Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 103 - Eligibility › Section DHS 103.087 - Conditions for continuation of eligibility

Current through June 24, 2024
(1) PREMIUMS.
(a)
Authority.
Subject to
				this section and s. 49.472, Stats., a person
				eligible for the medicaid purchase plan shall pay a monthly premium.
(b)
Applicability
.
1. An applicant or recipient eligible for the
				medicaid purchase plan whose total earned and unearned income is above 100% of
				the poverty line for the applicable household size shall pay a monthly premium
				and the applicant shall pay all retroactive premium amounts assessed or other
				premium payments due.
2. An
				applicant or recipient eligible for the medicaid purchase plan whose total
				earned and unearned income is at or below 100% of the poverty line for the
				applicable household size pay does not owe a monthly premium.
(c)
Premium
				amounts
.
1. An applicant or
				recipient eligible for the medicaid purchase plan shall pay a monthly premium
				in accordance with this subsection.
2. The county agency shall determine the
				amount of the premium an applicant shall pay according to the guidelines
				described in this subsection at the time of application.
3. All earned and unearned sources of income
				available to the applicant or recipient, except for the interest, dividends or
				other gains accrued from a recipient's independence account, shall be used in
				the premium determination.
4. The
				applicant's or recipient's monthly premium shall be at least $25.
(d)
Calculating the
				monthly adjusted earned and unearned income
. An applicant's or
				recipient's monthly adjusted income shall be calculated by subtracting
				applicant's or recipient's gross monthly countable earned and unearned income,
				their actual out-of-pocket medical and remedial expenses, long-term care costs,
				and impairment-related work expenses.
(f)
Calculating the total monthly
				premium
.
1. An applicant or
				recipient shall pay 3 percent of his or her adjusted earned and unearned
				monthly income under par. (d) that is in excess of 100 percent of the poverty
				line plus $25.
2. The monthly
				premium shall be recalculated by the county agency to reflect any changes in
				earned or unearned income as reported by the recipient. A recipient's premium
				amount may change for any of the following reasons:
a. Termination of the recipient from the
				medicaid purchase plan.
b. A change
				in the poverty line.
bm. A change in
				the SSI federal or state benefit payment rate, except that an annual cost of
				living adjustment to the SSI benefit payment rates will not affect the monthly
				premium amount until after the subsequent change in the poverty line.
c. Changes in income, impairment-related work
				expense costs or medical and remedial expense costs.
d. Contributions to a recipient's
				independence account greater than an amount equal to 50% of earned income as
				described in s.
				DHS 103.06
				(15).
e. Other changes in personal or financial
				status that alter medical assistance eligibility.
(g)
Monthly payments
.
1. Before the county agency may certify an
				applicant as eligible for the medicaid purchase plan, the applicant who owes a
				premium under this subsection shall pay the premium amount. The premium amount
				owed shall include the premiums for all retroactive and current months in which
				the applicant owes a premium as of the date eligibility is
				determined.
2. An applicant may
				claim retroactive medicaid purchase plan eligibility for a period of up to 3
				months prior to the month of application, but not prior to January 1, 2000. To
				be eligible for retroactive eligibility, an applicant shall pay the retroactive
				premium amount for each month claimed, in full, to the state's fiscal agent via
				the county agency, prior to the county agency certifying the applicant's
				eligibility for the medicaid purchase plan.
3. Based on arrangements made by the
				applicant or recipient, entities other than the applicant or recipient may pay
				monthly premiums on behalf of the applicant or recipient. The applicant or
				recipient shall be ultimately responsible for his or her monthly premium
				payment.
4. If the county agency
				does not receive payment by the last day of the calendar month for which the
				premium is owed, the department shall terminate the recipient's eligibility for
				the medicaid purchase plan, effective the last calendar day of the
				month.
5. The applicant or
				recipient shall pay monthly premium amounts in full.
6. If no premium is required and the
				applicant meets all other eligibility factors, the county agency shall approve
				the applicant for the medicaid purchase plan.
(h)
Non-payment of medicaid purchase
				plan premiums
.
1. An applicant or
				recipient required to pay a monthly premium shall be ineligible for
				re-enrollment for the period specified in par. (i) 2. when the applicant or
				recipient fails to pay his or her monthly premium within the time specified in
				par. (g) 4. resulting in a finding of premium non-payment.
2. Premium non-payment shall include
				attempted payment with an instrument such as a check or direct deposit, that
				has been returned, refused or dishonored. A guaranteed form of payment such as
				a cashier's check or money order shall be required to replace a returned,
				refused or dishonored payment.
3.
				Failure to pay premiums due to circumstances beyond the recipient's control may
				not be considered non-payment, provided that all past due premiums are paid in
				full. Circumstances beyond the recipient's control are any of the following:
a. Problems with an electronic funds transfer
				or direct deposit from a financial institution to the medicaid purchase plan
				program.
b. Problems with an
				employer's wage withholding.
c.
				Administrative error in processing the premium.
d. Any other circumstances that may be found
				to be good cause as determined by the department on a case-by-case
				basis.
e. Approval for a temporary
				premium waiver because the department has determined that paying the premium
				would be an undue hardship on the individual.
4. At the time of application or anytime
				thereafter, an applicant or recipient may sign a release statement identifying
				an emergency contact to receive copies of the person's notice of decision
				letters.
(i)
Consequences of premium non-payment
.
1. A person eligible for the medicaid
				purchase plan who fails to pay his or her monthly premium shall be terminated
				from the medicaid purchase plan and subject to restrictive re-enrollment as
				described under subd. 2.
2. A
				medicaid purchase plan participant who fails to make his or her monthly premium
				payments in the medicaid purchase plan shall be ineligible for a period of 3
				consecutive calendar months following the date that the medicaid purchase plan
				eligibility ends except for any month during that period when the recipient's
				individual income does not exceed 100 percent of the poverty line. During these
				3 calendar months, the person shall be eligible for the medicaid purchase plan
				only if all past premiums due are paid in full or a hardship waiver has been
				granted for the months the past due premiums are owed or a combination of the
				two. After these three calendar months have passed, a medicaid purchase plan
				recipient can be eligible.