|
State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
Due to differences between the eligibility rules used by the Federally Facilitated Marketplace for APTC and the eligibility rules used when counting income for BadgerCare Plus, the Marketplace may find someone to be at or below 100 percent of the FPL based on his or her annual income, while BadgerCare Plus may find someone to be above 100 percent of the FPL based on his or her current monthly income. Because of this difference in eligibility rules, the person is eligible for neither BadgerCare Plus nor APTCs. If applicants were left in this eligibility "gap," then the only option available to them is to pay for the full cost of private health insurance through the Marketplace. To prevent this from happening, these people must be enrolled based on a monthly equivalent of their expected annual income under a process called "gap filling."
When the Marketplace determines that the applicant’s annual income is below 100 percent of the FPL, the Marketplace will transfer the application as a gap filling referral. The IM agency must assess the referral to determine the following:
When an individual is found eligible under gap filling rules, the IM agency must document in case comments the income used to make the determination and how that amount was calculated. The worker must also clearly document the following information in the case comment:
IM workers should work with their CARES coordinator who will email EM CAPO to indicate when an individual has been found eligible as a gap filling referral. The email must include the following items:
EM CAPO will manually certify the individual for BadgerCare Plus and send a notice of decision informing the individual of his or her eligibility and change reporting rules.
When an applicant is determined ineligible under the gap filling rules, document in case comments the income used to make the determination, how that income was calculated, and confirm the denial in CWW to send out the notice of decision. The IM agency must manually send the Gap Filling Eligibility Determinations Supplemental Letter (F-01915), which provides more information about the denial under gap filling rules and next steps to get health care coverage. A copy of the letter must be scanned into the ECF.
If the applicant contacts his or her agency about the denial, the IM agency may need to clarify the reason for denial, which should be documented in case comments, and help explain the next steps for the applicant to follow up with the Marketplace in order to get health care coverage. Certain income may not have been reported or may have been inaccurately reported during the Marketplace application process, which led to the gap filling referral. The applicant can either re-apply at the Marketplace and report all expected annual income or file an appeal at the Marketplace within the allowable 90-day timeframe.
When determining income for a gap filling referral, use the income reported on the application, income discovered or verified through data exchanges, and other income to determine annual income. This includes, but is not limited to, using wages earned for previous quarters verified through SWICA, wages verified through the FDSH wage match, wages verified through an Employer Verifications of Earnings form (EVFE), or other verification and data exchanges verifying unemployment and Social Security income. If the information reported on the application is not clear or the sources of income cannot be verified through available data exchanges, the IM agency must send a verification request.
When budgeting annual income, consider the individual’s employment history and pattern of employment to determine if he or she is reasonably expected to have a change in income that would impact eligibility. For example, if an applicant has been working a seasonal job, such as construction or farming, with wages in the second and third quarters and unemployment in the first and fourth quarters of the past several years, it would be reasonable to expect the individual to continue that pattern of employment and unemployment unless the individual reports a change that indicates he or she is not returning to that employment.
