7.4 Current Health Insurance Coverage

7.4.4 Current Coverage for BadgerCare Plus Prenatal Program

7.4.1 Introduction

Beginning July 1, 2012, there are two Current Coverage policies in effect:

The 80% Current Coverage Test.
The 9.5% Current Coverage Test.

The 80% Current 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.

7.4.2 The 80% Coverage Test

Certain children who currently have individual or family health insurance coverage through an employed family member currently living in the household AND who meets the following criteria are not eligible for BadgerCare Plus:

The child is not exempt from access and coverage policies (See 7.1); and
Coverage is provided by an employer; and the employer pays at least 80% of the premium or
Coverage is available under the State of Wisconsin employee health plan (regardless of plan type, or premium amount contributed by state or local government).

Example 1: Dave applies for BadgerCare Plus in March for himself and his family. They have income that exceeds 150% of the federal poverty level. He is currently covered by family health insurance through his employer and the employer pays 80% of the premium. His children are not eligible for BadgerCare Plus because they are currently covered. Dave is not eligible because his income is over the income limit for the parent and caretaker coverage group.

Children under 19 years of age who are ineligible due to current coverage can become eligible by meeting a deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan.. (See Chapter 17)

7.4.3 The 9.5% Current Coverage Test

Note: This policy will only be effective until March 31, 2014.

For parents and caretakers who are not exempt (See 7.1), an individual with current coverage to employer sponsored health insurance is not eligible for BadgerCare Plus.

An individual has current coverage to employer sponsored insurance if:

The individual is covered under the plan in the month for which eligibility is being determined, and
The cost of coverage for the employee-only plan does not exceed 9.5% of the monthly household income,

Household income is above 150% of the FPL and the coverage is under a State Employee’s health care plan, regardless of the amount of the premium.

Note: Non-pregnant, non-disabled parents and caretaker relatives with state employee health insurance coverage, 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.

7.4.4 Current Coverage for BadgerCare Plus Prenatal Program

Pregnant women who are otherwise eligible only for the BadgerCare Plus Prenatal Program because of their inmate or immigration status are not eligible for the BadgerCare Plus Prenatal program if they are 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. The plan does not have to be employer sponsored.

This page last updated in Release Number: 14-01

Release Date: 02/07/14

Effective Date: 02/01/14