Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 103 - Eligibility › Section DHS 103.03 - Non-financial conditions for eligibility

Current through June 24, 2024
In order to be eligible for MA, a person shall meet both
				  non-financial conditions for eligibility in this section and financial
				  conditions for eligibility under s.
				  DHS
				  103.04. The non-financial conditions for eligibility
				  are:
(1) BadgerCare PLUS-RELATEDNESS
				OR SSI-RELATEDNESS.
(a)
Requirement.
To be non-financially eligible for MA, an
				applicant shall be BadgerCare Plus-related or SSI-related.
(b)
BadgerCare Plus-related
				persons.
In this subsection, "BadgerCare Plus-related" means a person
				who meets one of the following conditions:
1.
				The person is pregnant and meets the conditions specified in s.
				49.471 (4) (a)
				1, 1g., or 1m., Stats.
2. The person is a child under age 19 who
				meets the conditions specified in s.
				49.471 (4) (a)
				3, 3g., 3m. or 7., Stats., and under par.
				(f).
2m. The person is an unborn
				child as defined in s.
				49.471 (1) (k),
				Stats., and meets the conditions under par. (f).
3. The person is a caretaker relative or a
				caretaker relative's spouse if the spouse resides with the caretaker relative's
				child who meets the conditions specified in s.
				49.471 (4) (a)
				4 or 7., Stats.
4. The person is a foster child under 19
				years of age living in a foster home licensed under s.
				48.62, Stats., or a group home
				licensed under s. 48.625, Stats., is a child under
				the care of a subsidized guardianship under s.
				48.623, Stats., or is a child in
				an adoption assistance placement under s.
				48.975, Stats.
5. The person is a former foster care
				recipient and meets the conditions specified under s.
				49.471 (4) (a)
				5, Stats.
6. The person meets the
				conditions to receive family planning services under s.
				49.45 (24s),
				Stats.
7. The person is diagnosed
				with tuberculosis and meets the conditions under s.
				49.46 (1) (a)
				15., Stats.
8. The person is at
				least 19, but under 21 years of age and resides in an intermediate care
				facility, skilled nursing facility, or inpatient psychiatric hospital and meets
				the conditions under s.
				49.47 (4),
				Stats.
(c)
SSI-related persons.
In this subsection, "SSI-related person"
				means a person who meets one of the following conditions:
1. The person is age 65 or over; or
2. The person is blind or
				disabled.
(d)
Verification of blindness or disability.
Except as provided
				under par. (e), the blindness or disability claimed under par. (c) 2. shall be
				verified in one of the following ways:
1. By
				presentation of a current old age and survivors disability insurance (OASDI)
				disability award notice;
2. By
				presentation of a current medicare card indicating blindness or disability;
				or
3. By receipt of a disability
				determination made by the department's bureau of social security disability
				insurance, along with current medical reports.
(e)
Presumption of disability in an
				emergency.
1. Under emergency
				circumstances, a person may be presumed disabled for purposes of demonstrating
				SSI-relatedness and be eligible for MA without the verification required under
				par. (d).
2. When an emergency need
				for MA exists, the department shall make a preliminary disability determination
				within 7 days of the date a completed disability determination form is
				received.
3. An emergency need for
				MA shall exist when the applicant is:
a. A
				patient in a hospital;
b. Seriously
				impaired and the attending physician states the applicant will be unable to
				work or return to normal functioning for at least 12 months;
c. In need of long-term care and the nursing
				home will not admit the applicant until MA benefits are in effect; or
d. Unable to return home from a nursing home
				unless in-home service or equipment is available and this cannot be obtained
				without MA benefits.
Note:
Copies of the disability determination
				  form may be obtained from the county or tribal income maintenance
				  agency.
(f)
BadgerCare Plus
				eligibility
. To be non-financially eligible for BadgerCare Plus, a
				person shall meet all of the following conditions:
1. The person meets one of the conditions in
				par. (b).
2. Except as provided in
				subd. 5m., the person is a child age 1 through 5 with household income over
				191% of the federal poverty line or age 6 through 18 with household income over
				156% of the federal poverty line, and does not have health insurance coverage
				that meets both of the following criteria:
a.
				The health insurance coverage is provided by an employer that pays 80% of the
				premium or coverage is provided under the state of Wisconsin employee health
				plan.
b. The health insurance
				covers services provided in a service area that is within a reasonable driving
				distance from the person's residence.
2m. The person is an unborn child and the
				unborn child's mother does not have health insurance coverage that covers
				services provided in a service area that is within a reasonable driving
				distance from the person's residence.
