Section 103.087. Conditions for continuation of eligibility.

 

(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 at or above 150% 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 below 150% of the poverty line for the applicable household size need not pay a monthly premium.

3. An applicant or recipient eligible for the medicaid purchase plan whose premium, calculated as described in par. (c) , is greater than $10.00 shall pay a premium for the cost of the health care coverage offered under the medicaid purchase plan.

(c) Premium amounts .

1. An applicant or recipient eligible for the medicaid purchase plan shall pay a monthly premium in accordance with this subsection and the premium schedule in Table 103.087.

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 calculated by locating the sum of the monthly adjusted unearned income plus the monthly adjusted earned income on the premium schedule in Table 103.087.

(d) Calculating the monthly adjusted unearned income .

1. An applicant's or recipient's monthly adjusted unearned income shall be calculated by subtracting the monthly income disregards in subd. 1. a. to c. from 100% of the applicant's or recipient's gross monthly countable unearned income.

a. The allowance shall be equal to the sum of the monthly federal supplemental security income cash benefit, the monthly state supplemental security cash benefit, and $20, rounded to the nearest dollar.

b. To be claimed as a monthly income disregard, the cost may not have been claimed by the applicant or recipient under any other medicaid purchase plan income disregard.

c. To be claimed as a monthly income disregard, the cost may not have been claimed by the applicant or recipient under any other medicaid purchase plan income disregard.

2. If the applicant or recipient has monthly unearned income equal to $0, the monthly income disregards described in subd. 1. a. to c. apply to the applicant's or recipient's gross monthly earned income. If the applicant or recipient has monthly income disregards greater than his or her monthly unearned income, the difference shall be applied as a deduction to the applicant's or recipient's monthly earned income.

(e) Calculating monthly adjusted earned income . An applicant's or recipient's monthly adjusted earned income shall be 3% of the applicant's or recipient's gross monthly earned income after the amount of any monthly income disregards greater than the applicant's or recipient's total unearned income have been subtracted.

(f) Calculating the total monthly premium .

1. The sum of the amounts determined in pars. (d) and (e) shall be applied to the premium schedule in Table 103.087. If the sum of the monthly adjusted earned and monthly adjusted unearned income is greater than $1025.00, the total monthly premium amount is the exact amount of the sum.

Table 103.087: Medicaid Purchase Plan Premium Schedule - See PDF for table

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 or SSI federal or state benefit payment rate.

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. An applicant or recipient may pay monthly premiums in advance, but only for the months in the applicant's or recipient's current medicaid review period. The applicant or recipient shall pay advance 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.

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 at least 6 consecutive calendar months following the date that the medicaid purchase plan eligibility ends. After 6 calendar months, the person shall be eligible for the medicaid purchase plan only if all past premiums due are paid in full or 12 calendar months have passed since the expiration of medicaid purchase plan eligibility, whichever is sooner.

(2)   Cooperation with buy-in to employer-provided health care coverage.

(a) The applicant eligible for the medicaid purchase plan and the applicant's parent, if the applicant is a dependent child aged 18 or 19, shall cooperate when the department determines whether it is cost-effective to purchase coverage under the employer-provided health plan for the person under s. DHS 108.02 (14) . In this subsection, "cooperate" means provide necessary information in order to determine cost-effectiveness, sign up with the health plan when requested by the department and comply with any other requirements of the health plan.

(b)

1. Except as provided in subd. 2. , a person who fails or refuses to cooperate with the department's buy-in to employer-provided health care coverage is not eligible for the medicaid purchase plan.

2. An exception to subd. 1. shall be made in cases where a person who is otherwise eligible for medical assistance is unable to enroll in the group health plan on his or her own behalf. An example of a person who is otherwise eligible for medical assistance but unable to enroll in the group health plan on his or her own behalf may be a child whose parent refuses to enroll the child or a spouse unable to enroll on his or her own behalf.

History: Cr. Register, November, 2000, No. 539 , eff. 12-1-00; correction in (2) (a) made under s. 13.92 (4) (b) 7. , Stats., Register December 2008 No. 636 .