Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.15 - Treatment of spouses

Current through June 24, 2024
Notwithstanding ss.
					 DHS
					 109.13 and
					 109.14, when the spouse of a
					 SeniorCare participant files an application or review of eligibility for
					 SeniorCare under s.
					 DHS
					 109.14(7), or requests a new benefit
					 period, and is required under s.
					 DHS
					 109.12(1) to be in the same fiscal
					 test group as the participant, the eligibility of the spouse for benefits and
					 services under s.
					 DHS
					 109.13 and the duration of the spouse's benefit period
					 shall be determined in the following manner, unless both the participant and
					 the participant's spouse jointly file a request for a new benefit period under
					 s.
					 DHS
					 109.14:
(1)
				  The department shall determine the eligibility of the spouse under s.
				  DHS
				  109.11, and, if eligible for SeniorCare, determine the
				  beginning eligibility date of the spouse's benefit period according to s.
				  DHS
				  109.14.
(2) If the department under sub. (1)
				  determines the spouse is eligible for SeniorCare the spouse's benefit period
				  shall end on the same date as the participant's benefit period ends.
(3) If the department determines the spouse
				  is ineligible for SeniorCare, the benefits and services that the participant
				  spouse may receive during the participant's current benefit period may not be
				  affected.
(4) If the income of the
				  spouse was not used to determine the SeniorCare benefit for the participant
				  spouse, both of the following apply:
(a) The
				  department shall determine the annual income for the fiscal test group for the
				  12-month period beginning with the month the application request for the spouse
				  is received.
(b) The benefit and
				  services under s.
				  DHS
				  109.13 that the spouse may receive shall be determined
				  as follows:
1. 'Annual income exceeds 240% of
				  poverty line.'
a. If the annual income of the
				  fiscal test group exceeds 240% of the poverty line for a 2-person family, the
				  spouse may receive spend-down services under s.
				  DHS 109.13(4) (a)
				  2.
b. When determining whether the spouse meets
				  the SeniorCare spend-down under s.
				  DHS 109.13(4)
				  (c), the amount of the SeniorCare spend-down
				  shall be prorated. The prorated amount shall be the annual spend-down amount
				  under s.
				  DHS 109.13(4)
				  (b) multiplied by the number of months of the
				  spouse's benefit period derived from subs. (1) and (2), divided by 12. Only
				  prescription drug costs of the spouse may count towards meeting the prorated
				  spend-down.
c. If the spouse meets
				  the prorated spend-down during the benefit period, the spouse may receive the
				  deductible benefit and services under s.
				  DHS 109.13(3)
				  (b). When determining whether the spouse
				  meets the SeniorCare deductible under s.
				  DHS 109.13(3) (c)
				  and (d), the amount of the SeniorCare
				  deductible shall be prorated. The prorated deductible amount shall be $850
				  multiplied by the number of months of the spouse's benefit period derived from
				  subs. (1) and (2), divided by 12.
d. If the spouse meets the prorated
				  deductible during the benefit period, the spouse may receive the prescription
				  benefit under s.
				  DHS 109.13(2)
				  (b).
2. `Annual income between 160-240% of poverty
				  line.'
a. If the annual income of the fiscal
				  test group is greater than 160%, but not in excess of 240% of the poverty line
				  for a 2-person family, the spouse may receive the deductible benefit and
				  services under s.
				  DHS 109.13(3)
				  (b).
b. When determining whether the spouse meets
				  the SeniorCare deductible under s.
				  DHS 109.13(3) (c)
				  and (d), the amount of the SeniorCare
				  deductible shall be prorated. The prorated deductible amount shall be the
				  dollar amount specified in s.
				  DHS 109.13(3)
				  (c) multiplied by the number of months of the
				  spouse's benefit period derived from subs. (1) and (2), divided by 12.
c. If the spouse meets the
				  prorated deductible during the benefit period, the spouse may receive the
				  prescription benefit under s.
				  DHS 109.13(2)
				  (b).
3. `Annual income less than 160% of poverty
				  line.'
a. If the annual income of the fiscal
				  test group does not exceed 160% of the poverty line for a 2-person family, the
				  spouse may receive the prescription benefit under s.
				  DHS
				  109.13(2).