Current through February 26, 2024
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. Once determined eligible, a person shall
continue to receive benefits until the person requests the benefits to be
ended, the person loses Wisconsin residency as defined in sub. (3), or the
person becomes deceased. The non-financial conditions for eligibility
are:
Note: DHS 103.03 (intro.) is amended by CR 21-067
effective the first day of the month after the emergency period, as defined in
42 USC
1320b-5(g) (1) (B) and
declared in response to the COVID-19 pandemic, ends, to read:
DHS 103.03 Note (intro.) 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.
Note: Copies of the disability determination
form may be obtained from the county or tribal income maintenance
agency.
(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 Badger Care 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.
4. The non-financial eligibility requirements
in subd. 1. shall not be enforced until the first day of the month following
the end of the emergency period defined in section 1135 (g) (1) (B) of the
Social Security Act,
42 USC
1320b-5(g) (1) (B), and
declared by the United States Secretary of Health And Human Services in
relation to the COVID-19 pandemic.
Note: Subd. 4. is repealed by CR 21-067 effective the
first day of the month after the emergency period, as defined in
42 USC
1320b-5(g) (1) (B) and
declared in response to the COVID-19 pandemic,
ends.
(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.
5. 'Suspension during the COVID-19
pandemic.' The Medicaid purchase plan health and employment counseling
eligibility provisions in subds. 1. to 4. shall not be enforced until the first
day of the month following the end of the emergency period defined in section
1135 (g) (1) (B) of the Social Security Act,
42 USC
1320b-5(g) (1) (B), and
declared by the United States Secretary of Health And Human Services in
relation to the COVID-19 pandemic.
Note: Subd. 5. is repealed by CR 21-067 effective the
first day of the month after the emergency period, as defined in
42 USC
1320b-5(g) (1) (B) and
declared in response to the COVID-19 pandemic, ends.
(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.