Chapter DHS 103

DHS 103.075(7)(e) (e) The amount of income that the institutionalized spouse is required to contribute toward the cost of his or her care; and

DHS 103.075(7)(f) (f) Each spouse’s right to a fair hearing under sub. (8) concerning ownership or availability of income or resources and the determination of the community spouse monthly income or resource allowance.

DHS 103.075(8) (8) Fair hearing.

DHS 103.075(8)(a) (a) An institutionalized spouse or a community spouse may request a fair hearing in accordance with the procedures set out in s. DHS 104.01 (5) in regard to any of the following:

DHS 103.075(8)(a)1. 1. The determination of the community spouse monthly income allowance under sub. (6) (b) 1.;

DHS 103.075(8)(a)2. 2. The determination of the amount of the monthly income otherwise available to the community spouse used in the calculation under sub. (6) (b) 1.;

DHS 103.075(8)(a)3. 3. The amount of the couple’s total countable assets determined under sub. (4) (c);

DHS 103.075(8)(a)4. 4. The determination of the spousal share of resources under sub. (4) (c) 3.; and

DHS 103.075(8)(a)5. 5. The determination of the community spouse resource allowance under sub. (4) (c) 3.

DHS 103.075(8)(b) (b) If the institutionalized spouse has made an application for MA and a fair hearing is requested under par. (a), the agency shall hold the hearing within 30 days after the request.

DHS 103.075(8)(c) (c) If either spouse establishes at a fair hearing that, due to exceptional circumstances resulting in financial duress, the community spouse needs income above the level provided by the minimum monthly maintenance needs allowance determined under sub. (6) (b), the hearing officer shall determine an amount adequate to provide for the community spouse’s needs. In this paragraph,“exceptional circumstances resulting in financial duress” means situations that result in the community spouse not being able to provide for his or her own necessary and basic maintenance needs. The agency shall use the amount determined by the hearing officer in place of the minimum monthly maintenance needs allowance determined under sub. (6) (b).

DHS 103.075(8)(d) (d) If either spouse establishes at a fair hearing that the community spouse resource allowance determined by the agency under sub. (4) (c) 3. does not generate enough income to raise the community spouse’s income to the minimum monthly maintenance needs allowance under s. 49.455 (4) (c), Stats., the hearing officer shall establish an amount to be used under sub. (5) (b) that results in a community spouse resource allowance that generates sufficient income to raise the community spouse’s monthly income to the minimum monthly maintenance needs allowance under s. 49.455 (4) (c), Stats.

DHS 103.075(8)(e) (e) Neither the institutionalized spouse nor the community spouse shall have the right to a fair hearing under this section until after an MA application is filed and MA eligibility and the benefit level are determined.

DHS 103.075 History History: Cr. Register, March, 1993, No. 447, eff. 4-1-93; correction in (8) (a) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 103.08 DHS 103.08 Beginning of eligibility.

DHS 103.08(1) (1) Date. Except as provided in subs. (2) to (5), eligibility shall begin on the date on which all eligibility requirements were met, but no earlier than the first day of the month 3 months prior to the month of application. Retroactive eligibility of up to 3 months may occur even though the applicant is found ineligible in the month of application.

DHS 103.08(2) (2) Spend-down period.

DHS 103.08(2)(a) (a)

DHS 103.08(2)(a)1. 1. The spend-down period shall begin on the first day of the month in which all eligibility factors except income were met, but no earlier than the first day of the month 3 months prior to the month of application. However, at the recipient’s option, it may begin on the first day of any of the 3 months prior to the date of application if all eligibility factors, except income, were met in that month. A recipient’s decision to choose an optional beginning date shall be recorded in the agency’s case record. For persons who previously received MA and then reapply, the spend-down period cannot cover the time during which they were receiving MA.

DHS 103.08(2)(a)2. 2. The BadgerCare Plus-related or SSI-related MA group shall be eligible as of the date within the spend-down period on which the expenditure of excess income or the obligation to expend excess income is achieved.

DHS 103.08(2)(a)3. 3. The applicant shall be responsible for some bills or parts of bills for services received on the first day of eligibility if there is remaining unspent and unobligated excess income on that day.

