Section 103.04. Asset and income limits.

  The nonexempt assets and budgetable income of the MA group or, when applicable, the fiscal test group, shall be compared to the following asset and income limits established in this section to determine the eligibility of the MA group:

(1)   Categorically needy.

(a) The MA group or fiscal test group shall first be tested against the categorically needy standard. Persons who meet the non-financial eligibility conditions and who meet the income and asset standards specified in this subsection shall be determined eligible as categorically needy in accordance with s. 49.46 (1) (e) , Stats., and shall receive MA benefits in accordance with s. 49.46 (2) , Stats., and chs. DHS 101 to 108 .

(b) The AFDC-related categorically needy income standard for MA applicants shall be the appropriate AFDC assistance standard as specified in s. 49.19 (11) (a) 1. , Stats., except that persons who are ineligible to receive AFDC solely because of the application of s. 49.19 (11) (a) 6. , Stats., which specifies that payments that are not whole dollar amounts shall be rounded down to the nearest whole dollar, shall receive MA as categorically needy. The AFDC-related categorically needy asset standard shall be the same as that set out in s. 49.19 (4) , Stats.

(c) The SSI-related categorically needy income standard shall be the maximum SSI payment including state supplement that a single person or a couple, as appropriate, could receive in Wisconsin under s. 49.77 , Stats., or federal title XVI of the social security act of 1935, as amended. The SSI-related categorically needy asset standard shall be the same as specified in section 1613 of title XVI of the social security act of 1935, as amended.

(2)   Medically needy. If the MA group or fiscal test group is not eligible as categorically needy, the medically needy standard shall be applied. Persons who meet non-financial conditions for eligibility and meet the income and assets criteria set forth in s. 49.47 (4) (b) and (c) , Stats., and this chapter, except for AFDC-related adult caretakers who are not blind, disabled or age 65 or older, shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6) , Stats., and chs. DHS 101 through 108 .

(3)   Excess income cases.

(a) In this subsection, "spend–down period" means the period during which excess income may be expended or obligations to expend excess income may be incurred for the purpose of obtaining AFDC-related or SSI-related MA eligibility, as described under s. DHS 103.08 (2) (a) .

(b) When an SSI-related or AFDC-related fiscal test group is found ineligible as medically needy and excess income is the only reason, the group may expend or incur obligations to expend the excess income above the appropriate medically needy income limit pursuant to s. 49.47 (4) (c) 2. , Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6) , Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.

(c) Health insurance premiums actually incurred or paid, plus any medical service recognized by state law received by a member of the MA or fiscal test group shall be counted toward fulfilling the excess income expenditure or incurrence requirement when the service is prescribed or provided by a medical practitioner who is licensed by Wisconsin or another state and if either or both of the following conditions are met:

1. The service is received during the spend-down period; or

2. The expense was incurred prior to the spend-down period and a fiscal test group member is still legally responsible for the debt and is consistently making payments, in which case the payments made during the spend-down period shall be counted.

(d) No medical costs that are incurred and are to be paid or have been paid by a person other than the applicant or members of the fiscal test group may be counted toward fulfilling the excess income expenditure or incurrence requirement. No expense for which a third party is liable, including but not limited to medicare, private health insurance, or a court-ordered medical support obligation, may be used to meet the expenditure of excess income requirement.

(4)   Special financial standards for institutionalized persons. The categorically needy and medically needy asset standards shall be the same for institutionalized persons as for non-institutionalized persons, except that in determining initial eligibility under s. DHS 103.075 for an institutionalized individual with a community spouse the asset standard shall be the regular SSI-related MA group size one asset standard as provided under s. 49.47 (4) (b) 3g. , Stats., plus the community spouse resource allowance as provided under s. 49.455 (6) (b) , Stats. The eligibility standards against which an institutionalized person's income is tested shall be the following:

(a) Categorically needy standard. The categorically needy standard for an institutionalized person shall be an amount equal to 3 times the federal share of the SSI payment for one person living in that person's own home.

(b) Medically needy standard. An institutionalized person shall be determined medically needy in accordance with requirements under 42 CFR 435.1007 .

(5)   Irregular cases.

(a) Mixture of AFDC and SSI-relatedness. When there is a mixture in an MA group of AFDC-relatedness and SSI-relatedness, AFDC-related financial eligibility procedures shall be used except when no minor child is in the home, in which case SSI-related procedures shall be used.

(b) Fiscal test groups in which some are receiving AFDC and some are applying for MA only.

1. If some members of the fiscal test group are receiving AFDC and some are not, the eligibility of the non-AFDC recipients shall be determined by comparing the assets of the entire fiscal test group to the appropriate asset standard and by comparing the income of the non-AFDC members or, if appropriate, the fiscal test group, to the appropriate share of the total family income standard.

2. For purposes of this paragraph, the family consists of parents and all children, including AFDC recipients, in the household for whom either spouse is legally responsible, except that the family does not include SSI recipients and children who do not have a legally responsible parent in the home.

(c) SSI-related child when family is ineligible. A blind or disabled child in a family found financially ineligible for AFDC-related MA may have his or her eligibility determined individually according to SSI-related financial procedures for child-only cases specified in s. DHS 103.05 .

