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State of Wisconsin |
Release 24-03 |
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 below 100% of the FPL based on their annual income, while BadgerCare Plus may find someone to be above 100% of the FPL based on their current monthly income. Because of this difference in eligibility rules, the person is eligible for neither BadgerCare Plus nor advanced premium tax credits (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. This is also known as "gap filling."
When a parent, caretaker relative, or childless adult has monthly income above 100% FPL, and they meet all other eligibility requirements, their eligibility will be determined using their annual income. The annual income limit is 100% FPL.
Gap filling determinations use the expected annual income for the current year. Since the person may not have yet received the income, documentation of this income may be difficult or impossible to obtain at the time of application or change report. Verification of expected annual income is not required. However, the expected annual income reported by the applicant or member must be validated by the agency using all available information. This may include, but is not limited to:
If the information reported on the application is not clear or the sources of income cannot be validated through available data exchanges, the IM agency must send a request to the applicant or member for more information.
This method should also be used when determining eligibility under gap filling rules for backdated months (see SECTION 25.8.1 BACKDATED ELIGIBILITY).
When budgeting expected annual income for eligibility in the same calendar year, the applicant or member’s employment history and pattern of employment will be considered in determining if they are reasonably expected to have a change in income that would impact eligibility.
| Example 1 | Irene has been enrolled in BadgerCare Plus off and on in previous years. She completes a new health care application on October 2. She reports that she has a seasonal job from September 1 through December 15. During this time, her monthly income is above 100% FPL, but her annual income is under 100% FPL. The worker notices in Irene’s case that she has had this seasonal job in previous years. Irene’s past years’ wages in the second and third quarters are consistent with the income she is reporting on this new application. Based on this past information and the information Irene is reporting on her application, it is reasonable to expect that Irene is continuing this same pattern of employment. The worker uses this past information to validate Irene’s reported expected annual income. |
If a person is over both the monthly income limit and the annual income limit, they are not eligible for BadgerCare Plus. If this is the only reason they are not eligible for BadgerCare Plus, their application will be sent to the Marketplace.
The certification period for members whose eligibility is determined using annual income is 12 months.
If a BadgerCare Plus member moves from eligibility based on monthly income to eligibility based on annual income, or vice versa, during their certification period, their certification period end date (that is, the renewal date) remains the same.
| Example 1 | William applies for health care on June 8. He works a seasonal job, and his monthly income is above 100% FPL, but his annual income is below 100% FPL. He is determined eligible for BadgerCare Plus using annual income. His certification period is June 1 through May 31 of the following year. On November 20, he reports to the agency that his monthly income has decreased below 100% FPL and provides verification of his new income. William is now eligible for BadgerCare Plus using monthly income. His BadgerCare Plus certification period end date remains May 31. |
Renewals will be conducted the same as other BadgerCare Plus renewals (see Chapter 26 Renewals for more information).
Members are still subject to change reporting requirements while enrolled in BadgerCare Plus under gap filling rules. A member can lose eligibility during the certification period if:
See Chapter 27 Change Reporting for more information.
When a 12-month certification period extends over two calendar years, expected annual income will be collected from current members eligible under gap filling rules in January of the new year through a written request for the new year’s expected annual income:
This page last updated in Release Number: 24-01
Release Date: 04/03/2024
Effective Date: 01/01/2024
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.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10171