DHS 103.04DHS 103.04Asset and income limits. The nonexempt assets and budgetable income of the MA group or, when applicable, the fiscal test group, shall be compared to the following asset and income limits established in this section to determine the eligibility of the MA group:
DHS 103.04(1)(1)Categorically needy.
DHS 103.04(1)(a)(a) The MA group or fiscal test group shall first be tested against the categorically needy standard. Persons who meet the non-financial eligibility conditions and who meet the income and asset standards specified in this subsection shall be determined eligible as categorically needy in accordance with s. 49.46 (1) (e), Stats., and shall receive MA benefits in accordance with s. 49.46 (2), Stats., and chs. DHS 101 to 108.
DHS 103.04(1)(b)(b) The BadgerCare Plus-related categorically needy income standard for MA applicants shall be the appropriate standard as specified in s. DHS 103.03 (1) (a).
DHS 103.04(1)(c)(c) The SSI-related categorically needy income standard shall be the maximum SSI payment including state supplement that a single person or a couple, as appropriate, could receive in Wisconsin under s. 49.77, Stats., or federal title XVI of the social security act of 1935, as amended. The SSI-related categorically needy asset standard shall be the same as specified in section 1613 of title XVI of the social security act of 1935, as amended.
DHS 103.04(2)(2)Medically needy. If the MA group or fiscal test group is not eligible as categorically needy, the medically needy standard shall be applied. SSI-related persons who meet non-financial conditions for eligibility and meet the income and assets criteria set forth in s. 49.47 (4) (b) and (c), Stats., and this chapter shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 through 108.
DHS 103.04(3)(3)Excess income cases.
DHS 103.04(3)(a)(a) In this subsection, “spend–down period” means the period during which excess income may be expended or obligations to expend excess income may be incurred for the purpose of obtaining BadgerCare Plus-related or SSI-related MA eligibility, as described under s. DHS 103.08 (2) (a).
DHS 103.04(3)(b)(b) When an SSI-related fiscal test group is found ineligible as medically needy and excess income is the only reason, the group may expend or incur obligations to expend the excess income above the appropriate medically needy income limit pursuant to s. 49.47 (4) (c) 2., Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.
DHS 103.04(3)(bg)(bg) When a child is found ineligible for BadgerCare Plus-related MA solely under s. DHS 103.03 (1) (f), the BadgerCare Plus-related fiscal test group may expend or incur obligations to expend the excess income above the appropriate income limit pursuant to s. 49.471 (7) (b) 2., Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.
DHS 103.04(3)(br)(br) When a pregnant woman is found ineligible for BadgerCare Plus-related MA solely under s. DHS 103.03 (1) (f), the BadgerCare Plus-related fiscal test group may expend or incur obligations to expend the excess income above the appropriate income limit pursuant to s. 49.471 (7) (b) 1., Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.
DHS 103.04(3)(c)(c) Health insurance premiums actually incurred or paid, plus any medical service recognized by state law received by a member of the MA or fiscal test group shall be counted toward fulfilling the excess income expenditure or incurrence requirement when the service is prescribed or provided by a medical practitioner who is licensed by Wisconsin or another state and if either or both of the following conditions are met:
DHS 103.04(3)(c)1.1. The service is received during the spend-down period; or
DHS 103.04(3)(c)2.2. The expense was incurred prior to the spend-down period and a fiscal test group member is still legally responsible for the debt and is consistently making payments, in which case the payments made during the spend-down period shall be counted.
DHS 103.04(3)(d)(d) No medical costs that are incurred and are to be paid or have been paid by a person other than the applicant or members of the fiscal test group may be counted toward fulfilling the excess income expenditure or incurrence requirement. No expense for which a third party is liable, including but not limited to medicare, private health insurance, or a court-ordered medical support obligation, may be used to meet the expenditure of excess income requirement.
DHS 103.04(4)(4)Special financial standards for institutionalized persons. The categorically needy and medically needy asset standards shall be the same for institutionalized persons as for non-institutionalized persons, except that in determining initial eligibility under s. DHS 103.075 for an institutionalized individual with a community spouse the asset standard shall be the regular SSI-related MA group size one asset standard as provided under s. 49.47 (4) (b) 3g., Stats., plus the community spouse resource allowance as provided under s. 49.455 (6) (b), Stats. The eligibility standards against which an institutionalized person’s income is tested shall be the following:
DHS 103.04(4)(a)(a) Categorically needy standard. The categorically needy standard for an institutionalized person shall be an amount equal to 3 times the federal share of the SSI payment for one person living in that person’s own home.
DHS 103.04(4)(b)(b) Medically needy standard. An institutionalized person shall be determined medically needy in accordance with requirements under 42 CFR 435.1007.
DHS 103.04(5)(5)Irregular cases; mixture of BadgerCare Plus and SSI-relatedness. When there is a mixture in an MA group of BadgerCare Plus-relatedness and SSI-relatedness, each individual will be tested using the appropriate modified adjusted gross income rules under sub. (7) or SSI-related standards.
DHS 103.04(6)(6)BadgerCare Plus.
DHS 103.04(6)(a)(a) An individual who meets the requirements of s. DHS 103.03 (1) (f) and (2) to (9) and the income limits in this subsection is eligible for BadgerCare Plus.
DHS 103.04(6)(b)(b) For all children under age 19, pregnant women and individuals requesting only family planning services under s. 49.45 (24s), Stats., in BadgerCare Plus fiscal test groups, the income limit is 306% of the poverty line.
DHS 103.04(7)(7)Special BadgerCare Plus budgeting procedures.
DHS 103.04(7)(a)(a) MAGI budgeting rules. MAGI rules shall be used to determine eligibility for BadgerCare Plus. For eligibility determinations, all of the following apply:
DHS 103.04(7)(a)1.1. MAGI rules in this section shall be used to determine financial eligibility for individuals who are BadgerCare Plus-related individuals under s. DHS 103.03 (1) (b), except for individuals under s. DHS 103.03 (1) (b) 4. and 5., and who are non-financially eligible for BadgerCare Plus under s. DHS 103.03 (f).
DHS 103.04(7)(a)2.2. MAGI shall be determined by doing all of the following:
DHS 103.04(7)(a)2.a.a. Identifying the members of each individual’s BadgerCare Plus fiscal test group per sub. (7) (b), and determining the group size.
DHS 103.04(7)(a)2.b.b. Adding the countable income per sub. (7) (d) of all members of the individual’s BadgerCare Plus fiscal test group per sub. (7) (c).
DHS 103.04(7)(a)2.c.c. Comparing the total income of each individual’s BadgerCare Plus fiscal test group to the federal poverty line for that group’s size.