17.2 Pregnant Women

17.2.1 Introduction
17.2.2 Deductible Period
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 percent of the FPLFederal Poverty Level for a six-month period. To meet the deductible, the pregnant woman or other family members included in the BadgerCare Plus group must incur medical bills equal to the pregnant woman's deductible amount.

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

(For eligibility regarding the BadgerCare Plus Prenatal Program for inmates of a public institution or non-qualifying immigrants, see Section 41.2 BadgerCare Plus Prenatal Program Eligibility Requirements).

A pregnant woman with assistance group income over 300 percent of the FPL must meet a deductible to become eligible for BadgerCare Plus, even if she is a parent or caretaker of born children.

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

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

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 2: 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 3: Julie is pregnant and due November 15. She applied for BadgerCare Plus April 1 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 due to excess income in some backdated 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 4: 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 percent of the FPL. In June, she would have been eligible because she had no income.

In April and May, her income was over 300 percent of the FPL by $200 a month. She has two 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:

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 includes the income of someone other than the pregnant woman, her spouse, or, if she is younger than 19 years old, her parents, subtract the income of that person(s), but do not change the size of the assistance group.
Compare the total income of each month with 300 percent of the FPL. If any month's income is less than or equal to 300 percent of the FPL, ignore it. If any 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: 17-01

Release Date: 04/11/2017

Effective Date: 04/11/2017