13-02 Version of 7.8 Access/Coverage Overview
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State of Wisconsin
Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

7.8 Access/Coverage Overview

7.8.1 Access/Coverage Overview prior to January 1, 2014

7.8.2 Access/Coverage Overview for new applicants on or after February 1, 2014

7.8.3 BC+ Prenatal Program Access/Coverage Overview

 

These overviews are intended to be a guide to help determine whether a BC+ member or applicantA request for BadgerCare Plus coverage. The request must be on the Department's or Federally-facilitated Marketplace’s application, registration form or account transfer (from Federally-facilitated Marketplace) and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. is subject to the BC+ insurance access/coverage requirements.

 

7.8.1 Access/Coverage Overview Prior to January 31, 2014

To determine whether an individual passes BC+ insurance access/coverage requirements through December 31, 2013, answer the following questions for each individual within a BC+ group.

 

  1. Is the applicant /member pregnant, disabled, a continuously eligible newborn or youth exiting out of home care?

    • If yes, the applicant/member is not subject to the access/coverage requirements.

    • If no, continue to question #2.

  1. Is the member a child under age 19 and is currently eligible for BC+, because a child's 150% deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. was met?

 

    • If yes, the applicant/member is not subject to the access/coverage requirements during the deductible period.

    • If no, continue to question #3.

 

  1. Is the member in a BadgerCare Plus Extension?
    • If yes, the applicant/member is not subject to the access/coverage requirements.
    • If no, continue to question #4.

 

  1. Is the applicant/member either:

    1. An infant under age 1 with household income at or below 300% FPL,

    2. A child age 1 through 5 with household income at or below 185% FPL, or

    3. A child age 6 through 18 with household income at or below 150% FPL?

    • If yes, the applicant/member is not subject to the access/coverage requirements.

    • If no, continue to question #5.

 

  1. Is this member a child under age 19?

 

  1. Does the applicant/member have access to health insurance, including access due to a qualifying event , through a current employer or the current employer of an adult member of the BC+ test group ?

 

  1. Does the employer pay 80% or more of the premium?

 

  1. Is the employer provided insurance the WI State employee health plan (regardless of plan type or premium amount contributed by state or local government)?

 

  1. Would the coverage begin in any of the three calendar months following:

    1. The month of BC+ applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. filing date; or

    2. The annual review month; or

    3. The employment start date?

 

  1. Did the applicant/member have access to employer provided health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult in the BC+ test group, in the twelve months prior to the application or review date?

 

  1. Would the employer have paid 80% or more of the premium (at any time in the last 12 months)?

 

  1. Would the employer provided insurance be under the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government)?

 

  1. Did the applicant/member have "good cause " for failure to enroll in an employer sponsored health insurance plan in the 12 months prior to the application (See 7.2.1)?

 

  1. Did the applicant/member lose employer provided health insurance coverage provided through an employer or an employer of an adult BC+ test group member in the three calendar months prior to the application?
    • If yes, continue to question #15.
    • If no, the applicant/member passes the BC+ insurance/access coverage requirements.

 

  1. Did the employer pay 80% or more of the premium?

 

  1. Was the employer provided insurance part of the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government)?

 

  1. Did the applicant/member have "good cause" for dropping the health insurance (See 7.6)?

 

  1. Is this member's income greater than 133% of the FPL?

 

  1. Does the applicant/member have access to health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult member of the BC+ test group?

 

  1. Is the cost of the premium for an employee-only plan offered by the employer more than 9.5% of the household income in the month for which you are determining eligibility?

 

  1. Is the employer provided insurance the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government) and is household income over 150% of the FPL?

 

  1. Would the coverage begin in any of the three calendar months following:

 

  1. Would the coverage begin in any of the months for which you are determining eligibility and are those months immediately following:

    1. The BC+ application filing date ; or

    2. The annual review; or

    3. The employment start date?

 

  1. Did the applicant/member have access to employer provided health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult in the BC+ test group, in the twelve months prior to the application or review date?

 

  1. Was the cost of the premium for an employee-only plan offered by the employer more than 9.5% of the household income in the month for which you are determining eligibility?

 

  1. Was the employer provided insurance under the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government) and is the household income over 150% of the FPL?

 

  1. Did the applicant/member have "good cause" for failure to enroll in an employer sponsored health insurance plan in the 12 months prior to the application (See 7.2.1)?

 

  1. Did the applicant/member lose employer provided health insurance coverage provided through an employer or an employer of an adult BC+ test group member in the three calendar months prior to the application?

 

  1. Was the cost of the premium for an employee-only plan offered by the employer more than 9.5% of the household income in the month for which you are determining eligibility?

 

  1. Was the employer provided insurance part of the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government) and is the household income over 150% of the FPL?

 

  1. Did the applicant/member have "good cause" for dropping the health insurance (See 7.6)?

7.8.2 Access/Coverage Overview for new applicants on or after February 1, 2014

To determine whether an individual passes BC+ insurance access/coverage requirements beginning January 1, 2014, answer the following questions for each individual within a BC+ group.

 

  1. Is the applicant /member pregnant, disabled, a continuously eligible newborn or youth exiting out of home care?

    • If yes, the applicant/member is not subject to the access/coverage requirements.

    • If no, continue to question #2.

