7.3 Current Access to Health Insurance

7.3.1 The Current Access Test
7.3.2 Good Cause for the Current Access Test

7.3.1 The Current Access Test

The Current Access Test policies apply to non-exempt children (see Section 7.1 Health Insurance Conditions of Eligibility). These children and BadgerCare Plus Prenatal Program members with access to health insurance, including access due to a Qualifying EventA qualifying event allows an employee to enroll in the employer's health insurance plan outside the designated open enrollment period. Qualifying events include obtaining a new dependent through marriage, birth, adoption or placement for adoption and loss of other insurance coverage the employee was covered under at the time of the last open enrollment period. The employee has 30 days from the qualifying event to enroll in the insurance. This applies to permanent employees who have a normal work week of 30 or more hours., through an employed family member who is currently living in the household are not eligible for BadgerCare Plus benefits if:

The access is 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 pays at least 80% of the premium or the state of Wisconsin’s health care plan (regardless of plan type, or premium amount contributed by state or local government); 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. or member is a child under age 19 and the child is not exempt; and
The coverage would begin within three calendar months following:
1. The BadgerCare Plus application filing dateThe filing date for health care is the day a valid application or registration form is submitted to the Income Maintenance agency. The filing date sets the begin date of benefits. For paper applications, the filing date for health care is the date a signed valid application is delivered to the agency or the next business day if it is delivered after the agency’s regularly scheduled business hours. For phone applications, the filing date is not set until a valid signature is received by the agency. For online applications, the filing date for health care is the date the application was submitted electronically, regardless of whether or not it was submitted during regular business hours. For applications from the Federally Facilitated Marketplace, the filing date is the application date listed on the application. For ACCESS applications and Marketplace applications, agencies’ 30-day processing timelines are set by the date the application is actually received by the agency. Applications received after 4:30 p.m., on a weekend, or on a holiday start the agency’s 30-day processing timeline the next business day.; or
2. Annual review month; or
3. Employment start date

The child or BadgerCare Plus Prenatal Program member who could have been covered by the health insurance plan is ineligible for BadgerCare Plus benefits. Children under 19 years of age can become eligible by meeting a deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. (see Chapter 17 Deductibles).

Note	There are no good cause reasons for not enrolling in a health insurance plan when a person has current access.

Example 1

Janelle applies for BadgerCare Plus in January for herself and her child. She can enroll in a health insurance plan through her employer in March and her employer pays 80% of the premium. However, since coverage would not begin until May, Janelle does not have "current access” so her child is eligible for BadgerCare Plus until the next eligibility renewal (assuming there are no other changes that resulted in ineligibility). If Janelle’s circumstances remain unchanged, her child will be disenrolled at their next review because she had "past access.” Janelle is not eligible because her income is over the limit for the parent and caretaker coverage group.

Example 2

Bill applies for BadgerCare Plus in January for himself and his family. He can enroll in family health insurance through his employer and the employer pays 80% of the premium. Coverage would start in April. Bill chooses not to sign up because he thinks he will be eligible for BadgerCare Plus. His children are not eligible for BadgerCare Plus because Bill can sign up in this month and coverage would begin within the next three calendar months. Bill is not eligible because his income is over the limit for the parent and caretaker coverage group.

7.3.2 Good Cause for the Current Access Test

The only good cause reason for failing to enroll in a currently available employer-sponsored health insurance plan is that the insurance only covers services provided in a service area that is beyond a reasonable driving distance from a person's residence.

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