DHS 103.08(2)(b) (b) If the amount of the monthly excess income changes before the expenditure or obligation of excess income is achieved, the expenditure or obligation of excess income for the remainder of the 6–month period shall be recalculated. When the size of the BadgerCare Plus -related or SSI-related MA group changes, the monthly income limit shall be adjusted appropriately to the size of the new group, and the amount of excess income to be expended or obligated shall be adjusted accordingly. If any change is reported that may affect eligibility, the eligibility of the entire BadgerCare Plus-related or SSI-related MA group may be redetermined and, if there is determined to be excess income, a new spend–down period shall be established.

DHS 103.08(2)(c) (c)

DHS 103.08(2)(c)1. 1. Once the expenditure or obligation of excess income has been achieved, the BadgerCare Plus-related or SSI-related MA group shall be eligible for the balance of the 6–month spend–down period, unless it is determined that assets have increased enough to make the MA group ineligible, or that a change in circumstances has caused someone in the MA group to become ineligible for non-financial reasons.

DHS 103.08(2)(c)2. 2. If the entire group is determined ineligible, the MA benefits shall be discontinued with proper notice. If only one person in the MA group is determined ineligible for non-financial reasons, only that person’s BadgerCare Plus-related or SSI-related MA benefits shall, with proper notice, be discontinued. The other person or persons in the MA group continue their eligibility until the end of the 6–month period.

DHS 103.08(2)(c)3. 3. If the size of the MA group increases due to the addition of a child, that child is eligible for benefits during the rest of the spend–down period. An adult caretaker who enters the BadgerCare Plus-related or SSI-related MA group, except a woman who is medically verified as pregnant or a person who is SSI–related, is not eligible for benefits during the remainder of the spend–down period.

DHS 103.08(3) (3) Presumptive disability cases. If, in a presumptive disability case, the applicant meets all other conditions for eligibility, MA benefits shall begin on the date the presumptive disability finding is made and shall continue at least until the official disability determination is completed. Presumptive disability eligibility shall not be granted retroactively. MA benefits based on presumptive disability shall not be continued pending an appeal of a negative official disability determination.

DHS 103.08(4) (4) Pregnancy-related MA cases. For pregnancy-related cases pursuant to ss. 49.46 (1) (a) 1m. and 9. and 49.47 (4) (ag) 2. and (am) 1., Stats., eligibility shall begin on the date pregnancy is verified or the date of application, whichever is earlier, but eligibility may only be backdated as provided under sub. (1).

DHS 103.08(5) (5) BadgerCare cases. Eligibility for BadgerCare shall begin on the first day of the month in which all eligibility requirements are met, but no earlier than the first day of the month of application.

DHS 103.08 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (4), Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1), (2) (a) 2., (b) and (c), eff. 7-1-99; am. (1), (2) (a) 2., (b) and (c) and cr. (5), Register, March, 2000, No. 531, eff. 4-1-00; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 21-067: am. (2) (c) 1., 2. Register March 2022 No. 795, eff. 4-1-22, am. (2) (c) 1., 2. eff.the first day of the month after the emergency period, as defined in 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (2) (c) 2. made under s. 35.17, Stats., Register March 2022 No. 795; CR 23-046: am. (2) (a) 2., (b), (c) Register April 2024 No. 820, eff. 5-1-24.

DHS 103.085 DHS 103.085 Conditions for continuation of eligibility for BadgerCare Plus.

DHS 103.085(1) (1) Premiums.

DHS 103.085(1)(a) (a) Authority. Subject to s. 49.471 (10) (b) 2., Stats., and this section, a child under the age of 19 eligible for BadgerCare Plus may be required to pay a premium.

DHS 103.085(1)(b) (b) Applicability.

DHS 103.085(1)(b)1. 1. A child under age 19 eligible for BadgerCare Plus with budgetable income at or below 201% of the poverty line is not required to pay a premium toward the cost of the health care coverage.

DHS 103.085(1)(b)2. 2. Except as provided in subd. 3., 4., or 5., a child under age 19 eligible for BadgerCare Plus with budgetable income above 201% of the poverty line shall pay a premium toward the cost of the health care coverage.

DHS 103.085(1)(b)3. 3. A BadgerCare Plus applicant group does not owe a premium for the first month of BadgerCare Plus unless a member of the BadgerCare Plus fiscal test group was an MA recipient in the previous month.

DHS 103.085(1)(b)4. 4. A BadgerCare Plus applicant group does not owe a premium for the first month of BadgerCare Plus unless a member of the BadgerCare Plus fiscal test group was a BadgerCare Plus recipient in the previous 12 months.

