Section 103.03. Non-financial conditions for eligibility.

  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)   AFDC-relatedness, SSI-relatedness or BadgerCare eligibility.

(a) Requirement. To be non-financially eligible for MA, an applicant shall be AFDC-related, SSI-related or meet the non-financial requirements under par. (f) for BadgerCare.

(b) AFDC-related persons. In this subsection, "AFDC-related" means a person who meets one of the following conditions:

1. The person is pregnant and meets the conditions specified in s. 49.46 (1) (a) 1m. or 9. , 49.465 or 49.47 (4) (ag) 2. or (am) 1. , Stats.;

2. The person is a dependent child as defined in s. 49.19 (1) (a) , Stats., or is a child who meets the conditions specified in s. 49.46 (1) (a) 10. or 49.47 (4) (a) 1. or (am) 2. , Stats.;

3. The person is a caretaker relative; or

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., or is a child in an adoption assistance placement under s. 48.975 , 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.

(f) BadgerCare eligibility. To be non-financially eligible for BadgerCare, a person shall meet all of the following conditions:

1. The person is under age 19, a custodial parent living with his or her child who is under age 19 or the spouse of a custodial parent if the spouse resides with the custodial parent's child who is under the age of 19.

2. The person does not have health insurance coverage and has not been covered at any time in the previous 3 calendar months. The 3 calendar month period does not apply if the coverage ended for a good cause reason. A good cause reason is any of the following:

a. The person was covered by a group health insurance plan that was provided by a subscriber through his or her employer, and the subscriber's employment ended for a reason other than voluntary termination, except for cases in which the voluntary termination was a result of the incapacitation of the subscriber.

b. The person was covered by a group health insurance plan that was provided by a subscriber through his or her employer, and the subscriber changed to a new employer who does not offer family coverage.

c. The person was covered by a group health insurance plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.

d. COBRA continuation coverage was exhausted in accordance with 29 CFR 2590.701 - 2 (4).

e. The person was covered by insurance that has ended due to the death or change in marital status of the subscriber.

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

3. The person does not have access to family coverage under a group health insurance plan offered by an employer for which the employer pays 80% of the cost, excluding any deductibles or co-payments that may be required under the plan, or to a state employee health plan through any of the following:

a. The person's employer.

b. The employer of the person's spouse when the spouse is residing with the person.

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.

4. Except as provided in subd. 5. , the applicant for BadgerCare did not at any time in the 18 months immediately preceding application for BadgerCare have access to employer-subsidized health care coverage, or a state employee's health plan. The applicant is ineligible for BadgerCare the first day of the month that the employer's plan would have provided coverage for the recipient if the family had been enrolled in the plan. The applicant remains ineligible for each month that coverage would have been available up to 18 months from the month the failure to enroll in the plan occurred. The insurance the applicant had access to shall have been available only through one of the following:

a. The person's employer.

b. The employer of the person's spouse when the spouse is residing with the person.

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.

5. The 18 month period in subd. 4. 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 for BadgerCare at that time.

d. The person was covered by insurance that has ended due to the death or change in marital status of the subscriber.

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

6. The person is not eligible for MA under AFDC-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 AFDC-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.

(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.

(2)   Citizenship. U.S. citizenship shall be a requirement for eligibility for MA, except that an alien lawfully admitted for permanent residency may be eligible, including an alien lawfully present in the United States as a result of s. 203 (a) 7. (8. USC 1153), 207 (c) (8. USC 1157), 208 ( 8 USC 1158 ) or 212 (d) 5 ( 8 USC 1182 ) of the immigration and nationality act, an alien granted lawful temporary resident status under s. 245A ( 8 USC 1255a ), 210 ( 8 USC 1160 ) or 210A ( 8 USC 1161 ) of the immigration and nationality act or an alien otherwise permanently residing in the United States under color of law within the meaning of 42 CFR 435.408 . An alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 . USC 1396b (v).

(3)   Wisconsin residence.

(a) Definitions. In this subsection:

1. "Incapable of indicating intent" means:

a. The individual's IQ is 49 or less, or the individual has a mental age of 7 or less, based on tests acceptable to the department;

b. The individual is found legally incompetent under guardianship statutes; or

c. Medical documentation or other documentation acceptable to the department supports a finding that the individual is incapable of indicating intent.

2. "Intent to reside" means that a person intends that Wisconsin is the person's place of residence and that the person intends to maintain the residence indefinitely.

3. "Physical presence" means living in Wisconsin.

(b) Physical presence and intention. An eligible person shall be a Wisconsin resident, as determined under 42 CFR 435.403 . Residence shall be based on physical presence, except as provided in an interstate agreement, and on the person's intent to maintain Wisconsin residence indefinitely, except as otherwise provided in pars. (c) to (g) .

(c) Migrant farm workers. A migrant farm worker who is living in Wisconsin and who entered with a job commitment or to seek employment shall be considered a resident so long as there is no medical assistance being received from another state. In this paragraph, "migrant farm worker" means any person whose primary employment in Wisconsin is in the agricultural field or cannery work, is authorized to work in the United States, who is not immediate family by blood or marriage of the employer, and routinely leaves an established place of residence to travel to another locality to accept seasonal or temporary employment. Members of the migrant farm worker's family who live with the worker in Wisconsin shall also be considered Wisconsin residents.

