Chapter DHS 103

Register December 2008 No. 636

Chapter DHS 103

ELIGIBILITY

DHS 103.01   Introduction.

DHS 103.03   Non-financial conditions for eligibility.

DHS 103.04   Asset and income limits.

DHS 103.05   Determining assets and income in child-only cases.

DHS 103.06   Assets.

DHS 103.063   Divestment prior to August 9, 1989.

DHS 103.065   Divestment on or after August 9, 1989.

DHS 103.07   Income.

DHS 103.075   Prevention of spousal impoverishment.

DHS 103.08   Beginning of eligibility.

DHS 103.085   Conditions for continuation of eligibility for BadgerCare Plus.

DHS 103.087   Conditions for continuation of eligibility.

DHS 103.09   Termination of medical assistance.

DHS 103.10   Redetermination of eligibility.

DHS 103.11   Presumptive eligibility for pregnant women and women diagnosed with breast or cervical cancer or precancerous conditions.

Ch. DHS 103 Note Note: Chapter HSS 103 as it existed on February 28, 1986, was repealed and a new chapter HSS 103 was created effective March 1, 1986. Chapter HSS 103 was renumbered Chapter HFS 103 under s. 13.93, Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1997, No. 493. Chapter HFS 103 was renumbered to chapter DHS 103 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 103.01 DHS 103.01 Introduction.

DHS 103.01(1) (1) Persons eligible.

DHS 103.01(1)(a) (a) Eligibility for medical assistance shall be determined pursuant to ss. 49.453, 49.454, 49.455, 49.46 (1), 49.468, 49.47 (4), 49.471, 49.472 and 49.473, Stats., and this chapter, except that medical assistance shall be provided without eligibility determination to persons receiving SSI.

DHS 103.01(1)(b) (b) Presumptive eligibility for pregnant women shall be determined under s. 49.465, Stats., and this chapter.

DHS 103.01(1)(c) (c) Presumptive eligibility for children shall be determined under s. 49.471 (5) (b) 2., Stats., and this chapter.

DHS 103.01(1)(d) (d) Presumptive eligibility for women diagnosed with breast or cervical cancer or precancerous conditions shall be determined under s. 49.473 (3), Stats., and this chapter.

DHS 103.01(2) (2) Singular enrollment. No person may be certified eligible in more than one MA case.

DHS 103.01(3) (3) Definition. In this chapter, “modified adjusted gross income” or “MAGI” has the meaning under 42 USC 435.603.

DHS 103.01 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; renum. (1) to be (1) (a) and cr. (1) (b), Register, February, 1988, No. 386, eff. 3-1-88; am. (1) (a), Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1) (a), eff. 7-1-99; am. (1) (a), Register, March, 2000, No. 531, eff. 4-1-00; am. (1) (a), Register, November, 2000, No. 539, eff. 12-1-00; CR 23-046: am. (1) (a), cr. (1) (c), (d), (3) Register April 2024 No. 820, eff. 5-1-24.

DHS 103.03 DHS 103.03 Non-financial conditions for eligibility. In order to be eligible for MA, a person shall meet both non-financial conditions for eligibility in this section and financial conditions for eligibility under s. DHS 103.04. The non-financial conditions for eligibility are:

DHS 103.03(1) (1) BadgerCare Plus-relatedness or SSI-relatedness.

DHS 103.03(1)(a) (a) Requirement. To be non-financially eligible for MA, an applicant shall be BadgerCare Plus-related or SSI-related.

DHS 103.03(1)(b) (b) BadgerCare Plus-related persons. In this subsection, “BadgerCare Plus-related” means a person who meets one of the following conditions:

DHS 103.03(1)(b)1. 1. The person is pregnant and meets the conditions specified in s. 49.471 (4) (a) 1., 1g., or 1m., Stats.

DHS 103.03(1)(b)2. 2. The person is a child under age 19 who meets the conditions specified in s. 49.471 (4) (a) 3., 3g., 3m. or 7., Stats., and under par. (f).

