7.2 Past Access to Health Insurance

7.2.1.2 The 9.5 Percent Past Access Test

7.2.2 Good Cause for "Past Access Test" under Non-MAGI Rules 7.2.3 Good Cause for "Past Access Test" under MAGI Rules

7.2.1 Introduction

Beginning July 1, 2012, there are two Past Access policies in effect:

The 80% Past Access Test.
The 9.5% Past Access Test.

The 80% Past Access Test policies applies to non-exempt children (See 7.1). The 9.5% test applies to adult parents and caretakers until March 31, 2014. After April 1, 2014, parents and caretakers are no longer subject to a Past Access Test.

7.2.1.1 The 80 Percent Past Access Test

Children and any BadgerCare Plus Prenatal Program members who had access to health insurance, including access due to a qualifying event , in the twelve months prior to the application or renewal date are not eligible for BadgerCare Plus benefits if the access was through the current employer of an adult family member who is currently living in the household and,

The access was to a 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 plan through a current employer for which the employer paid at least 80% of the premium, or through the State of Wisconsin’s health care plan (regardless of plan type, or premium amount contributed by the employer); and

The 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 a child under age 19 and child is not exempt; and

There is no good cause reason for not signing up for the coverage.

The child or BadgerCare Plus Prenatal Program member is ineligible for BadgerCare Plus for twelve calendar months from the date the health insurance would have begun.

Example 1: Marilyn applied for BadgerCare Plus in April 2014 for herself and her children, ages 10 and 8; they have family income that exceeds 156% of the FPL. She could have enrolled in a family health insurance plan through her current employer in October 2013, and her employer pays 80% of the premium for that plan. Marilyn didn’t sign up because she felt the premiums, co-payments and deductibles would be unaffordable. If she had signed up, coverage would have begun in December 2013.

Since Marilyn did not sign up for employer-provided coverage within the last twelve months when it was available, and she does not have good cause. Her children are ineligible for BC + through November 2014, 12 months from the date the coverage would have begun, unless they become exempt during that time. Marilyn is not eligible because her income is over the 100% FPL limit for the parent and caretaker coverage group.

7.2.1.2 The 9.5% Past Access Test

Note: The 9.5% Past Access Test will no longer be effective beginning April 1, 2014.

Non-exempt parents and caretakers over age 18 with household incomes over 133% of the FPL who had access to health insurance, including access due to a qualifying event, in the twelve months prior to the application or renewal date, are not eligible for BadgerCare Plus benefits if the access was through the current employer of an adult family member who is currently living in the household and,

The individual could have enrolled in the employer’s plan under the current coverage period at any time in the past 12 months prior to the application or renewal date,
The cost of coverage for an employee-only plan does not exceed 9.5% of the monthly household income, and
There is no good cause reason for not signing up for the coverage.

When an employed parent or caretaker has been determined to have had past access, the individual’s spouse will also be considered to have past access if the employer offers a plan that would provide coverage to the spouse, such as employee + spouse or employee + family coverage.

Non-pregnant, non-disabled parents and caretaker relatives with household income above 150% of the FPL will not be eligible for BadgerCare Plus benefits if they had past access to a State Employee’s health care plan, regardless of the amount of the premium. Non-pregnant, non-disabled parents and caretakers with access to state employee health insurance, who have household income between 133% and 150% FPL, are only ineligible for BadgerCare Plus if the employee-only premiums are not more than 9.5% of household income.

Example 2: Joe and his wife, Mary, apply for BadgerCare Plus for themselves and their 3 children on July 2, 2012. Their income is 145% of the FPL. Joe works for ABC Company. ABC Company offers an employee-only plan as well as a family plan. Joe’s cost for the employee-only plan is less than 9.5% of the household’s countable income. The last open enrollment period to sign up for the employer sponsored insurance was October 1, 2011 through October 31, 2011. The plan coverage period is January 1, 2012 through December 31, 2012.

Since Joe could have enrolled in the past 12 months and could have had coverage under the current coverage period, and the premiums would have been less than 9.5% of the family’s income, he is ineligible. Since the employer offers a family plan that would cover Mary, she is also ineligible. Children under age 19 are not subject to the 9.5% access tests so the children’s eligibility is not affected.

7.2.2 Good Cause for 80% and 9.5% "Past Access Test" under Non-MAGI Rules

Good cause reasons for failure to enroll in an employer sponsored health insurance plan in the 12 months prior to application or renewal are:

Discontinuation of health insurance benefits by the employer;
During the time period when the employee failed to enroll in the health insurance coverage, one or more members of the individual’s family was covered through:
1. A private health insurance policy; or
2. Medicaid, or BadgerCare Plus;

And no one in the Test Group at that time was eligible for:

- BadgerCare,
- BadgerCare Plus with a household income above 150% of the FPL,
- If the failure to enroll occurred on or after July 1, 2012, BadgerCare Plus with household income above 133% of the FPL,
- BadgerCare Plus Extension, or
- BadgerCare Plus as a Pregnant Woman (not including the BadgerCare Plus Prenatal Program).

The employment ended, or
Any other reason determined by DHS as a good cause reason. Local agencies must contact the DHS CARES Call Center for approval before granting good cause for any reason not stated above.

Example 3: Olivia applied for BadgerCare Plus in January 2012 for herself and her children. Although it was determined that she had access to employer sponsored health insurance in August of 2011 (past access), she has a good cause exemption because she and her children were enrolled in BadgerCare Plus from July 2011 through November 2011 and the family income at that time was only 120% of the FPL.

7.2.3 Good Cause for the 80% "Past Access Test" Under MAGI Rules

Good cause reasons for failure to enroll in an employer sponsored health insurance plan in the 12 months prior to application or renewal are:

Discontinuation of health insurance benefits by the employer;
During the time period when the employee failed to enroll in the health insurance coverage, one or more members of the individual’s family was covered through:
1. A private health insurance policy; or
2. Medicaid, or BadgerCare Plus;

And no one in the Test Group at that time was eligible for:

- BadgerCare Plus with an assistance group income above 156% of the FPL,
- BadgerCare Plus Extension, or
- BadgerCare Plus as a Pregnant Woman (not including the BadgerCare Plus Prenatal Program).

The employment through which the child is insured ended, or
Any other reason determined by DHS as a good cause reason. Local agencies must contact the DHS CARES Call Center for approval before granting good cause for any reason not stated above.

This page last updated in Release Number: 14-01

Release Date: 02/07/14

Effective Date: 02/01/14