Section 138.04. Participation in the health insurance premium subsidy program.

 

(1)   Eligibility. In order to participate in the health insurance premium subsidy program, a person shall satisfy all of the following requirements which pertain to the type of subsidy the person is seeking:

(a) Have residence in this state;

(b)

1. For a subsidy under s. 252.16 , Stats., have a family income that does not exceed 300% of the federal poverty line for a family the size of the individual's family;

2. For a subsidy under s. 252.17 , Stats., have a family income that does not exceed 300% of the federal poverty line for a family the size of the individual's family;

(c) Have an HIV infection;

(d) Have health insurance coverage under a group health plan, an individual health policy or Medicare part D, or is eligible for health insurance coverage under a group health plan, an individual health policy or Medicare part D;

(e) Is on unpaid medical leave if the person is seeking a subsidy for group health plan premiums while on unpaid medical leave; and

(f) Does not have escrowed under s. 103.10 (9) (c) , Stats., an amount sufficient to pay the individual's required contribution to his or her group health plan premium payments during an unpaid medical leave if the individual is seeking a subsidy for these payments.

(2)   Application process.

(a) Any individual who satisfies the eligibility conditions under sub. (1) and wants to participate in the health insurance premium subsidy program shall complete and submit to the department an application form, F-44614, which shall provide the following information:

1. The individual's name and address;

2. Names of the individual's family members and their ages;

3. Family income information;

4. Name and address of the individual's present or immediate past employer through whom the individual has or had health coverage and the name and address of the insurer or administrator of the health plan under which the individual is or was covered;

5. Authorization, in writing, for the department to do all of the following:

a. Contact the individual's employer or former employer or health insurer to verify the individual's employment status, the individual's eligibility for health insurance coverage and the premium and any other conditions of coverage, to make premium payments and for other purposes related to the administration of this chapter; and

b. Make any necessary disclosure to the individual's employer or former employer or health insurer regarding the individual's HIV status;

6. Written certification from a physician of the following:

a. That the individual has an HIV infection; and

b. That the individual is on an unpaid medical leave because of an illness or medical condition arising from or related to the individual's HIV infection or because of medical treatment or supervision of the illness or condition or that the individual's employment has been terminated or his or her hours have been reduced because of an illness or medical condition arising from or related to the individual's HIV infection; and

7. Any other information that the department requires for purposes of determining eligibility under sub. (1) or evaluating the health insurance premium subsidy program.

(b) Any individual who does not satisfy sub. (1) (b) , (d) or (e) , may submit an application form, F-44614, that the department will hold until the individual satisfies all the applicable requirements under sub. (1) . The department may not contact the individual's employer, former employer or health insurer until the individual satisfies all the applicable requirements under sub. (1) unless the individual authorizes the department, in writing, to make that contact and to make any necessary disclosure regarding the individual's HIV infection.

(3)   Notification of decision. Within 20 working days after receipt by the department of the information described under sub. (2) , the department shall determine whether or not the applicant satisfies the conditions under sub. (1) and do one of the following:

(a) If the applicant satisfies all the applicable requirements under sub. (1) , the department shall approve the application and notify the applicant in writing; or

(b) If the applicant does not satisfy an applicable requirement under sub. (1) , the department shall deny the application and notify the applicant, in writing, of the reasons for denial and of the right under sub. (5) to appeal the denial. If the denial is based upon inability to satisfy one or more of the requirements under sub. (1) (b) , (d) or (e) , the department shall include in the notice information that the department will hold the application until the applicant submits to the department written documentation that the requirement or requirements not met have been met, without need of the applicant to reapply.

(4)   Right to reapply. If the reasons listed by the department under sub. (3) (b) for denial change, an applicant may reapply.

(5)   Right to appeal. In the event that the department denies an application, the applicant may request a hearing under ch. 227 , Stats. The request for a hearing shall be submitted, in writing, to the department of administration's division of hearings and appeals and received by that office no later than 20 calendar days after the date of the letter of denial under sub. (3) (b) .

History: Cr. Register, May, 1991, No. 425 , eff. 6-1-91; am. (1) (intro.), (d) to (f) 1., (2) (a) (intro.), 5. a. and b., 6. b., 7., (b), (3) (a) and (b), r. and recr. (1) (i), Register, July, 1993, No. 451 , eff. 8-1-93; r. and recr. (1) (b) and (d), am. (1) (e), (2) (a) 4., 5.a., b and (b) and (5), r. (1) (f) to (h), and renum. (1) (i) to be (1) (f), Register, August, 1998, No. 512 , eff. 9-1-98; CR 10-084 : am. (1) (b) 2., (d), and (2) (a) (intro.) and (b) Register December 2010 No. 660 , eff. 1-1-11.

Note

To obtain a copy of F-44614, write or phone the Wisconsin Division of Public Health, AIDS/HIV Program, P.O. Box 2659, Madison, WI 53701-2659, [phone]. The completed form should be returned to the same office. Microsoft Windows NT 6.1.7601 Service Pack 1 The mailing address of the Division of Hearings and Appeals is P. O. Box 7875, Madison, WI 53707. Microsoft Windows NT 6.1.7601 Service Pack 1