. An individual described in sub. (4) (a) 7.

49.471(8)(d)1.g. g. An adult who is disabled.

49.471(8)(d)2. 2. An individual under par. (b) 2., or an individual who is an unborn child or an unborn child’s mother under par. (c) 2., is not ineligible if any of the following good cause reasons is the reason that the individual did not obtain the health insurance coverage under par. (b) 1. to which they had access:

49.471(8)(d)2.a. a. The individual’s employment ended.

49.471(8)(d)2.b. b. The individual’s employer discontinued health insurance coverage for all employees.

49.471(8)(d)2.c. c. One or more members of the individual’s family were eligible for other health insurance coverage or Medical Assistance under s. 49.46 or 49.47 at the time the employee failed to enroll in the health insurance coverage under par. (b) 1. and no member of the family was eligible for coverage under this section at that time or, if one or more members of the individual’s family were eligible for coverage under this section at that time, family income did not exceed 150 percent of the poverty line or the individual qualified for a medical assistance eligibility extension as provided in sub. (4) (a) 7.

49.471(8)(d)2.d. d. The individual’s access to health insurance coverage has ended due to the death or change in marital status of the subscriber.

49.471(8)(d)2.dg. dg. The insurance is owned by someone not residing with the family and continuation of the coverage is beyond the family’s control.

49.471(8)(d)2.dr. dr. The insurance only covers services provided in a service area that is beyond a reasonable driving distance.

49.471(8)(d)2.e. e. Any other reason that the department determines is a good cause reason.

49.471(8)(e) (e) If a pregnant woman has health insurance coverage and her family income exceeds 200 percent of the poverty line, the woman is required, as a condition of eligibility, to maintain the health insurance coverage.

49.471(9) (9) Employer verification of insurance coverage.

49.471(9)(a) (a)

49.471(9)(a)1. 1. Except as provided in subd. 2., for an applicant or recipient with a family income that exceeds 150 percent of the poverty line, the department shall verify insurance coverage and access information directly with the employer through which the applicant or recipient may have health insurance coverage or access to coverage.

49.471(9)(a)2. 2. Subdivision 1. does not apply to any of the following:

49.471(9)(a)2.a. a. A pregnant woman.

49.471(9)(a)2.b. b. A child described in sub. (4) (a) 2. or 2m.

49.471(9)(a)2.c. c. An individual described in sub. (4) (a) 5.

49.471(9)(b) (b) An employer that receives a request from the department for insurance coverage and access to coverage information shall supply the information requested by the department in the format specified by the department within 30 calendar days after receiving the request.

49.471(9)(c) (c)

49.471(9)(c)1. 1. Subject to subds. 2. and 3., an employer that does not comply with the requirements under par. (b) shall be required to pay, within 45 days after the requested information was due, a penalty equal to the full per member per month cost of coverage under BadgerCare Plus for the individual about whom the information is requested, and for each of the individual’s family members with coverage under BadgerCare Plus, for each month in which the individual and the individual’s family members are covered before the employer provides the information.

49.471(9)(c)2. 2. An employer with fewer than 250 employees may not be required to pay more than $1,000 in penalties under this paragraph that are attributable to any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in penalties under this paragraph that are attributable to any 6-month period.

49.471(9)(c)3. 3. Notwithstanding subd. 1., an employer shall not be subject to any penalties if the employer, at least once per year, timely provides to the department, in the manner and format specified by the department, information from which the department may determine whether the employer provides its employees with access to health insurance coverage.

49.471(9)(c)4. 4. All penalty assessments collected under this paragraph shall be credited to the appropriation accounts under s. 20.435 (4) (jw) and (jz).

49.471(9)(d) (d) An employer may contest a penalty assessment under par. (c) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by ch. 227.

49.471(10) (10) Cost sharing.

49.471(10)(a) (a) Copayments. Except as provided in s. 49.45 (18) (am) 2. and (b) 2., all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to a person eligible for medical assistance under s. 49.46, 49.468, or 49.47.

49.471(10)(b) (b) Premiums.

49.471(10)(b)1. 1. Except as provided in subds. 1m. and 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income.