(d) Non-institutionalized persons. The residence of a person under age 21 shall be determined in accordance with the rules governing residence under the AFDC program except that non-institutionalized persons under age 21 whose MA eligibility is based on blindness or disability are residents if they are physically present in Wisconsin.

(e) Institutionalized persons.

1. For any institutionalized person who is under age 21, or who is age 21 or older and became incapable of indicating intent before age 21, the state of residence is that of:

a. The parents or the legal guardian, if one has been appointed, and parental rights have terminated at the time of placement in an institution; or

b. The parent applying for MA on behalf of the applicant if the parent resides in another state and there is no appointed legal guardian.

2. Institutionalized persons over age 21 are Wisconsin residents when they are physically present with the intent to reside in Wisconsin except that persons who become incapable of indicating intent at or after age 21 are residents of the state in which they are physically present.

(f) Out-of-state institutional placements. When a state arranges for a person to be placed in an institution located in another state, the state making the placement is the state of residence irrespective of the person's indicated intent or ability to indicate intent.

(g) Establishment of residence. Once established, residence is retained until superseded by a new place of residence.

(4)   Furnishing of a social security number.

(a) All individuals for whom MA benefits are requested shall have a social security number and shall furnish the number to the agency, except an individual who is one of the following:

1. An alien who is requesting medical assistance only for emergency services; or

2. A child who is eligible for medical assistance under 42 USC 1396a (e) (4). During the time that the child is eligible under 42 USC 1396a (e) (4), the agency shall use the mother's social security number.

(b) If an applicant does not have a social security number, application for the number shall be made by or on behalf of the applicant to the federal social security administration. If there is a refusal to furnish a number or apply for a number, the person for whom there is a refusal is not eligible for MA. The department may not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's social security number.

(5)   Assignment of medical support. The parent or caretaker relative of a dependent child enumerated in s. 49.19 (1) (a) , Stats., shall be deemed to have assigned all rights to medical support to the state as provided in s. 49.45 (19) (a) , Stats. If there is a refusal to make the assignment, the person who refuses is not eligible for MA.

(6)   Not a person detained by legal process. A person detained by legal process is not eligible for MA benefits. For purposes of this subsection, "detained by legal process" means incarcerated because of law violation or alleged law violation, which includes misdemeanors, felonies, and delinquent acts. A person who returns to the court after observation, is found not guilty of a law violation by reason of mental deficiency and is subsequently committed to a mental institution shall not be considered detained by legal process.

(7)   Not a person residing in an institution for mental diseases. A person 21 to 64 years of age who resides in an institution for mental diseases (IMD) is not eligible for MA benefits, unless the person is 21 years of age, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident of the IMD since then. An IMD resident 21 to 64 years of age may be eligible for MA benefits while on convalescent leave from the IMD.

(8)   Not an ineligible caretaker relative. A caretaker relative enumerated in s. 49.19 (1) (a) , Stats., with whom a dependent child as defined in s. 49.19 (1) (a) , Stats., is living when the income and resources of the MA group or fiscal test group exceed the limitations of ss. 49.19 and 49.77 , Stats., or title XVI of the social security act of 1935, as amended, is not eligible unless the caretaker relative is SSI-related in accordance with sub. (1) (c) , or is a woman who is medically verified to be pregnant.

(9)   Not a striker. A person on strike is not eligible. When the striker is a caretaker relative, all members of the MA group who are 18 years of age or older shall be ineligible except that if the member of the MA group who is on strike is medically verified pregnant or, if the MA group includes a medically verified pregnant woman, the pregnant woman continues to be eligible during her pregnancy and through the month in which the 60th day following the end of pregnancy falls. In this subsection, "striker" means anyone who on the last day of the month is involved in a strike or a concerted effort with other employees to stop work, including a stoppage of work due to the expiration of a collective bargaining agreement, or any concerted slowdown or other concerted interruption of operations by employees.

History: Cr. Register, February, 1986, No. 362 , eff. 3-1-86; am. (1) (b) 1., Register, February, 1988, No. 386 , eff. 3-1-88; emerg. r. and recr. (7), eff. 8-1-88; r. and recr. (7), Register, December, 1988, No. 396 , eff. 1-1-89; emerg. am. (7), eff. 6-1-89; am. (7), Register, February, 1990, No. 410 , eff. 3-1-90; am. (1) (b) 1., 2. and 4, (2), (3) (b) and (9), r. and recr. (4), Register, March, 1993, No. 447 , eff. 4-1-93; emerg. am. (1) (a) and (b) 3., eff. 7-1-99 ; am. (1) (a) and (b) 3. and cr. (1) (f), Register, March, 2000, No. 531 , eff. 4-1-00; cr. (1) (g) and (h), Register, November, 2000, No. 539 , eff. 12-1-00; correction in (1) (b) 1. made under s. 13.92 (4) (b) 7. , Stats., Register December 2008 No. 636 .

Note

Copies of the disability determination form may be obtained from the county or tribal income maintenance agency. Microsoft Windows NT 6.1.7601 Service Pack 1