Chapter 49

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.

49.471(10)(b)1m. 1m. Except as provided in subd. 4., a recipient who is an adult parent or adult caretaker relative; who is not disabled, pregnant, or American Indian; and whose family income exceeds 133 percent of the federal poverty line shall pay a premium for coverage under BadgerCare Plus in an amount determined by the department that is based on a formula in which costs decrease for those with lower family incomes and that is no less than 3 percent of family income but no greater than 9.5 percent of family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted. If the department intends to impose a premium under this subdivision after December 31, 2013, the department shall request from the federal department of health and human services any necessary approval to continue imposing premiums under this subdivision.

Effective date note NOTE: Sub. (4) (b) 4. was repealed eff. 2-1-14 by 2013 Wis. Act 20, as affected by 2013 Wis. Acts 116 and 117.

49.471(10)(b)2. 2. Except as provided in subds. 3m. and 4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.

49.471(10)(b)3m. 3m. A recipient who is a child, who is not disabled, and whose family income is at a level determined by the department that is at least 150 percent of the poverty line shall pay a premium in an amount determined by the department. The department may apply this subdivision only to the extent the federal department of health and human services approves applying a premium to those individuals, if approval is required.

49.471(10)(b)4. 4. None of the following shall pay a premium, except as provided in subd. 3m.:

49.471(10)(b)4.a. a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line.

49.471(10)(b)4.b. b. A child who is eligible under sub. (4) (a) 2. or 2m.

49.471(10)(b)4.c. c. A child whose family income does not exceed 200 percent of the poverty line.

49.471(10)(b)4.d. d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.

49.471(10)(b)4.e. e. A child who obtains eligibility under sub. (7) (b) 2.

49.471(10)(b)4.f. f. An individual who is eligible under sub. (4) (a) 5.

49.471(10)(b)4.g. g. An individual described in sub. (4) (a) 7.

49.471(10)(b)5. 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient’s coverage terminates. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 12 consecutive calendar months following the date on which the recipient’s coverage terminated, except for any month during that 12-month period when the recipient’s family income does not exceed 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient’s coverage terminated, except for any month during that period when the recipient’s family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums.

49.471(11) (11) Benchmark plan benefits and copayments. Except as provided in sub. (11r) and s. 49.45 (24j), recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments:

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.