Chapter 49

49.471(4)(e) (e) If the department obtains approval from the federal department of health and human services to provide an alternate benchmark plan under sub. (11r), to the extent the federal department of health and human services approves, the department may enroll in the alternate benchmark plan under sub. (11r) any individual whose family income exceeds 100 percent of the poverty line, who is either an adult who is not pregnant or a child, and who applies and is otherwise eligible to receive benefits under this section, except that the department shall enroll a child who has a parent who is enrolled in a plan under this section in the same plan as his or her parent.

49.471(5) (5) Presumptive eligibility.

49.471(5)(a) (a) In this subsection:

49.471(5)(a)1. 1. “Qualified entity” means an entity that satisfies the requirements under 42 USC 1396r-1a (b) (3) (A), as determined by the department.

49.471(5)(a)2. 2. “Qualified provider” means a provider that satisfies the requirements under 42 USC 1396r-1 (b) (2), as determined by the department.

49.471(5)(b) (b)

49.471(5)(b)1. 1. Except as provided in sub. (6) (a) 1., a pregnant woman is eligible for the benefits specified in par. (c) during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman’s family income does not exceed 300 percent of the poverty line and ending on the applicable day specified in subd. 3.

49.471(5)(b)2. 2. Except as provided in sub. (6) (a) 2., a child who is not an unborn child is eligible for the benefits described in s. 49.46 (2) (a) and (b) during the period beginning on the day on which a qualified entity determines, on the basis of preliminary information, that the child’s family income does not exceed any of the following and ending on the applicable day specified in subd. 3., unless the federal department of health and human services approves the department’s request to not extend eligibility to children during this period:

49.471(5)(b)2.a. a. 150 percent of the poverty line for a child who is 6 years of age or older but has not yet attained the age of 19.

49.471(5)(b)2.b. b. 185 percent of the poverty line for a child who is one year of age or older but has not yet attained the age of 6.

49.471(5)(b)2.c. c. 300 percent of the poverty line for a child who is under one year of age.

49.471(5)(b)3. 3.

49.471(5)(b)3.a. a. If the woman or child applies for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the day on which the department or the county department under s. 46.215, 46.22, or 46.23 determines whether the woman or child is eligible for benefits under sub. (4), except that a child who is not an unborn child is not eligible for benefits described in s. 49.46 (2) (a) and (b) during that time if the federal department of health and human services approves the department’s request not to provide those benefits during that time.

49.471(5)(b)3.b. b. If the woman or child does not apply for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the last day of the month following the month in which the provider or entity makes the determination under this paragraph.

49.471(5)(c) (c)

49.471(5)(c)1. 1. On behalf of a woman under par. (b) 1. whose family income does not exceed 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits described in s. 49.46 (2) (a) and (b).

49.471(5)(c)2. 2. On behalf of a woman under par. (b) 1. whose family income exceeds 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits under sub. (11).

49.471(5)(d) (d) A woman or child who is determined to be eligible under par. (b) shall apply for benefits under sub. (4) on or before the last day of the month following the month in which the qualified provider or entity makes the eligibility determination.

49.471(5)(e) (e) A qualified provider or entity that determines that a woman or child is eligible under par. (b) shall do all of the following:

49.471(5)(e)1. 1. Notify the department of that determination within 5 working days after the day on which the determination is made.

49.471(5)(e)2. 2. Notify the woman or child of the requirement under par. (d) at the time of the determination.

49.471(5)(f) (f) The department shall provide qualified providers and qualified entities with application forms for the benefits under sub. (4) and information on how to assist women and children in completing the forms.

49.471(6) (6) Miscellaneous eligibility and benefit provisions.

49.471(6)(a) (a)

49.471(6)(a)1. 1. Except as provided in subd. 4., any pregnant woman, including a pregnant woman under sub. (5) (b) 1., is eligible for medical assistance under this section for any of the 3 months prior to the month of application if she met the eligibility criteria under this section in that month.

49.471(6)(a)2. 2. Except as provided in subd. 3. or 4., any child who is not an unborn child, including a child under sub. (5) (b) 2., parent, or caretaker relative whose family income is less than 150 percent of the poverty line is eligible for medical assistance under this section for any of the 3 months prior to the month of application if the individual met the eligibility criteria under this section and had a family income of less than 150 percent of the poverty line in that month.

49.471(6)(a)3. 3. Any individual described in subd. 2. who is not disabled, not elderly, and not pregnant, who is an adult, and whose family income exceeds 133 percent of the federal poverty level is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.

49.471(6)(a)4. 4. To the extent allowed by the federal department of health and human services, any individual described in subd. 1. or 2. who is not disabled is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits.