DHS 103.085(1)(b)5. 5. A child under the age of 19 shall not be required to pay a premium if any of the following apply:

DHS 103.085(1)(b)5.a. a. The child is a Native American or an Alaskan Native.

DHS 103.085(1)(b)5.b. b. The child is under age 1.

DHS 103.085(1)(b)5.c. c. The child is pregnant.

DHS 103.085(1)(b)5.d. d. The child is eligible under s. 49.471 (4) (a) 5., Stats.

DHS 103.085(1)(b)5.e. e. The child is eligible under s. 49.471 (4) (a) 7., Stats.

DHS 103.085(1)(b)5.f. f. The child is eligible under s. 49.471 (7) (b) 2., Stats.

DHS 103.085(1)(c) (c) Amounts. A child eligible for BadgerCare Plus required under this subsection to pay a premium shall pay the amount indicated in the schedule provided in Table 103.085, except as provided under par. (cm). Income for each child’s BadgerCare Plus fiscal test group shall be determined according to s. DHS 103.07.

DHS 103.085(1)(cm) (cm) Caps on premiums. Families must pay either the combined premiums for all of the children required to pay or an amount equal to five percent of the family’s countable monthly income, whichever is less.

DHS 103.085(1)(d) (d) Payment.

DHS 103.085(1)(d)1. 1. All children otherwise eligible for BadgerCare Plus in a family who are required to pay a premium under this section shall pay the premium amount in full to the agency before the agency may certify the children’s initial eligibility for BadgerCare Plus.

DHS 103.085(1)(d)2. 2. Premiums are due by the 10th of the month prior to the month for which the premium is required.

DHS 103.085(1)(d)3. 3. If no payment is received by the end of the month for which the premium is required, the department shall terminate the group’s eligibility for BadgerCare, effective at the end of the month.

DHS 103.085(1)(d)4. 4. The department shall allow a variety of premium payment methods. A group may choose one of the following methods for premium payment:

DHS 103.085(1)(d)4.a. a. Wage withholding.

DHS 103.085(1)(d)4.b. b. Electronic funds transfer (EFT).

DHS 103.085(1)(d)4.c. c. Direct payment by check or money order.

DHS 103.085(1)(e) (e) Refunds. The department shall issue a refund for a premium which has been paid when the premium is for one of the following:

DHS 103.085(1)(e)2. 2. A month that the child’s budgetable income drops to or below 200% of the poverty line and the change in income that brought the child’s budgetable income to or below 200% of the poverty line was reported within 10 days of the date the change occurred.

DHS 103.085(1)(e)3. 3. A month which requires a lower premium amount due to a change in circumstances which was in effect for the entire month so long as the change was reported within 10 days of the date it occurred. In a case where the change was not reported within 10 days of the date it occurred, the effective date of the lower premium amount due is the first day of the month in which the change was reported.

DHS 103.085(1)(f) (f) Consequence of failure to pay BadgerCare premiums. A child required to pay a premium shall be ineligible for re-enrollment for the period specified in sub. (3) when the group fails to pay its premium within the time specified in par. (d).

DHS 103.085(3) (3) Re-enrollment restriction.

DHS 103.085(3)(a) (a) Period of ineligibility. A BadgerCare Plus group that fails to make a premium payment under sub. (1) is not eligible for BadgerCare Plus for a period of at least 3 consecutive calendar months following the date that BadgerCare Plus eligibility ends, unless one of the circumstances in par. (b) applies. Eligibility is restored as described in par. (c). After 3 calendar months, the child shall be eligible for BadgerCare Plus if otherwise eligible.

DHS 103.085(3)(b) (b) Reasons restriction on re-enrollment may not apply. The restriction on re-enrollment under this section does not apply for any of the following reasons:

DHS 103.085(3)(b)1. 1. The failure to pay premiums was due to a circumstance beyond the group’s control, provided that all past due premiums have been paid in full. A circumstance beyond the group’s control includes any of the following:

DHS 103.085(3)(b)1.a. a. A problem with an electronic funds transfer from a bank account to the BadgerCare Plus program.

DHS 103.085(3)(b)1.b. b. A problem with an employer’s wage withholding.

DHS 103.085(3)(b)1.c. c. An administrative error in processing the premium.

DHS 103.085(3)(b)1.d. d. A fair hearing decision.