  1. Is the member a child under age 19 and is currently eligible for BC+, because a child's 150% deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. was met?

    • If yes, the applicant/member is not subject to the access/coverage requirements during the deductible period.

    • If no, continue to question #3.

 

  1. Is the member in a BadgerCare Plus Extension?
    • If yes, the applicant/member is not subject to the access/coverage requirements.
    • If no, continue to question #4.

 

  1. Is the applicant/member either:

    1. An infant under age 1 with household income at or below 300% FPL,

    2. A child age 1 through 5 with household income at or below 185% FPL, or

    3. A child age 6 through 18 with household income at or below 150% FPL?

    • If yes, the applicant/member is not subject to the access/coverage requirements.

    • If no, continue to question #5.

 

  1. Is this member a child under age 19?

 

  1. Does the employer pay 80% or more of the premium?

 

  1. Is the employer provided insurance the WI State employee health plan (regardless of plan type or premium amount contributed by state or local government)?

 

  1. Would the coverage begin in any of the three calendar months following:

    1. The month of BC+ application filing date; or

    2. The annual review month; or

    3. The employment start date?

 

  1. Did the applicant/member have access to employer provided health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult in the BC+ test group, in the twelve months prior to the application or review date?

 

  1. Would the employer have paid 80% or more of the premium (at any time in the last 12 months)?

 

  1. Would the employer provided insurance be under the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government)?

 

  1. Did the applicant/member have "good cause " for failure to enroll in an employer sponsored health insurance plan in the 12 months prior to the application (See 7.2.1)?
    • If yes, continue to question #13.

    • If no, the applicant is ineligible for BC+ for 12 months from the date the coverage would have begun, unless s/he becomes exempt from health insurance/access coverage requirements during that time.

 

  1. Did the applicant/member lose employer provided health insurance coverage provided through an employer or an employer of an adult BC+ test group member in the three calendar months prior to the application?
    • If yes, continue to question #14.

    • If no, the applicant/member is not subject to the BC+ insurance/access coverage requirements.

 

  1. Did the employer pay 80% or more of the premium?

 

  1. Was the employer provided insurance part of the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government)?

 

  1. Did the applicant/member have "good cause" for dropping the health insurance (See 7.6)?

7.8.3 BC+ Prenatal Program Insurance Access/Coverage Overview

Use this overview only for the BC+ Prenatal Program. (Pregnant individual who is not eligible for BC+ solely due to immigration status or because she is an inmate.)

 

  1. Does she have access to health insurance, including access due to a qualifying event, through a current employer or the current employer or an adult member of the BC+ test group.

  2.  Does the employer pay 80% or more of the premium?

 

  1. Is the employer provided insurance the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government)?

 

  1. Would the coverage begin in any of the three calendar months following:

    1. The month of BC+ Prenatal application filing date; or

    2. The annual review month; or

    3. The employment start date.

 

    • If yes, the applicant is not eligible for BC+ Prenatal benefits.

    • If no, continue to question #5.

  1. Did she have access to employer provided health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult in the BC+ test group, in the twelve months prior to the application or review date?

  2. Would the employer have paid 80% or more of the premium (at any time in the last 12 months)?

  3. Would the employer provided insurance be under the WI State employee health plan (regardless of plan type, or premium amount contributed by state or local government)?"

  4. Did she have " good cause " for failure to enroll in an employer sponsored health insurance plan in the 12 months prior to application (7.2.1)?

    • If yes, continue to question #9.

    • If no, she is ineligible for BC+ Prenatal 12 months from the date the coverage would have begun, unless she becomes exempt during that time.

  5. Is the woman covered by any HIPAAHIPAA is the Health Insurance Portability and Accountability Act. A HIPAA Standard Plan is any group health care plan that provides medical care to covered individuals and/or their dependents directly or through insurance, reimbursement, or by some other means. Medical care means amounts paid for diagnosis, cure, mitigation (moderation), treatment or prevention of disease; or amounts paid for the purpose of affecting any structure or function of the body. A policy that pays for a doctor's services in either an in-patient or outpatient setting qualifies as a HIPAA plan. The amount or type of benefits paid; co-insurance, deductibles, caps, etc., do not matter as long as the plan meets the HIPAA Standard Plan criteria. The health care plan cannot be limited to a single type of covered service or only accessible in a very defined circumstance. Plans limited to accident, disability, vision, long term care or dental are not examples of HIPAA plans. health insurance policy?

    • If yes, she is ineligible to enroll in the BC+ Prenatal Program.

    • If no, continue to question #10.

  6. Has the woman lost coverage under a major medical health insurance plan which meets the standards of a HIPAA standard plan in the prior three calendar months?

    • If yes, continue to question #11.

    • If no, she passes BC+ Prenatal insurance access/coverage requirements.

  7. Did she have a "good cause" for losing the major medical health insurance which met the standards of a HIPAA standard plan (7.6)?

    • If yes, she passes BC+ Prenatal insurance access/coverage requirements.

    • If no, she is ineligible for the BC+ Prenatal Program for three calendar months following the month the insurance coverage ended.

 

 

 

 

This page last updated in Release Number: 13-02

Release Date: 10/25/13

Effective Date: 10/24/13

The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Publication Number: P-10171