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.