|
Example 1: Megan’s application has an August, 1, 2016, filing date and is sent with the Gap Filling Indicator. She reports that she is currently on unemployment and receives $1,452 per month. When the worker is processing the application, there are wages earned for the first quarter of 2016 in the amount of $5,000, and the unemployment query shows that she was fired in February 2016 and that she started receiving unemployment compensation on March 1, 2016. Based on income she has already received in 2016 ($5,000 in wages plus $7,260 in unemployment from March through July), she has already received $12,260 this year, which is over 100 percent of the FPL for a group of one, so she does not meet gap filling rules. Megan is not eligible for BadgerCare Plus. |
|
Example 2: Greg’s application has a November 15, 2016, filing date and is sent with the Gap Filling Indicator. He reports that he is currently on unemployment and receives $1,000 per month. When the worker is processing the application, there are wages earned in the second and third quarters of 2016, 2015, and 2014 at a local roofing company. Wages earned so far in 2016 total $5,200. Unemployment received so far in 2016 includes $2,400 received from January through March, $1,000 received in October, and $500 so far in November, for a total of $3,900. He is still filing unemployment and has more than $3,000 available to be paid. To determine the anticipated income for the remainder of the year, the worker would continue to budget $1,000 for unemployment per month for November and December. Greg’s total income expected for 2016 is $10,600 ($5,200 in wages, $2,400 in unemployment from January through March, and $3,000 in unemployment from October through December). Because his annual income is expected to be under 100 percent of the FPL, Greg is eligible for BadgerCare Plus under gap filling rules. |
|
Example 3: Erin’s application has an August 1, 2016, filing date and is sent with the Gap Filling Indicator. She reports that she is currently working and earns $1,400 per month (paid bi-weekly with earnings of $700 per pay period) with no other income. Her job started July 1, 2016, and she received one paycheck in July. Her anticipated annual income is $7,700 ($1,400 per month from August through December and $700 for July). Because her annual income is expected to be under 100 percent of the FPL, Erin is eligible for BadgerCare Plus under gap filling rules. |
|
Example 4: Ron’s application has an August 25, 2016, filing date and is sent with the Gap Filling Indicator. He reports that he is currently on unemployment and receives $1,000 per month. When the worker is processing the application on September 1, 2016, SWICA shows wages earned in the second quarter of 2016 in the amount of $3,200, wages earned in the first quarter of 2015 with a different employer, and no other wages earned since 2012. The unemployment query shows he is receiving $1,000 per month, which started July 1, 2016, and he has $2,300 remaining unemployment compensation to be paid out, which would provide $1,000 per month for September and October, and the remaining $300 to be paid in November. His anticipated annual income is $7,500 ($3,200 in wages, $2,000 in unemployment from July through August, and $2,300 in unemployment anticipated from September through November). Because his annual income is expected to be under 100 percent of the FPL, Ron is eligible for BadgerCare Plus under gap filling rules. |
|
Example 5: Amber and Ryan are married and reside together. Their application has a February 15, 2016, filing date and is sent with the Gap Filling Indicator. Amber is currently on unemployment and receives $1,452 per month and reports that they have no other income. When the worker is processing the application on February 28, 2016, SWICA shows earnings between $15,000 and $20,000 per quarter for the first, second, and third quarters of each year for the past four years. The unemployment query shows that Amber is currently receiving $1,452 per month, which started October 1, 2015, and she has $9,500 remaining to be paid; the query also shows that she received unemployment from October through December for the past four years when laid off from her job. However, the most recent claim shows that Amber was not laid off, she was fired. The worker contacts Amber to clarify that she will not be returning to that job and Amber confirms that in the past, she had been laid off at the end of the season, but she was fired on October 1, 2015, and has been on unemployment since then. Because she is not expected to return to that job, their anticipated annual income is $12,404 ($2,904 in unemployment from January through February and $9,500 in unemployment anticipated from March through September). Because their annual income is expected to be under 100 percent of the FPL, Amber and Ryan are eligible for BadgerCare Plus under gap filling rules. |
Individuals are still subject to change reporting requirements while enrolled in BadgerCare Plus under gap filling rules. The individual can lose eligibility during the certification period if:
Because the Marketplace considers annual income on a calendar-year basis, the manual gap filling certification will last until the end of the calendar year. Approximately 45 days prior to the end of the year, members will receive a notice from EM CAPO advising them that their eligibility is ending and directing them to return to the Marketplace (or, if appropriate, to reapply for BadgerCare Plus).
EM CAPO will end the gap filling certification if the member has become eligible in another category of BadgerCare Plus or Medicaid. EM CAPO does not send a notice of termination to the member if the gap filling certification ended due to the member becoming eligible in another category of BadgerCare Plus or Medicaid.
This page last updated in Release Number: 17-01
Release Date: 04/11/2017
Effective Date: 10/27/2016
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