DHS 103.085(3)(b)2. 2. The child’s income decreases to at or below 201% of the poverty line.

DHS 103.085(3)(b)3. 3. Payment is received in full for all owed premiums before the end of the three-month restrictive re-enrollment period.

DHS 103.085(3)(b)4. 4. Any other circumstance affecting payment of the premium which the department determines is beyond the group’s control, but not including insufficient funds.

DHS 103.085(3)(c) (c) Resuming BadgerCare eligibility. Eligibility for BadgerCare shall resume in the following manner for persons with a re-enrollment restriction that ended due to a reason described in par. (b):

DHS 103.085(3)(c)1. 1. For a child with a reason under par. (b) 1. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for any months that the group had been closed during the restriction period, provided that payment of any outstanding premiums owed is made and the child was otherwise eligible for BadgerCare Plus in those months.

DHS 103.085(3)(c)2. 2. For a child with a reason under par. (b) 3. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for any calendar months that the child’s BadgerCare Plus fiscal test group’s income was at or below 201% of the poverty line and the child was otherwise eligible for BadgerCare Plus in those months.

DHS 103.085(3)(c)3. 3. For a child with a reason under par. (b) 4. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for all months that the child had been ineligible during the restriction period, provided that payment of any outstanding premiums owed is made and the child is otherwise eligible for BadgerCare Plus in those months.

DHS 103.085 History History: Emerg. cr. eff. 7-1-99; cr. Register, March, 2000, No. 531, eff. 4-1-00; correction in (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-039: renum. (3) (b) (intro.) and 1. to (3) (b) (intro.) and am., r. (3) (b) 2., (6) Register October 2021 No. 790, eff. 11-1-21; CR 23-046: am. (title), (1) (a), (b) 1. to 4., cr. (1) (b) 5., am. (1) (c), r. and recr. Table 103.085, cr. (1) (cm), am. (1) (d) 1., r. (1) (d) 5., am. (1) (e) (intro.), r. (1) (e) 1., am. (1) (e) 2., (f), r. (2), am. (3) (a), (b) (intro.), r. and recr. (3) (b) 1. to 3., am. (3) (c) 1., r. and recr. (3) (c) 2. cr. (3) (c) 3., r. (4), (5) Register April 2024 No. 820, eff. 5-1-24; correction in (1) (c) made under s. 35.17, Stats., Register April 2024 No. 820.

DHS 103.087 DHS 103.087 Conditions for continuation of eligibility.

DHS 103.087(1) (1) Premiums.

DHS 103.087(1)(a) (a) Authority. Subject to this section and s. 49.472, Stats., a person eligible for the medicaid purchase plan shall pay a monthly premium.

DHS 103.087(1)(b) (b) Applicability.

DHS 103.087(1)(b)1. 1. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is above 100% of the poverty line for the applicable household size shall pay a monthly premium and the applicant shall pay all retroactive premium amounts assessed or other premium payments due.

DHS 103.087(1)(b)2. 2. An applicant or recipient eligible for the medicaid purchase plan whose total earned and unearned income is at or below 100% of the poverty line for the applicable household size pay does not owe a monthly premium.

DHS 103.087(1)(c) (c) Premium amounts.

DHS 103.087(1)(c)1. 1. An applicant or recipient eligible for the medicaid purchase plan shall pay a monthly premium in accordance with this subsection.

DHS 103.087(1)(c)2. 2. The county agency shall determine the amount of the premium an applicant shall pay according to the guidelines described in this subsection at the time of application.

DHS 103.087(1)(c)3. 3. All earned and unearned sources of income available to the applicant or recipient, except for the interest, dividends or other gains accrued from a recipient’s independence account, shall be used in the premium determination.

DHS 103.087(1)(c)4. 4. The applicant’s or recipient’s monthly premium shall be at least $25.

DHS 103.087(1)(d) (d) Calculating the monthly adjusted earned and unearned income. An applicant’s or recipient’s monthly adjusted income shall be calculated by subtracting applicant’s or recipient’s gross monthly countable earned and unearned income, their actual out-of-pocket medical and remedial expenses, long-term care costs, and impairment-related work expenses.

DHS 103.087(1)(f) (f) Calculating the total monthly premium.

DHS 103.087(1)(f)1. 1. An applicant or recipient shall pay 3 percent of his or her adjusted earned and unearned monthly income under par. (d) that is in excess of 100 percent of the poverty line plus $25.