17-01 Version of 7.1 Health Insurance Conditions of Eligibility

To prevent the crowd out of private insurance, BadgerCare Plus benefits may be denied or terminated for people who have current health insurance coverage or have access (or have had access) to certain employer-sponsored health insurance policies when those people:

Are children ages one through five with household incomes over 191% of the FPLFederal Poverty Level and children ages six through 18 with household incomes over 156% of the FPL,
Are pregnant women eligible under the BadgerCare Plus Prenatal Program at any income level,
Are not in an exempt category (see list below) and,
Do not have a good cause reason for failure to enroll in an employer-sponsored health insurance plan

The following people are exempt from the policies related to employer-sponsored health insurance access and coverage:

Infants younger than one year old
Children younger than 19 years old who have met a deductible (exempt only during the deductible period)
Children who are in an extension
Children ages one through five (up to age six) with household income at or below 191% of the FPL
Children ages six to 18 with household income at or below 156% of the FPL
Former Foster Care Youth
Pregnant women and pregnant minors, other than those in the BadgerCare Plus Prenatal Program
All adults 19 years old or older

BadgerCare Plus Prenatal Program members are subject to different policies related to health insurance coverage. Refer to Section 7.4. Current Health Insurance Coverage for the policies regarding the rules for current coverage under the BadgerCare Plus Prenatal Program.

Health insurance conditions that impact eligibility include:

Past access (see Section 7.2 Past Access to Health Insurance)
Current access (see Section 7.3 Current Access to Health Insurance)
Coverage (see Section 7.4 Current Health Insurance Coverage)

IM workers are not responsible for determining current or past access to health insurance. The process will be done through the Employer Verification of Health Insurance database (see Section 9.9.6.1 Employer Verification of Health Insurance [EVHI] Database).

Childless adults are not eligible for BadgerCare Plus if they are enrolled in any part of Medicare.

This page last updated in Release Number: 17-01
Release Date: 04/11/2017
Effective Date: 04/11/2017