17.2 Pregnant Women

17.2.3 Calculating the Deductible Amount

17.2.1 Introduction

The deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. amount for a pregnant woman is the amount of countable income above 300% FPL for a six month period. To meet the deductible she or other family members included in the BadgerCare Plus group must incur medical bills equal to her deductible amount. If she applied prior to February 1, 2014, when the deductible is met she will be covered under the Benchmark plan through March 31, 2014 with no premium until two months after giving birth. Effective February 1, 2014, all pregnant women who are applying for BadgerCare Plus, including those eligible through deductibles, will be covered under the Standard Plan.

Note: For eligibility regarding BadgerCare Prenatal for inmates of a public institution or non-qualifying immigrants , see 41.2 for that specific policy.

Note: If there is more than one pregnant woman in the BadgerCare Plus group, all of them become eligible when a deductible is met.

Through March 31, 2014, a self-employed pregnant woman with assistance group income over 300% FPL, who is also the parent or caretaker relative of a child, does not have to meet a deductible. She is eligible with no premium under the Benchmark plan. If she is not the parent or caretaker relative of a born child, she would have to meet a deductible to become eligible for BadgerCare Plus.

Beginning April 1, 2014, a pregnant woman with assistance group income over 300% FPL must meet a deductible to become eligible for BadgerCare Plus, regardless of if she is self-employed or a parent or caretaker of born children. She will be eligible for coverage under the Standard Plan once she meets the deductible.

Effective January 1, 2014, a pregnant minor with family income over 300% FPL (under non-MAGI rules) or 306% FPL (under MAGI rules) has the option to either prepay the pregnancy deductible or to wait to meet the deductible.

If the pregnant woman applies after the birth of her baby and becomes eligible by meeting a deductible in the back dated months, she is only eligible as a pregnant woman until the end of the month she gives birth.

Example: Janet applies for BadgerCare Plus in July and requests a BadgerCare Plus deductible period from April through September. She gave birth on June 30th. Janet paid the full deductible amount, so is certified from April 1st through June 30th. She should be tested as a caretaker relative effective July 1st if she is living with the newborn or any other child under her care.

Note: Effective April 1, 2014, if Janet has no children living with her, she can also be tested for BadgerCare Plus eligibility as a childless adult.

17.2.2 Deductible Period

The pregnant woman can choose to begin the BadgerCare Plus deductible period as early as three months prior to the month of 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. , and as late as the month of application.

A pregnant woman can choose a BadgerCare Plus deductible period which includes a month in which, if he or she had applied, he or she would have been ineligible for a non-financial reason. Although excess income is still calculated over a six month period, the individual can only be certified for BadgerCare Plus during the dates when he or she was non-financially eligible.

Example 1: Luanne applied for BadgerCare Plus on June 1st and requests a BadgerCare Plus deductible period from April through September. She gave birth on June 2nd and gave the baby up for adoption. Luanne paid the full deductible amount, so is certified from April 1st through June 30th.

A new deductible period can be established at any time before the current deductible has been met.

Example 2: Julie is pregnant and due November 15th. She applied for BadgerCare Plus April 1st and a deductible period was set up for April through September. She did not incur enough expenses to meet the deductible. In July, Julie’s income decreased and she requested a new deductible period from July through November. Because she had not met the original deductible, the new deductible period could be established.

A pregnant woman who is ineligible for excess income in some backdate months, but has no excess income in others, does not have to choose to have a BadgerCare Plus deductible. She can choose to be certified in the months she is eligible and to accept the ineligibility of the other months when she had excess income.

Example 3: Rachel is pregnant and applied for BadgerCare Plus in July. She had no income and did not expect any income in the future. She was eligible in July. She also requested BadgerCare Plus eligibility for April to cover some medical expenses she had in April. In April and May she had income in excess of 300% of the FPL. In June she would have been eligible because she had no income.

In April and May her income was over 300% of FPL by $200 a month. She has 2 choices:

Choose a BadgerCare Plus deductible period of April through September. After meeting the BadgerCare Plus deductible of $400 she would be certified for BadgerCare Plus from April through September or 60 days past the birth of her baby, with no premium.

Not choose a BadgerCare Plus deductible period. She would not have to meet a BadgerCare Plus deductible. She could be certified immediately for June through 60 days past the birth of her baby but would have to forego BadgerCare Plus for May and June because of the excess income in May and June.

17.2.3 Calculating the Deductible Amount

To calculate the dollar amount of the BadgerCare Plus deductible for a pregnant woman under non-MAGIApply to households whose eligibility is determined using BadgerCare Plus relationship rules (prior to March 31, 2014) to budget income for a household prior to transitioning to MAGI BadgerCare Plus budgeting rules. rules:

Determine the BadgerCare Plus deductible period
Find the BadgerCare Plus group's total countable income for each month in the deductible period.
Compare the total income of each month with 300% FPL. If a month's income is less than or equal to 300% FPL, ignore it. If a month's income is more than the income limit, find the excess income by subtracting the income limit from the income of that month.
Add together the excess income of the months in the deductible period. The result is the pregnant woman’s BadgerCare Plus deductible amount.

When calculating a deductible amount for backdated months, use the actual, not prospective, income received in the backdated months.

To calculate the dollar amount of the BadgerCare Plus deductible for a pregnant woman under MAGIModified Adjusted Gross Income. MAGI rules are used to determine BadgerCare Plus eligibility for new applicants beginning in 2014 and for existing members as of March 31, 2014, or their next regularly scheduled renewal, whichever is later. MAGI rules are based on tax relationships and family relationships, and they consider taxable income and whether children and tax dependents are required to file. rules:

Determine the BadgerCare Plus deductible period
Find the BadgerCare Plus group's total countable income for each month in the deductible period.
If the assistance group's total countable income include the income of someone other than the pregnant woman, her spouse, or if she under age 19, her parents, subtract the income of that person, but do not change the group size of the AG.
Compare the total income of each month with 300% FPL. If a month's income is less than or equal to 300% FPL, ignore it. If a month's income is more than the income limit, find the excess income by subtracting the income limit from the income of that month.
Add together the excess income of the months in the deductible period. The result is the pregnant woman’s BadgerCare Plus deductible amount.

When calculating a deductible amount for backdated months, use the actual, not prospective, income received in the backdated months.

This page last updated in Release Number: 14-03

Release Date: 09/05/14

Effective Date: 02/01/14