DHS 103.03(1)(b)2m. 2m. The person is an unborn child as defined in s. 49.471 (1) (k), Stats., and meets the conditions under par. (f).

DHS 103.03(1)(b)3. 3. The person is a caretaker relative or a caretaker relative’s spouse if the spouse resides with the caretaker relative’s child who meets the conditions specified in s. 49.471 (4) (a) 4. or 7., Stats.

DHS 103.03(1)(b)4. 4. The person is a foster child under 19 years of age living in a foster home licensed under s. 48.62, Stats., or a group home licensed under s. 48.625, Stats., is a child under the care of a subsidized guardianship under s. 48.623, Stats., or is a child in an adoption assistance placement under s. 48.975, Stats.

DHS 103.03(1)(b)5. 5. The person is a former foster care recipient and meets the conditions specified under s. 49.471 (4) (a) 5, Stats.

DHS 103.03(1)(b)6. 6. The person meets the conditions to receive family planning services under s. 49.45 (24s), Stats.

DHS 103.03(1)(b)7. 7. The person is diagnosed with tuberculosis and meets the conditions under s. 49.46 (1) (a) 15., Stats.

DHS 103.03(1)(b)8. 8. The person is at least 19, but under 21 years of age and resides in an intermediate care facility, skilled nursing facility, or inpatient psychiatric hospital and meets the conditions under s. 49.47 (4), Stats.

DHS 103.03(1)(c) (c) SSI-related persons. In this subsection, “SSI-related person” means a person who meets one of the following conditions:

DHS 103.03(1)(c)1. 1. The person is age 65 or over; or

DHS 103.03(1)(c)2. 2. The person is blind or disabled.

DHS 103.03(1)(d) (d) Verification of blindness or disability. Except as provided under par. (e), the blindness or disability claimed under par. (c) 2. shall be verified in one of the following ways:

DHS 103.03(1)(d)1. 1. By presentation of a current old age and survivors disability insurance (OASDI) disability award notice;

DHS 103.03(1)(d)2. 2. By presentation of a current medicare card indicating blindness or disability; or

DHS 103.03(1)(d)3. 3. By receipt of a disability determination made by the department’s bureau of social security disability insurance, along with current medical reports.

DHS 103.03(1)(e) (e) Presumption of disability in an emergency.

DHS 103.03(1)(e)1. 1. Under emergency circumstances, a person may be presumed disabled for purposes of demonstrating SSI-relatedness and be eligible for MA without the verification required under par. (d).

DHS 103.03(1)(e)2. 2. When an emergency need for MA exists, the department shall make a preliminary disability determination within 7 days of the date a completed disability determination form is received.

DHS 103.03(1)(e)3. 3. An emergency need for MA shall exist when the applicant is:

DHS 103.03(1)(e)3.a. a. A patient in a hospital;

DHS 103.03(1)(e)3.b. b. Seriously impaired and the attending physician states the applicant will be unable to work or return to normal functioning for at least 12 months;

DHS 103.03(1)(e)3.c. c. In need of long-term care and the nursing home will not admit the applicant until MA benefits are in effect; or

DHS 103.03(1)(e)3.d. d. Unable to return home from a nursing home unless in-home service or equipment is available and this cannot be obtained without MA benefits.

DHS 103.03 Note Note: Copies of the disability determination form may be obtained from the county or tribal income maintenance agency.

DHS 103.03(1)(f) (f) BadgerCare Plus eligibility. To be non-financially eligible for BadgerCare Plus, a person shall meet all of the following conditions:

DHS 103.03(1)(f)1. 1. The person meets one of the conditions in par. (b).

DHS 103.03(1)(f)2. 2. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and does not have health insurance coverage that meets both of the following criteria:

DHS 103.03(1)(f)2.a. a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is provided under the state of Wisconsin employee health plan.

DHS 103.03(1)(f)2.b. b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.