Section 103.085. Conditions for continuation of eligibility for BadgerCare.

 

(1)   Premiums.

(a) Authority . Subject to s. 49.665 (5) , Stats., and this section, a group eligible for BadgerCare may be required to pay a premium.

(b) Applicability .

1. A group eligible for BadgerCare with budgetable income at or below 150% of the poverty line is not required to pay a premium toward the cost of the health care coverage.

2. Except as provided in subd. 3. or 4. , a group eligible for BadgerCare with budgetable income above 150% of the poverty line shall pay a premium toward the cost of the health care coverage.

3. A BadgerCare applicant group does not owe a premium for the first month of BadgerCare unless a member of the BadgerCare fiscal test group was an MA recipient in the previous month.

4. A BadgerCare applicant group does not owe a premium for the first month of BadgerCare unless a member of the BadgerCare fiscal test group was a BadgerCare recipient in the previous 12 months.

(c) Amounts . A group eligible for BadgerCare required under this subsection to pay a premium shall pay the amount indicated in the schedule provided in Table 103.085. Income shall be determined according to s. DHS 103.07 . - See PDF for table

(d) Payment .

1. A group otherwise eligible for BadgerCare that is required to pay a premium under this section shall pay the premium amount in full to the agency before the agency may certify the group's initial eligibility for BadgerCare.

2. Premiums are due by the 10th of the month prior to the month for which the premium is required.

3. If no payment is received by the end of the month for which the premium is required, the department shall terminate the group's eligibility for BadgerCare, effective at the end of the month.

4. The department shall allow a variety of premium payment methods. A group may choose one of the following methods for premium payment:

a. Wage withholding.

b. Electronic funds transfer (EFT).

c. Direct payment by check or money order.

5. A group may pay premiums in advance for more than one month, but only for months in the group's BadgerCare eligibility period.

(e) Refunds . The department shall issue a refund for a premium which has been paid in advance when the premium is for one of the following:

1. A month that the group is ineligible for BadgerCare.

2. A month that the group's budgetable income drops to or below 150% of the poverty line and the change in income that brought the group's budgetable income to or below 150% of the poverty line was reported within 10 days of the date the change occurred.

3. A month which requires a lower premium amount due to a change in circumstances which was in effect for the entire month so long as the change was reported within 10 days of the date it occurred. In a case where the change was not reported within 10 days of the date it occurred, the effective date of the lower premium amount due is the first day of the month in which the change was reported.

(f) Consequence of failure to pay BadgerCare premiums. A group required to pay a premium shall be ineligible for re-enrollment for the period specified in sub. (3) when the group fails to pay its premium within the time specified in par. (d) .

(2)   Quitting BadgerCare.

(a) Termination of benefits . Except as provided in par. (b) , a group eligible for BadgerCare and required under sub. (1) to pay a premium shall be subject to re-enrollment restrictions under sub. (3) when that group voluntarily terminates BadgerCare eligibility.

(b) Reasons for quitting BadgerCare . A group that quits BadgerCare shall not be subject to a restrictive re-enrollment period if the group requests termination of BadgerCare for one of the following reasons:

1. The BadgerCare group is moving out of Wisconsin.

2. No one in the BadgerCare group remains non-financially eligible for BadgerCare.

3. A member of the BadgerCare group is starting employment that provides health care benefits.

4. Other health insurance coverage has become available to the BadgerCare group.

5. Any other reason, as determined by the department, not related to payment of the premium.

(3)   Re-enrollment restriction.

(a) Period of ineligibility. A BadgerCare group that fails to make a premium payment under sub. (1) or quits BadgerCare under sub. (2) is not eligible for BadgerCare for a period of at least 6 consecutive calendar months following the date that BadgerCare eligibility ends, unless one of the circumstances in par. (b) applies. Eligibility is restored as described in par. (c) . After 6 calendar months, the group shall be eligible for BadgerCare only if all past premiums due are paid in full or 12 calendar months have passed after the expiration of BadgerCare eligibility, whichever is sooner.

