17-01 Version of 7.2 Past Access to Health Ins

7.2.1 The Past Access Test
7.2.2 Good Cause for the Past Access Test

7.2.1 The Past Access Test

The Past Access Test policies apply to non-exempt children (see Section 7.1 Health Insurance Conditions of Eligibility). These children and any BadgerCare Plus Prenatal Program members who had access to health insurance, including access due to a qualifying event, in the 12 months prior to the application or renewal date are not eligible for BadgerCare Plus benefits if the access was through the current employer of an adult family member who is currently living in the household and,

The access was to a 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 plan through a current employer for which the employer paid at least 80 percent of the premium, or through the state of Wisconsin’s health care plan (regardless of plan type or premium amount contributed by the employer); and

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. is a child under age 19 and child is not exempt; and

There is no good cause reason for not signing up for the coverage.

The child or BadgerCare Plus Prenatal Program member is ineligible for BadgerCare Plus for 12 calendar months from the date the health insurance would have begun.

Example

Marilyn applied for BadgerCare Plus in April 2016 for herself and her children, ages 10 and 8; they have family income that exceeds 156 percent of the FPL. She could have enrolled in a family health insurance plan through her current employer in October 2015, and her employer pays 80 percent of the premium for that plan. Marilyn did not sign up because she felt the premiums, copayments, and deductibles would be unaffordable. If she had signed up, coverage would have begun in December 2015.

Since Marilyn did not sign up for employer-provided coverage within the last 12 months when it was available and she does not have good cause, her children are ineligible for BadgerCare Plus through November 2016, 12 months from the date the coverage would have begun, unless they become exempt during that time. Marilyn is not eligible because her income is over the 100 percent FPL limit for the parent and caretaker coverage group.

7.2.2 Good Cause for the Past Access Test

Good cause reasons for failure to enroll in an employer-sponsored health insurance plan in the 12 months prior to application or renewal are:

Discontinuation of health insurance benefits by the employer;
During the time period when the employee failed to enroll in the health insurance coverage, one or more members of the individual’s family was covered through:
1. A private health insurance policy; or
2. Medicaid, or BadgerCare Plus;
3. And no one in the Test Group at that time was eligible for:
  1. BadgerCare Plus with an assistance group income above 156 percent of the FPL,
  2. BadgerCare Plus extension, or
  3. BadgerCare Plus as a pregnant woman (not including the BadgerCare Plus Prenatal Program).
The employment through which the child is insured ended,
The insurance only covers services provided in a service area that is beyond a reasonable driving distance from the person’s residence, or
Any other reason determined by DHS as a good cause reason. Local agencies must contact the DHS CARES Call Center for approval before granting good cause for any reason not stated above.

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