3. Except as provided in subd. 5m., the
				person is a child age 1 through 5 with household income over 191% of the
				federal poverty line or age 6 through 18 with household income over 156% of the
				federal poverty line, and the person does not have access to coverage under a
				group health insurance plan that meets all of the following criteria:
a. The health insurance coverage is provided
				by an employer that pays 80% of the premium or coverage is available under the
				state of Wisconsin employee health plan.
b. The health insurance coverage would begin
				within 3 calendar months following the BadgerCare Plus application filing date,
				the BadgerCare Plus annual renewal month, or the start date of the employment
				through which the child can access the health insurance coverage.
c. The employer of the person's parent,
				step-parent or other caretaker relative residing with the person, when the
				person is under 19 years of age.
cm. The health insurance covers services
				provided in a service area that is within a reasonable driving distance from
				the person's residence.
d. The
				health insurance policy is through the child's employer, the employer of the
				child's spouse when the spouse is residing with the child, or the employer of
				the child's parent, step-parent or other caretaker relative residing with the
				child.
3m. If the person
				is an unborn child, the unborn child's mother does not have access to coverage
				under a group health insurance plan that meets all of the following criteria:
a. The health insurance coverage is provided
				by an employer that pays 80% of the premium or coverage is available under the
				state of Wisconsin employee health plan.
b. The health insurance coverage would begin
				within 3 calendar months following the BadgerCare Plus application filing date,
				the BadgerCare Plus annual renewal month, or the start date of the employment
				through which the mother can access the health insurance coverage.
c. The health insurance covers services
				provided in a service area that is within a reasonable driving distance from
				the person's residence.
d. The
				health insurance policy is through the mother's employer or the employer of the
				mother's spouse when the spouse is residing with the mother.
e. When the mother is under 19 years old, the
				health insurance coverage is through the employer of the mother's parent,
				step-parent, or other caretaker relative residing with the mother.
4. Except as provided in subd. 5.
				or 5m., if the person did not, at any time in the 12 months immediately
				preceding application for BadgerCare Plus, have access to employer-subsidized
				health care coverage or a state employee health plan and is any of the
				following:
a. A child ages 1 through 5 with
				household income over 191% of the federal poverty level.
b. A child ages 6 through 18 with household
				income over 156% of the federal poverty line.
4g. The child under subd. 4. is ineligible
				for BadgerCare Plus the first day of the month that the employer's plan would
				have provided coverage for the child if the family had been enrolled in the
				plan. The child remains ineligible for each month that coverage would have been
				available up to 18 12 months from the month the failure to enroll in the plan
				occurred if the health insurance plan meets all of the following criteria:
a. The health insurance coverage is provided
				by an employer that pays 80% of the premium or coverage is available under the
				state of Wisconsin employee health plan.
b. The health insurance covers services
				provided in a service area that is within a reasonable driving distance from
				the person's residence.
c. The
				health insurance policy is through the child's employer, the employer of the
				child's spouse when the spouse is residing with the child, or the employer of
				the child's parent, step-parent or other caretaker relative residing with the
				child.
4r. Except as
				provided in subd. 5., if the person is an unborn child, the unborn child's
				mother did not, at any time in the 12 months immediately preceding application
				for BadgerCare Plus, have access to employer-subsidized health care coverage,
				or a state employee's health plan. The unborn child is ineligible for
				BadgerCare Plus the first day of the month that the employer's plan would have
				provided coverage for the unborn child's mother if the family had been enrolled
				in the plan. The unborn child remains ineligible for each month that coverage
				would have been available up to 12 months from the month the failure to enroll
				in the plan occurred if the health insurance plan meets all of the following
				criteria:
a. The health insurance coverage is
				provided by an employer that pays 80% of the premium or coverage is available
				under the state of Wisconsin employee health plan.
b. The health insurance covers services
				provided in a service area that is within a reasonable driving distance from
				the person's residence.
c. The
				health insurance policy is provided through the mother's employer, the employer
				of the mother's spouse when the spouse is residing with the mother, or the
				employer of the mother's parent, step-parent or other caretaker relative
				residing with the child, if the mother is under 19 years of age.
5. The 12 month period in subds.
				4. and 4m. does not apply if one of the following statements is true about
				access to employer-subsidized health care coverage:
a. The employment ended.
b. The person's employer discontinued health
				care coverage for all employees.
c.
