15-02 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 and Coverage Overview

7.8.1 Access and Coverage Overview Prior to January 31, 2014

7.8.2 Access and Coverage Overview for New Applicants on or After February 1, 2014

7.8.3 BadgerCare Plus Prenatal Program Access and Coverage Overview

 

These overviews are intended to be a guide to help determine whether or not a BadgerCare Plus 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 BadgerCare Plus insurance access and coverage requirements.

7.8.1 Access and Coverage Overview Prior to January 31, 2014

To determine whether or not an individual passes BadgerCare Plus insurance access and coverage requirements through January 31, 2014, answer the following questions for each individual within a BadgerCare Plus group.

 

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

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

    • If no, continue to question #2.
       

  1. Is the member a child younger than 19 years old and currently eligible for BadgerCare Plus because a child's 150 percent 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 member is not subject to the access and 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 or member is not subject to the access and coverage requirements.
    • If no, continue to question #4.

 

  1. Is the applicant or member one of the following:

    1. An infant younger than 1 year old with household income at or below 300 percent FPLFederal Poverty Level

    2. A child 1 through 5 years old with household income at or below 185 percent FPL

    3. A child 6 through 18 years old with household income at or below 150 percent FPL

 

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

    • If no, continue to question #5.

 

  1. Is this member a child younger than 19 years old?

 

  1. Does the applicant or 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 BadgerCare Plus test group?

 

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

 

  1. Is the employer-provided insurance the Wisconsin 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 after one of the following:

    1. The month of BadgerCare Plus 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

    2. The annual review month

    3. The employment start date

 

    • If yes, the applicant is not eligible for BadgerCare Plus benefits.

    • If no, continue to question #10.

 

  1. Did the applicant or 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 BadgerCare Plus test group in the 12 months prior to the application or review date?

 

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

 

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

 

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

    • If yes, continue to question #14.

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

 

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

 

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

 

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

    • If yes, continue to question #17.

    • If no, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

 

  1. Did the applicant or member have "good cause" for dropping the health insurance (see Section 7.6 Good Cause Reasons for Dropping Insurance Coverage)?

    • If yes, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

    • If no, the applicant or member is ineligible for BadgerCare Plus for three calendar months following the month in which the insurance coverage ended.

 

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

    • If yes, continue to question #19.

    • If no, the applicant or member is not subject to the access and coverage requirements.

 

  1. Does the applicant or 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 BadgerCare Plus test group?

 

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

 

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

 

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

    1. The month of BadgerCare Plus application filing date

    2. The annual review month

    3. The employment start date

 

    • If yes, the applicant is not eligible for BadgerCare Plus benefits.

    • If no, continue to question #24.

 

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

    1. The BadgerCare Plus application filing date

    2. The annual review

    3. The employment start date

 

    • If yes, the applicant is not eligible for BadgerCare Plus benefits.

    • If no, continue to question #24.

 

  1. Did the applicant or 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 BadgerCare Plus 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 percent of the household income in the month for which you are determining eligibility?

 

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

 

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

    • If yes, continue to question #28.

    • If no, the applicant is ineligible for BadgerCare Plus 12 months from the date the coverage would have begun, unless he or she becomes exempt during that time.

 

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

    • If yes, continue to question #29.

    • If no, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

 

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

 

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

    • If yes, continue to question #31.

    • If no, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

 

  1. Did the applicant or member have "good cause" for dropping the health insurance (see Section 7.6 Good Cause Reasons for Dropping Insurance Coverage)?

    • If yes, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

    • If no, the applicant or member is ineligible for BadgerCare Plus for three calendar months following the month in which the insurance coverage ended.

7.8.2 Access and Coverage Overview for New Applicants on or After February 1, 2014

To determine whether or not an individual passes BadgerCare Plus insurance access and coverage requirements beginning February 1, 2014, answer the following questions for each individual within a BadgerCare Plus group.

 

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

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

    • If no, continue to question #2.

  1. Is the member a child younger than 19 years old and currently eligible for BadgerCare Plus because a child's 150 percent deductible was met?

    • If yes, the member is not subject to the access and 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 or member is not subject to the access and coverage requirements.
    • If no, continue to question #4.

 

  1. Is the applicant or member one of the following:

    1. An infant younger than 1 year old with household income at or below 306 percent FPL

    2. A child 1 through 5 years old with household income at or below 191 percent FPL

    3. A child 6 through 18 years old with household income at or below 156 percent FPL

 

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

    • If no, continue to question #5.

 

  1. Is this member a child younger than 19 years old?

 

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

 

  1. Is the employer-provided insurance the Wisconsin 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 after one of the following:

    1. The month of BadgerCare Plus application filing date

    2. The annual review month

    3. The employment start date

 

    • If yes, the applicant is not eligible for BadgerCare Plus benefits.

    • If no, continue to question #9.

 

  1. Did the applicant or 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 BadgerCare Plus test group in the twelve months prior to the application or review date?

 

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

 

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

 

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

    • If no, the applicant or member is ineligible for BadgerCare Plus for 12 months from the date the coverage would have begun unless he or she becomes exempt from health insurance/access coverage requirements during that time.

 

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

    • If no, the applicant or member is not subject to the BadgerCare Plus insurance/access coverage requirements.

 

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

 

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

    • If yes, continue to question #16.

    • If no, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

 

  1. Did the applicant or member have "good cause" for dropping the health insurance (see Section 7.6 Good Cause Reasons for Dropping Insurance Coverage)?

    • If yes, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.

    • If no, the applicant or member is ineligible for BadgerCare Plus for three calendar months following the month in which the insurance coverage ended.

7.8.3 BadgerCare Plus Prenatal Program Insurance Access and Coverage Overview

Use this overview only for the BadgerCare Plus Prenatal Program. The BadgerCare Plus Prenatal Program is for pregnant women who are not eligible for BadgerCare Plus solely due to immigration status or due to being 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 of an adult member of the BadgerCare Plus test group?

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

 

  1. Is the employer-provided insurance the Wisconsin 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 after one of the following:

    1. The month of BadgerCare Plus Prenatal application filing date

    2. The annual review month

    3. The employment start date

 

    • If yes, the applicant is not eligible for BadgerCare Plus 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 BadgerCare Plus test group in the twelve months prior to the application or review date?

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

  3. Would the employer-provided insurance be under the Wisconsin 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 (see Section 7.2.1 Introduction)?

    • If yes, continue to question #9.

    • If no, she is ineligible for the BadgerCare Plus Prenatal Program 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 BadgerCare Plus Prenatal Program.

    • If no, continue to question #10.
       

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

    • If yes, continue to question #11.

    • If no, she passes BadgerCare Plus Prenatal insurance access and 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 (see Section 7.6 Good Cause Reasons for Dropping Insurance Coverage)?

    • If yes, she passes BadgerCare Plus Prenatal insurance access and coverage requirements.

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

 

 

 

This page last updated in Release Number: 15-02

Release Date: 09/02/2015

Effective Date: 02/01/2014

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