49.471(6)(b) (b) A pregnant woman who is determined to be eligible for benefits under sub. (4) remains eligible for benefits under sub. (4) for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 90th day after the last day of the pregnancy falls without regard to any change in the woman’s family income.

49.471(6)(c) (c) If a child who is eligible for benefits under sub. (4) is receiving inpatient services covered under sub. (4) on the day before his or her 19th birthday and, but for attaining 19 years of age, the child would remain eligible for benefits under sub. (4), the child remains eligible for benefits until the end of the stay for which the inpatient services are being furnished.

49.471(6)(d) (d) If an application under this section shows that an individual is an essential person, the individual shall be provided the benefits specified under sub. (4) (a).

49.471(6)(f) (f) The medical assistance eligibility provisions for migrant workers and their dependents under s. 49.47 (4) (av) apply to BadgerCare Plus.

49.471(6)(g) (g)

49.471(6)(g)1. 1. Except as provided in subd. 2., as a condition of eligibility for coverage under this section, an individual with income shall provide verification, as determined by the department, of that income.

49.471(6)(g)2. 2. Subdivision 1. does not apply to an individual under sub. (4) (a) 5. or a child under the age of 18.

49.471(6)(h) (h) Within 10 days after the change occurs, a recipient shall report to the department any change that might affect his or her eligibility or any change that might require premium payment by a recipient who was not required to pay premiums before the change.

49.471(6)(i) (i) For purposes of determining eligibility and family income, the department shall include a family member who is temporarily absent from the home for not more than 6 months, as determined by the department.

49.471(6)(j) (j) All of the following apply to BadgerCare Plus in the same respect as they apply under s. 49.46:

49.471(6)(j)1. 1. Section 49.46 (2) (c) and (cm), relating to benefits for individuals who are eligible for Medicare.

49.471(6)(j)2. 2. Section 49.46 (2) (d), relating to prohibiting payments for any part of any service payable through 3rd-party liability or any governmental or private benefit system.

49.471(6)(j)3. 3. Section 49.46 (2) (dm), relating to prohibiting payment for services to residents of institutions for mental diseases.

49.471(6)(j)4. 4. Section 49.46 (2) (f), relating to prohibiting payment for gastric bypass or stapling surgery.

49.471(6)(k) (k) For an individual who is eligible for medical assistance under this section and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under sub. (11) (a) or s. 49.46 (2) (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug.

49.471(6)(L) (L) The department shall request from the federal department of health and human services approval of a state plan amendment or a waiver of federal law to implement subs. (6) (b) and (7) (b) 1. and ss. 49.46 (1) (a) 1m. and (j) and 49.47 (4) (ag) 2.

49.471(7) (7) Special income provisions.

49.471(7)(b) (b)

49.471(7)(b)1. 1. A pregnant woman whose family income exceeds 300 percent of the poverty line may become eligible for coverage under this section if the difference between the pregnant woman’s family income and the applicable income limit under sub. (4) (a) is obligated or expended for any member of the pregnant woman’s family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision continues without regard to any change in family income for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 90th day after the last day of the woman’s pregnancy falls. Eligibility obtained by a pregnant woman under this subdivision extends to all pregnant women in the pregnant woman’s family.

49.471(7)(b)2. 2. A child who is not an unborn child, whose family income exceeds 150 percent of the poverty line, and who is ineligible under this section solely because of sub. (8) (b), or whose family income exceeds 300 percent of the poverty line, may obtain eligibility under this section if the difference between the child’s family income and 150 percent of the poverty line is obligated or expended on behalf of the child or any member of the child’s family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision during any 6-month period, as determined by the department, continues for the remainder of the 6-month period and extends to all children in the family.

49.471(7)(b)3. 3. For a pregnant woman to obtain eligibility under subd. 1., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the pregnant woman’s monthly family income and the monthly family income that is 300 percent of the poverty line. For a child to obtain eligibility under subd. 2., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the child’s monthly family income and the monthly family income that is 150 percent of the poverty line.

49.471(7)(d) (d) In addition to applying other income counting requirements the department shall do all of the following:

49.471(7)(d)1. 1. When calculating the family income of a member of a household who is not disabled, include the income of all adults residing in the home for at least 60 consecutive days but exclude the income of a grandparent in a household containing 3 generations, unless the grandparent applies for or receives benefits as a parent or caretaker relative under this section.

49.471(7)(d)2. 2. When determining the size of a family for purposes of determining income eligibility, exclude from family size an adult whose income is included in a calculation of family income solely under subd. 1.

49.471(7)(d)3. 3. Apply this paragraph only to the extent the federal department of health and human services approves the income eligibility calculation methods, if approval is required.