				A member or members of the family were eligible for other health insurance
				coverage or MA at the time the employee failed to enroll in the
				employer-subsidized health care coverage and no member of the group was
				eligible at that time for BadgerCare Plus with an assistance group income above
				156% of the federal poverty line.
e. Any other reason determined by the
				department to be a good cause reason.
6. The person is not eligible for MA under
				BadgerCare Plus-related or SSI-related criteria in this chapter.
7. A person required to pay a premium under
				s.
				DHS 103.085
				(1) has made the first payment.
8. A person has not chosen to receive
				BadgerCare Plus-related or SSI-related MA through a spend-down, as described in
				s.
				DHS 103.08 (2)
				(a), or has chosen to end a spend-down period
				at any time prior to the date at which the expenditure or obligation of excess
				income has been achieved.
(fm)
Exemption from health insurance
				coverage requirements.
A child is exempt from the health insurance
				coverage requirements in sub. (1) (f) 2., 3., and 4., if they meet any of the
				following criteria:
1. The child is younger
				than 19 years old, has met a deductible, and is in the deductible
				period.
2. The child is in an
				extension.
3. The person is age 18
				and was in foster care, subsidized guardianship, or court-ordered kinship care
				on the date they turned 18 years old.
4. The child is pregnant.
(g)
Medicaid purchase plan
				non-financial eligibility.
To be non-financially eligible for the
				medicaid purchase plan a person shall meet the conditions described in par. (c)
				for SSI-related persons and shall be age 18 or older and the person shall meet
				any of the following conditions:
1.
a. The person shall be employed.
b. The person shall be enrolled in a
				department-certified health and employment counseling program.
c. The health of the person participating in
				the medicaid purchase plan for at least 6 months shall have deteriorated to the
				point that he or she is unable to participate under subd. 1. a. or b. and the
				county agency has waived the requirement for a period up to 6 calendar months.
				The county agency may waive the requirement if the person is hospitalized,
				injured or suffers any other health setback. The county agency may waive the
				requirement as long as it had not granted a waiver of the requirement twice
				within the 36 months immediately preceding the current waiver request. The
				waiver periods shall be non-consecutive. The person shall supply proof of
				health difficulties. In addition to the discretion the county agency has to
				grant a waiver, the department may grant a temporary waiver of the work
				requirement upon a showing of good cause.
2. The person meets SSI-related non-financial
				eligibility requirements under par. (c) as verified under par. (d) and s.
				49.472 (3) (c),
				Stats.
3. The applicant meets the
				eligibility requirements described in s.
				DHS
				103.087.
(h)
Medicaid purchase plan health and
				employment counseling eligibility.
1. 'Initial eligibility.' To be eligible for
				the health and employment counseling program within the medicaid purchase plan,
				a person shall complete an employment plan.
a. The employment plan shall be reviewed by a
				screening agency and approved by the department before the person receives
				approval from the department as a participant.
b. The screening agency shall refer the
				person to community resources as appropriate to meet all employment plan
				requirements. The screening agency may assist the person in completing the
				written employment plan or providing any other services required under the
				plan.
c. A notice of participation
				status shall be sent by the department to the person, the screener and the
				appropriate county or tribal economic support office.
2. 'Period of eligibility.'
a. A person may participate in a health and
				employment counseling program for a period of up to nine consecutive calendar
				months and for any allowable periods of extension described under subd.
				3.
b. Upon completion of a period
				of eligibility, a person shall be ineligible for a health and employment
				counseling program for a period of 6 consecutive calendar months. Following the
				6-month period, a person may begin a new period of eligibility, but a given
				person may only use 2 periods of eligibility within a period of 5 consecutive
				calendar years.
c. Participation in
				a health and employment counseling program approved by the department meets the
				eligibility requirement in par. (g) 1. b.
3. 'Extending eligibility.'
a. If a person is not employed at the end of
				the period of eligibility, the person may request an extended period of
				eligibility from the department. The extended period of eligibility shall be
				valid for a period of three consecutive calendar months.
b. The extended period of eligibility shall
				be approved by the department.
c.
				The person may not request more than one extension of eligibility per period of
				eligibility.
d. After participation
				in a health and employment counseling [program] ends, a person may continue to
				receive services from an agency that also provides screening services, in
				accordance with the agency's rules.
4. 'Retroactive eligibility.'
a. A person may request retroactive
				participation in a health and employment counseling program for a period of up
				to three months if the person demonstrates he or she met all eligibility
				requirements of the employment plan during those months.
b. Any retroactive months of eligibility
				requested by the person shall count toward the period of eligibility as
				described in this paragraph.
c. The
				department shall approve requested months of retroactive eligibility.