(d) Non-legally responsible relative (NLRR) case.

1. If SSI-related adults are caring for a minor child for whom they are not legally responsible, the adults shall have their financial eligibility determined according to AFDC-related procedures, except that their eligibility may be determined according to SSI-related financial procedures if they are found ineligible for AFDC-related MA because of earned income or if they elect to be processed as SSI-related.

2. The income and assets of a child residing with an NLRR shall be measured against the AFDC-related standard for one person, except that when the NLRR child is blind or disabled eligibility shall be determined according to SSI-related financial procedures.

3. If the child is found financially ineligible, the eligibility of the NLRR caretaker relative shall be determined by measuring that relative's income and assets against AFDC-related eligibility standards.

(e) Child residing in a licensed foster or group home. For a child who lives in a foster or group home licensed under chs. DCF 56 or 57 , only the child's own income and assets shall be used when determining the child's financial eligibility. The child's income and assets shall be measured against the AFDC-related income and asset standards for one person.

(6)   BadgerCare.

(a) A group that meets the requirements of s. DHS 103.03 (1) (f) and (2) to (9) and the income limits in this subsection or in s. DHS 103.085 (6) is eligible for BadgerCare.

(b) For all applicant BadgerCare fiscal test groups, the income limit is 185% of the poverty line, or a lower percentage of the poverty line established by the department in accordance with s. 49.665 (4) (at) , Stats.

(7)   Special BadgerCare budgeting procedures.

(a) BadgerCare group. The following persons who reside in the home with the primary person shall be included in the BadgerCare group if otherwise non-financially eligible and applying for BadgerCare:

1. The primary person.

2. The primary person's spouse.

3. A natural or adoptive child under age 19 of the primary person.

4. A parent of a child under subd. 3.

5. The spouse of a parent under subd. 4.

6. The natural or adoptive child of the primary person's child under subd. 3.

7. The spouse of the child in subd. 3. , if that child is a parent.

(b) BadgerCare fiscal test group.

1. The income of the following persons shall be included when determining the eligibility of the BadgerCare group:

a. Any person listed in par. (a) .

b. Except for SSI recipients, any person residing with members of the BadgerCare group who is legally responsible for any member.

2. Except for SSI recipients, the needs of the following persons shall be used to determine the eligibility of the BadgerCare group:

a. Any person listed in par. (a) .

b. Children under age 19 of the primary person who are eligible for AFDC-related or SSI-related MA.

c. Any person residing with members of the BadgerCare group, and who is legally responsible for any member.

(c) Non-legally responsible relative (NLRR) case. The income of a minor child residing with an NLRR caretaker shall be measured against the BadgerCare income limits for one person.

(d) 18 year old case. An 18 year old who resides with his or her parent or parents may have his or her BadgerCare eligibility determined either with the parent or parents or separately.

(8)   Medicaid purchase plan financial eligibility criteria.

(a) A person who meets the requirements of s. DHS 103.03 (1) (g) and (2) to (9) and the income and asset limits described in this subsection is eligible for the medicaid purchase plan.

(b) The person's total net family income is less than 250% of the federal poverty line as determined by the person's family size. Net income is calculated using the standard SSI disregards and exemptions. The income disregards are the following:

1. Sixty-five dollars and one-half of the family's remaining earned income. If the family does not have any unearned income, $85 and one-half of the family's remaining earned income.

2. Twenty dollars of any unearned income.

3. Impairment-related work expenses.

(c) The person has non-exempt assets less than the asset limit described under s. 49.472 (3) (b) , Stats.

(d) If the person leaves the medicaid purchase plan and subsequently re-enrolls in the program, the person's independence account and any interest, gains, or dividends from that account are disregarded for purposes of subsequent eligibility determinations.

(9)   Special medicaid purchase plan budgeting procedures.

(a) Medicaid purchase plan group . Any of the following persons who reside in the home with the applicant or recipient shall be included in determining the family size of the person applying for the medicaid purchase plan, with this family size used in calculating the person's financial eligibility under this section:

1. The applicant.

2. The applicant's spouse.

3. Any dependent child of the applicant as described in s. 49.141 , Stats.

(b) Medicaid purchase plan fiscal test group . The income of any person listed in par. (a) 1. or 2. shall be included when determining financial eligibility of the applicant.

(c) Medicaid purchase plan coverage .

1. Medical assistance under the medicaid purchase plan applies to the applicant or recipient only.

2. The monthly premium for the medicaid purchase plan is calculated using only the income of the applicant or recipient.

History: Cr. Register, February, 1986, No. 362 , eff. 3-1-86; am. (4) (intro.), Register, March, 1993, No. 447 , eff. 4-1-93; correction in (1) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520 ; emerg. am. (3) (a), eff. 7-1-99 ; am. (3) (a) and cr. (6) and (7), Register, March, 2000, No. 531 , eff. 4-1-00; cr. (8) and (9), Register, November, 2000, No. 539 , eff. 12-1-00; corrections in (1) (b), (2), (3) (b) and (5) (e) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636 ; correction in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register July 2015 No. 715 .