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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 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 people 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 have eligibility for BadgerCare Plus determined based on their expected annual income under a process called "gap filling."
Gap filling referrals and requests may be received through any of the following:
The Marketplace will transfer an application as a gap filling referral if it determines that the applicant’s annual income is at or below 100 percent of the FPL but monthly income is above 100 percent of the FPL.
The applicant’s monthly income is above 100 percent of the FPL, but he or she provides a copy of his or her Marketplace denial letter stating he or she may be eligible for BadgerCare Plus.
The applicant or member is denied or terminated due to excess monthly income and requests a gap filling eligibility determination.
The worker initiates a gap filling eligibility determination because it is apparent that the person is ineligible for BadgerCare Plus based on current monthly income but would be eligible under gap filling rules.
The IM agency must assess the referral or request to determine the following for each person in the household:
When a person 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 a person has been found eligible as a gap filling referral. The email must include the following items:
EM CAPO will manually certify the person for BadgerCare Plus and send a notice of decision informing the person of his or her eligibility and change reporting rules.
When an applicant is determined ineligible under the gap filling rules, IM workers should document in case comments the income used to make the determination, how that income was calculated, and confirm the denial in CWW to send the notice of decision. IM workers must also send one of the following manual letters, which provide more information about the denial under gap filling rules and next steps:
The Member Request Gap Filling Eligibility Determinations Supplemental letter, F-01915A, must be used if both of the following conditions apply:
The applicant or member has requested a gap filling eligibility determination.
The applicant or member does not have a gap filling indicator or a denial letter from the Marketplace.
The Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental letter, F-01915, must be used for gap filling denials when either of the following conditions applies:
The agency processes an application for someone with a gap filling indicator.
The applicant has received a denial letter from the Marketplace.
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. For gap filling referrals from the Marketplace, certain income may not have been reported or may have been inaccurately reported during the Marketplace application process. The applicant can either apply at the Marketplace and report all expected annual income or file an appeal at the Marketplace within the allowable 90-day timeframe if he or she has applied and been denied for coverage at the Marketplace.
When determining annual income under gap filling rules, 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.
This method should be also used when determining eligibility under gap filling rules for backdated months (see Section 25.8.1 Backdated Eligibility) and when determining whether someone would have qualified under gap filling rules as part of reviewing a potential overpayment (see Section 28.3 Unrecoverable Overpayments).
When budgeting expected annual income for eligibility in the same calendar year, consider the person’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 person to continue that pattern of employment and unemployment unless the person reports a change that indicates he or she is not returning to that employment.
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Example 1: Megan’s application has an August 1 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 in the amount of $5,800, and the unemployment query shows that she was fired in February and that she started receiving unemployment compensation on March 1. Based on income she has already received this year ($5,800 in wages plus $7,260 in unemployment from March to July), she has already received $13,060 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. The worker confirms the denial in CWW and sends the Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental letter (F-01915). |
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Example 2: Greg’s application has a November 15 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 the last three years at a local roofing company. Wages earned so far in the current year total $5,200. Unemployment received so far 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 the year 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. |
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Example 3: Erin’s application has an August 1 filing date and is sent with the Gap Filling Indicator. She reports that she is currently working and earns $1,400 per month (paid biweekly with earnings of $700 per pay period) with no other income. Her job started July 1 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. |
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Example 4: Amber and Ryan are married and reside together. Their application has a February 15 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, 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 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, 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. |
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Example 5: Monica submits a BadgerCare Plus application on July 23. She reports that she started a seasonal job in June and that it will end in September. Monica earns $1,500 per month and has no other source of income. Monica believes her income might be over the monthly limit, but will likely be below the annual limit. She contacts the IM agency to request a gap filling eligibility determination.
Based on her monthly income, Monica is over the limit for BadgerCare Plus. However, her expected annual income is $6,000 (employment wages from June to September). Because her annual income is expected to be at or below 100 percent of the FPL, Monica is eligible for BadgerCare Plus under gap filling rules. |
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Example 6: Byron has been enrolled in BadgerCare Plus as a childless adult since October. At the time of his enrollment, Byron had no income. In March, Byron began receiving SSDI income in the amount of $1,400. Since he is over the monthly income limit, his BadgerCare Plus eligibility ends on April 30, and he is sent a notice of decision. Byron contacts the IM agency on May 3, to request a gap filling eligibility determination. Byron’s anticipated income is $14,000 (SSDI income in the amount of $1,400 per month for the 10 months from March to December). Since his annual income is expected to exceed 100 percent of the FPL, Byron is not eligible for BadgerCare Plus under gap filling rules. The worker confirms the denial in CWW and sends the Member Request Gap Filling Eligibility Determinations Supplemental letter, F-01915A. |
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Example 7: Samantha applies for BadgerCare Plus on August 20 and reports she will begin receiving SSDI payments in the amount of $1,400 per month beginning in September. Employment queries show that Samantha has not earned any wages for the year. Samantha will be eligible for BadgerCare Plus for August but will be ineligible for September due to her monthly income exceeding 100 percent of the FPL. Since Samantha had no other annual income, the worker believes that Samantha may be eligible for BadgerCare Plus under gap filling rules. Her expected annual income is $5,600 (SSDI income in the amount of $1,400 per month from September to December). Her annual income is expected to be at or below 100 percent of the FPL, so Samantha is eligible for BadgerCare Plus under gap filling rules. |
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Example 8: Kyle has been enrolled in BadgerCare Plus since April. At the time of his enrollment, he reported his employment ended last February and he filed for unemployment, but he has not yet heard if he qualifies. When processing the application, the IM worker noted in case comments that Kyle had consistent wages from a job he had in the previous year, but his wages for the first quarter were $2,200, which was significantly lower than his wages from the third and fourth quarters of the previous year.
On July 25, Kyle contacts the IM agency to report that he started receiving unemployment in the amount of $1,300 per month. The unemployment query confirms that Kyle received unemployment compensation beginning July 1, in the amount of $1,300 per month. He will receive $7,800 for the months of July through December. Based on his monthly income, Kyle would be over the limit for BadgerCare Plus. However, the worker believes that Kyle may still be eligible under gap filling rules based on his expected annual income, which is $10,000 ($2,200 in wages from the first quarter and $7,800 from anticipated unemployment benefits from July to December). His annual income is expected to be at or below 100 percent of the FPL, so Kyle would be eligible for BadgerCare Plus under gap filling rules. |
People are still subject to change reporting requirements while enrolled in BadgerCare Plus under gap filling rules. A person can lose eligibility during the certification period if:
When a person is no longer eligible for the reasons noted above, the IM agency should inform EM CAPO to end eligibility and send the termination notice. If the person has exceeded the annual income limit during the gap filling certification period, include the person’s new reported annual income amount in any communication with EM CAPO when requesting the person’s eligibility be terminated.
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).
If the member becomes eligible in another category of BadgerCare Plus or Medicaid, the gap filling certification will end. 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: 19-01
Release Date: 04/19/2019
Effective Date: 02/01/2019
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