14-03 Version of 32.1 Presumptive Eligibility for Children
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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. 

32.1 Presumptive Eligibility (PE) for Children

32.1.1 Eligible Children for PE

32.1.2 Qualified Entities

 

Note: Wisconsin’s presumptive eligibility programs are known by multiple terms: Express Enrollment, Temporary Enrollment, and Presumptive Eligibility. Express Enrollment (EE) is the online application in ACCESS for making PE determinations. Presumptive Eligibility (PE) is the determination of whether an applicant is eligible to temporarily enroll in BadgerCare Plus (BadgerCare Plus) or Family Planning Only Services (FPOS). Temporary Enrollment (TE) is when an applicant has been found eligible to temporarily enroll in BadgerCare Plus or FPOS. All such policy in this handbook will be collectively referred to as Presumptive Eligibility.

32.1.1 Eligible Children for PE

Children can be presumptively eligible for BadgerCare Plus if they meet the following financial and non-financial criteria:
  

  1. Under age 19 (Minors under age 18 must apply with a parent/guardian)
  2. A U.S. citizen or lawfully present in the United States (no requirement for the amount of time the person is lawfully present in the US) and
  3. Through January 31, 2014:

    • If the child is younger than age 1, the family’s gross income must be at or below 300% of the Federal Poverty Level.

    • If the child is age 1 through 5, the family’s gross income must be at or below 185 % of the Federal Poverty Level.

    • If the child is age 6 through 18, the family’s gross income must be at or below 150 % of the Federal Poverty Level.

     

  1. Effective February 1, 2014

    • If the child is younger than age 1, the child’s assistance group's (AGs) income must be at or below 306% of the Federal Poverty Level (FPL).

    • If the child is age 1 through 5, the child’s AGs income must be at or below 191 % of the FPL.

    • If the child is age 6 through 18, the child’s AGs income must be at or below 156% of the FPL.

 

Note: See section 16.1.2 for additional information on 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. income disregards.

 

PE can begin on the day on which a qualified entity determines that the child meets the criteria listed above by completing an application for a PE determination through ACCESS for Partners and Providers (APP).

 

A child is allowed to have only one period of PE in a 12 month period.

32.1.2 Qualified Entities

Qualified entities that can be certified by ForwardHealth to temporarily enroll children in BadgerCare Plus through the Express Enrollment program include:

 

  1. Medicaid (MA) Providers.

  2. Head Start (HS) programs.

  3. Authorized Child Care (CC) providers.  

  4. WIC agencies.

  5. Faith-based organizations such as the YMCA.

  6. Certain Community-based organizations such as the Boys and Girls Club.

  7. Authorized agencies offering emergency food and shelter.

  8. Elementary and secondary schools.

  9. Qualified Hospitals

  10. Any other entity the state so deems as approved by the Secretary.

  

Once certified by the fiscal agent to enroll children through the presumptive eligibility category, the qualified entity will:

 

  1. Complete an online PE application through ACCESS for Partners and Providers designed for PE determinations.
     

  2. Provide a temporary BadgerCare Plus card for the child if he or she meets the non-financial and financial criteria for PE.
     

  3. Provide a denial notice to the child if he or she does not meet the requirements for PE.
     

  4. Advise 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. that a ForwardHealth card will replace the temporary card and provide BadgerCare Plus benefits for up to two months. (The card will be received within 3-5 business days.)
     

  5. Stress the importance of applying through the local agency for ongoing BadgerCare Plus eligibility. In addition, they will advise applicants that they may apply for BadgerCare Plus via the Internet through the ACCESS web site, over the telephone, through the mail or in person.
     

If an application is made for BadgerCare Plus at the local IM agency by the end of the month following the month in which the child was determined presumptively eligible, the enrollment period ends the day on which the agency completes processing the BadgerCare Plus application, regardless of the result of the eligibility determination.

 

If a full BadgerCare Plus application is not submitted by the end of the month following the month in which the child was temporarily enrolled, the PE period ends the last day of the month following the month in which the child was enrolled.

 

Example: Joe Green applied for BadgerCare Plus PE for his son Jim on February 4th at the Center Street Boys Club. Jim was found presumptively eligible for  BadgerCare Plus from February 4th through March 31st. Joe submits a BadgerCare Plus ACCESS application to the local IM agency on February 10th. The agency completes processing the application on March 1st. Jim is found ineligible for BadgerCare Plus for February and March and the application is denied. A notice is sent to Joe informing him Jim is not eligible for BadgerCare Plus and his BadgerCare Plus presumptive eligibility is terminated effective March 1st.

 

 

This page last updated in Release Number: 14-03

Release Date: 09/05/14

Effective Date: 02/01/14

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