Section 138.05. Payment of health insurance premiums.

 

(1)   Amount and period of subsidy.

(a) Except as provided in pars. (e) , (f) , (g) , and (h) , if an individual satisfies s. DHS 138.04 (1) and has been notified by the department under s. DHS 138.04 (3) (a) that the application has been approved, the department shall take one of the following actions, as appropriate, on or after the date of the notice of decision under s. DHS 138.04 (3) (a) :

1. For a subsidy under s. 252.17 , Stats., the department shall pay the full amount of the premium due for coverage under a group health plan during an unpaid medical leave for an individual whose family income does not exceed 200% of the federal poverty line.

2. For a subsidy under s. 252.16 , Stats., the department shall pay the full amount of the premium due for health insurance coverage for an individual whose family income does not exceed 200% of the federal poverty line.

3. For a subsidy under s. 252.16 , Stats., the department shall pay the full amount of the premium, subject to an annual premium contribution assessment under par. (d) , due for health insurance coverage for an individual whose family income exceeds 200% but does not exceed 300% of the federal poverty line.

4. For a subsidy under s. 252.17 , Stats., the department shall pay the full amount of the premium, subject to a premium contribution assessment under par. (dm) , due for health insurance coverage during an unpaid medical leave for an individual whose family income exceeds 200% but does not exceed 300% of the federal poverty line.

(b) The department may not refuse to pay a premium because the health plan coverage that is available to the individual who satisfies s. DHS 138.04 (1) includes coverage of the individual's spouse or domestic partner under ch. 770 , Stats. , and dependents.

(c) Except as provided in par. (e) , the department shall terminate payments when:

1. The individual's unpaid medical leave ceases;

2. The individual no longer satisfies s. DHS 138.04 (1) ; or

3. Upon the expiration or termination of the individual's health insurance coverage.

(d) Upon approval of an application for a subsidy under s. 252.16 , Stats., the department shall annually assess a premium contribution to be paid by eligible individuals whose family income exceeds 200% but does not exceed 300% of the federal poverty line. The amount of the contribution shall equal 3% of the annual policy premium. The annual policy premium shall be determined by annualizing the first monthly premium that is due for the benefit year.

(dm) Upon approval of an application for a subsidy under s. 252.17 , Stats., the department shall assess a premium contribution to be paid by an eligible individual whose family income exceeds 200% but does not exceed 300% of the federal poverty line. The amount of the contribution shall equal 3% of the annual policy premium prorated for the number of months that the individual is on an unpaid medical leave. The annual policy premium shall be determined by annualizing the first monthly premium that is due for the benefit year.

(e) The obligation of the department to make payments under this section is subject to the availability of funds in the appropriation account under s. 20.435 (1) (am) , Stats.

(f) For COBRA continuation coverage policies, the amount paid under par. (a) may not exceed the applicable premium as defined in 29 USC 1164 or 42 USC 300bb-4 , as amended to April 7, 1986.

(g) For non-COBRA policies, the amount paid under par. (a) may not exceed the amount of the premium of the most cost-effective policy available to the individual.

(h) If an individual who satisfies s. DHS 138.04 (1) has an amount escrowed under s. 103.10 (9) (c) , Stats., that is not sufficient to pay the required contribution to his or her premium payments while on unpaid medical leave, the amount paid under par. (a) may not exceed the individual's required contribution for the duration of the unpaid medical leave minus the amount escrowed.

(2)   Payment of premiums. The department shall make payment of premiums allowed under sub. (1) to the insurer, the administrator of an employer self-funded plan or the employer that provides health insurance coverage, or to the covered individual when the individual, in order to meet a premium due date, makes a payment directly to the insurer or employer and provides the department with proof that the payment was made.

History: Cr. Register, May, 1991, No. 425 , eff. 6-1-91; am. (1) (a), (b), (c) 1., 3. and (2), cr. (1) (g), Register, July, 1993, No. 451 , eff. 8-1-93; am. (1) (a) to (c), (e), (f) and (2), r. and recr. (1) (d), renum. (1) (g) to be (h) and cr. (1) (g), Register, August, 1998, No. 512 , eff. 9-1-98; correction in (1) (e) made under s. 13.92 (4) (b) 7. , Stats.; CR 10-084 : am. (1) (a) 1. and 2., (b), and (e), cr. (1) (a) 4. and (dm) Register December 2010 No. 660 , eff. 1-1-11.