49.471(7)(e) (e) For the purpose of determining family income, the department shall apply the regulations defining a household under 42 CFR 435.603 (f). To determine the family size for a pregnant woman, the department shall include the pregnant woman and the number of babies she is expecting.

49.471(8) (8) Health insurance coverage and eligibility.

49.471(8)(a) (a)

49.471(8)(a)1. 1. Except as provided in subd. 2., any individual who is otherwise eligible under this section and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for BadgerCare Plus and if the department determines that it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor’s behalf.

49.471(8)(a)2. 2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with subd. 1., the failure does not affect the minor’s eligibility under this section.

49.471(8)(b) (b) Except as provided in pars. (c), (cg), (cr), (ct), and (d), an individual whose family income exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of the following applies:

49.471(8)(b)1. 1. The individual has individual or family health insurance coverage that is any of the following:

49.471(8)(b)1.a. a. Coverage provided by an employer and for which the employer pays at least 80 percent of the premium.

49.471(8)(b)1.b. b. Coverage under the state employee health plan under s. 40.51 (6).

49.471(8)(b)2. 2. The individual, in the 12 months before applying, had access to the health insurance coverage specified in subd. 1.

49.471(8)(b)3. 3. The individual could be covered under the health insurance coverage specified in subd. 1. if the coverage is applied for, and the coverage could become available to the individual in the month in which the individual applies for benefits under this section or in any of the next 3 calendar months.

49.471(8)(c) (c) An unborn child, regardless of family income, is not eligible for BadgerCare Plus if any of the following applies:

49.471(8)(c)1. 1. The unborn child or the unborn child’s mother has individual or family health insurance coverage.

49.471(8)(c)2. 2. The unborn child or the unborn child’s mother, in the 12 months before applying, had access to the health insurance coverage specified in par. (b) 1.

49.471(8)(c)3. 3. The unborn child or the unborn child’s mother could be covered under individual or family health insurance coverage if the coverage is applied for, and the coverage could become available to the unborn child or the unborn child’s mother in the month in which the unborn child applies for benefits under this section or in any of the next 3 calendar months.

49.471(8)(cg) (cg) An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line is not eligible for BadgerCare Plus if all of the following apply:

49.471(8)(cg)1. 1. The individual has any of the following:

49.471(8)(cg)1.a. a. Access to individual or family health coverage provided by an employer in which the monthly premium that an employee would pay for an employee-only policy does not exceed 9.5 percent of the family’s monthly income.

49.471(8)(cg)1.b. b. Access to individual or family health coverage under the state employee health plan.

49.471(8)(cg)2. 2. The individual has access to any coverage described in subd. 1. during any of the following times:

49.471(8)(cg)2.a. a. The 12 months before the first day of the month in which an individual applies for and the month in which an individual applies for BadgerCare Plus.

49.471(8)(cg)2.b. b. The 3 months after the last day of the month in which the individual applies for BadgerCare Plus.

49.471(8)(cg)2.c. c. The month including the date of the annual determination of the individual’s eligibility for Medical Assistance.

49.471(8)(cg)3. 3. The individual does not have as a reason for not obtaining health insurance any of the good cause reasons under par. (d) 2. a. to e.

49.471(8)(cr) (cr)

49.471(8)(cr)1. 1. Subject to subd. 4., an individual who is any of the following is not eligible for BadgerCare Plus if the criteria under par. (cg) 1. and 2. apply to that individual:

49.471(8)(cr)1.a. a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line.

49.471(8)(cr)1.b. b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.

49.471(8)(cr)1.c. c. An adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line.

49.471(8)(cr)2. 2. An individual under subd. 1. is not ineligible if any of the good cause reasons described in par. (d) 2. a. to e. is the reason that the individual did not obtain health insurance coverage.

49.471(8)(cr)3. 3. An individual under subd. 1. c. is not ineligible if any of the following good cause reasons is the reason the individual did not obtain health insurance coverage:

49.471(8)(cr)3.a. a. The parent of the individual is no longer employed by the employer through which the parent was eligible for coverage, and the parent does not have current coverage.

49.471(8)(cr)3.b. b. The employer of the parent of the individual discontinued providing health benefits to all employees.

49.471(8)(cr)4. 4. The department may apply this paragraph to eligibility determinations for BadgerCare Plus only if the federal department of health and human services approves of the conditions to make that individual ineligible, if approval is required.

49.471(8)(ct) (ct)

49.471(8)(ct)1. 1. If the federal department of health and human services approves the department’s request to add private major medical insurance as a type of coverage which causes ineligibility, an individual who is not disabled and not pregnant, who is over 18 years of age, whose family income exceeds 133 percent of the poverty line, and who has coverage provided by private major medical insurance in which the monthly premium does not exceed 9.5 percent of the family’s monthly income is not eligible for BadgerCare Plus.