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.