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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
The following items must be verified for BadgerCare Plus:
Citizenship and identity (see Section 4.2 Documenting Citizenship and Identity)
Immigrant status
Medical expenses (for deductibles only)
Documentation for Power of Attorney and Guardianship
Migrant worker’s eligibility in another state (see Section 12.3 Simplified Application)
Income
Health insurance access
Health insurance coverage (see Chapter 7 Health Insurance Access and Coverage Requirements)
Family re-unification plan for child welfare parents (see Chapter 10 Child Welfare Parents)
The placement status of a Former Foster Care Youth (Chapter 11 Foster Care Medicaid) on his or her 18th birthday
Tribal membership or Native American descent
Pre-tax deductions
MAGI tax deductions
Unless determined questionable, self-declaration is acceptable for all other items.
Do not request income verification from health care applicants and members unless the information cannot be obtained through an electronic data source, or information from the data source is not reasonably compatible with what the applicant or member has reported (see Section 9.12 Reasonable Compatibility).
Social security numbers (SSNs) need to be furnished for household members requesting BadgerCare Plus unless they are exempt from the SSN requirement (see Section 6.1 Social Security Number Requirements). SSNs are not required from non-applicants, including outside of the home tax dependents and co-filers.
An applicant is not required to provide a document or Social Security card. He or she only needs to provide a number, which is verified through the CARES SSN validation process.
If the SSN validation process returns a mismatch record, the member must provide the Social Security card or another official government document with the SSN displayed. If an applicant does not yet have an SSN he or she must be willing to apply for one.
Agencies must assist any household that requests help with applying for an SSN for any applicant or member who does not have one. “Assisting the applicant” may include helping with filing the SS-5 SSN Application form, obtaining a birth certificate on behalf of the applicant, or assisting with obtaining another document needed to apply for the SSN.
Health care eligibility may not be delayed if the person is otherwise eligible for benefits and any of the following are true:
In cases where an application for SSN has been filed with the Social Security Administration, an SSN must be provided by the time of the next health care renewal for the case or health care eligibility will be terminated for that individual. In addition, if eligibility for another program pends for provision of an SSN and the SSN application date on file is six months or older, eligibility for health care will also pend. Members must be given a minimum of 10 days to provide an SSN, but if they do not, health care eligibility must be terminated.
Even when citizenship cannot be verified due to a lack of a verified SSN, health care benefits should not be pended for lack of an SSN during the reasonable opportunity period for verification of citizenship (see Section 4.2.4.4 Reasonable Opportunity Period for Verification of Citizenship).
The member should be informed if the SSN validation process indicates another individual is using the same SSN. The member should contact the Social Security Administration and request they conduct an investigation. The IM worker cannot provide the member with any information that would identify the individual who is using the member's SSN.
If the Social Security Administration finds that the SSN has been used fraudulently it may:
Recommend further action be taken.
and/or
Provide the member with the information on the fraudulent action so that the member may pursue action through the legal system.
Verify the SSN only once.
A parent of a newborn may begin an SSN application on the newborn’s behalf while still in the hospital.
Do not require an SSN to be furnished or applied for on behalf of a newborn determined continuously eligible (see Section 8.2 Continuously Eligible Newborns) for BadgerCare Plus. Accept the parent’s statement about the existence and residence of the newborn.
Do not require or verify SSNs of people applying for BadgerCare Plus Emergency Services only (see Chapter 39 Emergency Services).
Do not require or verify SSNs of people applying for the BadgerCare Plus Prenatal Program (see Section 41.1 BadgerCare Plus Prenatal Program).
Verification of the individual’s immigration status is done through the FDSH or the Systematic Alien Verification for Entitlement (SAVE) system. Women applying for BadgerCare Plus Prenatal Program (see Chapter 41 Badger Care Plus Prenatal Program) and people applying for Emergency Services (see Chapter 39 Emergency Services) do not have to verify their immigration status.
Applicants who are otherwise eligible and are only pending for verification of immigration status must be certified for health care benefits during the reasonable opportunity period (see Section 4.3.2.2 Reasonable Opportunity Period for Verification of Immigration Status).
Verification is not required for pregnancy unless the worker has information that contradicts the applicant or member’s statement.
If pregnancy information is questionable, acceptable verification sources are:
Physician's statement.
Physician assistant's statement.
Licensed nurse practitioner's statement.
A written statement from a registered nurse working:
In a Healthy Birth Identification of Pregnancy Project (EDP).
In a Publicly funded family planning project.
As a Certified Nurse Midwife.
Note: If pregnancy must be verified, the BadgerCare Plus temporary enrollment card cannot be used as a source of verification, as pregnancy will not be verified for Temporary Enrollment for Pregnant Women (see Chapter 32 Presumptive Eligibility).
Medical expenses used to meet a deductible must be verified. The expense amount, any third party liability amount and date of service must all be verified.
If verification is not provided, do not include the expense to determine when a deductible has been met. Do not deny or terminate eligibility for failure to provide the requested verification.
Verify power of attorney and any guardianship type as specified by the court. Ask for any documentation regarding durable power of attorney or court-ordered guardianship.