(b) Reasons restriction on re-enrollment may not apply. The restriction on re-enrollment under this section does not apply for either of the following reasons:

1. The failure to pay premiums was due to a circumstance beyond the group's control, provided that all past due premiums have been paid in full. A circumstance beyond the group's control includes any of the following:

a. A problem with an electronic funds transfer from a bank account to the BadgerCare program.

b. A problem with an employer's wage withholding.

c. An administrative error in processing the premium.

d. Any other circumstance affecting payment of the premium which the department determines is beyond the group's control, but not including insufficient funds.

2. A significant change in household composition occurred. A significant change occurs when one of the following events occurs:

a. A parent or a parent's spouse in the group eligible for BadgerCare no longer resides in the home and has not resided in the home for at least 30 consecutive days.

b. A person not in the group eligible for BadgerCare, but who is legally responsible for a group member, no longer resides in the home and has not resided in the home for at least 30 consecutive days.

c. A caretaker relative of a minor in a group eligible for BadgerCare, or the caretaker relative's spouse, no longer resides in the home and has not resided in the home for at least 30 consecutive days.

(c) Resuming BadgerCare eligibility. Eligibility for BadgerCare shall resume in the following manner for persons with a re-enrollment restriction that ended due to a reason described in par. (b) :

1. For a BadgerCare group with a reason under par. (b) 1. for the re-enrollment restriction not to apply, BadgerCare eligibility shall be restored for any months that the group had been closed during the restriction period, provided that payment of any outstanding premiums owed is made and the group was otherwise eligible for BadgerCare in those months.

2. For a BadgerCare group with a reason under par. (b) 2. for the re-enrollment restriction not to apply, the restriction on re-enrollment shall not apply to the remainder of the 6-month period. Beginning the first of the month after the adult has been out of the home for 30 days, the group may again be eligible for BadgerCare, provided that payment of any outstanding premiums owed is made and the group is otherwise eligible. The BadgerCare group remains ineligible for any prior months when the restriction on re-enrollment was in effect.

(4)   Enroll in available employer-subsidized health plan.

(a) A BadgerCare recipient is ineligible for BadgerCare when one of the following fail to enroll in an available employer-subsidized health care coverage:

1. The recipient.

2. The recipient's spouse when the spouse is residing with the recipient.

3. The recipient's parent, step-parent or other caretaker relative residing with the recipient, when the recipient is under 19 years of age.

(b) Except as provided in par. (c) , the recipient is ineligible for BadgerCare effective on the first day of the month that the employer-subsidized health care coverage would have been in effect for the recipient if the family had been enrolled in the plan. The individual remains ineligible for each month that coverage would have been available up to 19 months from the month the failure to enroll in the plan occurred.

(c) Paragraph (b) does not apply if there was coverage and it ended for a good cause reason. A good cause reason is any of the following:

1. The employment ended for a reason other than voluntary termination.

2. The person changed to a new employer that does not offer family coverage.

3. The person's employer discontinued health plan coverage for all employees.

4. Any other reason determined by the department to be a good cause reason.

(5)   Cooperation with buy-in to a group health insurance plan. An adult in a group eligible for BadgerCare shall cooperate when the department determines whether it is cost-effective to purchase coverage for the group in an employer's group health insurance plan under s. DHS 108.02 (13) . In this subsection, "cooperation" means providing necessary information in order to determine cost effectiveness, signing up with the plan when requested by the department and cooperating with any other requirements of the health insurance plan. A person who fails or refuses to cooperate with buy-in is not eligible for BadgerCare.

(6)   Maximum income. A BadgerCare group remains eligible for BadgerCare while the fiscal test group's income is at or below 200% of the poverty line and the group is otherwise eligible for BadgerCare.

History: Emerg. cr. eff. 7-1-99 ; cr. Register, March, 2000, No. 531 , eff. 4-1-00; correction in (5) made under s. 13.92 (4) (b) 7. , Stats., Register December 2008 No. 636 .