If verification is not provided, do not grant the claimed power of attorney or guardian access to case notices or follow any direction provided by that individual unless he or she is an authorized representative. Do not deny or terminate eligibility for failure to provide the requested verification.
Verification of access to health insurance is required at the following times, unless the individual has already verified health insurance access within the last 12 months with the same employer:
BadgerCare Plus Application and Renewal.
Person Add - if adult (age 18 or over) is employed and part of the BadgerCare Plus test group.
When an adult (age 18 or over) in the BadgerCare Plus test group gets a new job.
When a change is processed causing total household income to exceed the following FPL thresholds:
Children ages 1 through 5 (up to age 6), 191 percent of the FPL
Children ages 6 to 18, 156 percent of the FPL
It is not the client’s responsibility to verify access to employer-sponsored health insurance. For the majority of BadgerCare Plus applicants and members the EVHI database will be used to verify insurance access. Information gathered from employers is stored in the database. The verification will be returned based on the employer details entered on the employment page. It will be critical for Income Maintenance workers to enter the correct FEIN number and all other employment details for each employment sequence so that all employers are correctly identified in the EVHI database.
If the employment details are not complete enough to verify access, the applicant will be sent a letter from the state requesting more information and the case will pend.
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Example 1: Mary is applying for BadgerCare Plus for herself and her two children. Mary’s employer has verified that permanent full-time employees and their children have access to health insurance; however, temporary employees do not. Mary did not indicate whether she is a permanent or temporary employee. Since that information is necessary to verify access to health insurance using the database, she will be sent a letter requesting the information. |
If the employer has not provided information about the health insurance they offer to their employees, the BadgerCare Plus eligibility will pend and a request will be sent from the State to the employer requesting that the information be provided.
BadgerCare Plus eligibility can pend up to the end of the 30 day application processing period. At that point, regardless of whether the employer has responded or not, eligibility must be confirmed. If the employer has not responded assume there is not access to employer sponsored health insurance.
BadgerCare Plus will not be terminated or denied due to an employer failure to respond to a request for verification of health insurance access. If BadgerCare Plus eligibility begins and an employer later responds to the verification request indicating that health insurance access is available to the employee, BadgerCare Plus eligibility will be terminated with adequate notice of adverse action. There will be no overpayment liability for the applicant.
Other types of verification can be used to document access to employer sponsored health insurance. If a BadgerCare Plus applicant or member needs medical services, agencies may use other contacts with employers in these situations to speed the verification process. Other forms of verification include:
EVF-H form
Employer statement
Collateral Contact with the employer
The following people are exempt from paying BadgerCare Plus premiums and benefit copayments:
Members of American Indian and Alaska Native tribes
Children of members of American Indian and Alaska Native tribes
Grandchildren of members of American Indian and Alaska Native tribes
People eligible to receive IHS
To receive these exemptions, verification of tribal membership, descent from a tribal member, or eligibility to receive IHS services is required. Verification may be done with a:
If verification is not provided, do not indicate in CARES that the person is a tribal member. Do not deny or terminate eligibility for failure to provide the requested verification.
People whose eligibility is determined using MAGI rules can claim pretax deductions in order to determine their MAGI taxable income. In order to claim a pretax deduction, verification of the amount is required. Verification sources such as pay stubs or other documentation from a person's employer can serve as acceptable documentation. See Section 16.3.2 Pretax Deductions for a list of pretax deductions.
If verification is not provided, do not include the deductions when determining eligibility. Do not deny or terminate eligibility for failure to provide the requested verification.
People whose eligibility is determined using MAGI rules can claim certain tax deductions from the IRS 1040 Form, regardless of whether or not the they files taxes (see Section 16.3.3 Tax Deductions). People who claim such deductions must provide verification that the expense is or was incurred. Verification could include:
Receipts.
Bank statements.
Check stubs.
Previous years’ tax forms.
If verification is not provided, do not include the deductions when determining eligibility. Do not deny or terminate eligibility for failure to provide the requested verification.
Verification of a person’s status as a Former Foster Care Youth is required only at initial application. Verify the status of the youth, including a youth from another state, with the local Child Welfare agency by using the BadgerCare Plus Former Foster Care Youth form, F-10184.
Note: It is not the applicant’s responsibility to verify his or her status.
If a Child Welfare agency does not provide verification within 30 days of the application filing date, confirm the person as a Former Foster Care Youth if he or she is otherwise eligible. Once the person is verified as a Former Foster Care Youth, additional verification of that status is not required even if the person becomes ineligible for BadgerCare Plus at some point and later reapplies.
If the gross amount of pension and annuity income has been verified, but the taxable amount has not, the gross amount must be used in the BadgerCare Plus or FPOS budget calculation. The individual’s benefits will not be terminated or denied due to failure to verify the taxable amount. If neither the gross nor the taxable amount is verified, the individual’s benefits will be terminated or denied due to lack of verification.
This page last updated in Release Number: 19-01
Release Date: 04/19/2019
Effective Date: 03/02/2019
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