17.2 Pregnant Members

17.2.1 Introduction
17.2.2 Deductible Period
17.2.3 Calculating the Deductible Amount

17.2.1 Introduction

A pregnant member with assistance group income over 306% of the FPL must meet a deductible to become eligible for BadgerCare Plus.

For a pregnant member, the deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. amount is the amount of countable income above 300% of the FPLFederal Poverty Level for a six-month period. To meet the deductible, the pregnant member or other family members included in the BadgerCare Plus assistance group must incur medical bills equal to the pregnant member's deductible amount.

Note	If there is more than one pregnant member in the BadgerCare Plus assistance group, all of them become eligible when a deductible is met.

If an individual applies before the pregnancy ends and meets the deductible while pregnant, they remain eligible for BadgerCare Plus for the rest of the pregnancy and through the end of the month in which the 60th day following the end of the pregnancy occurs. The member remains eligible for this period as a pregnant member regardless of when the deductible period ends.

If an individual applies after the pregnancy ends and becomes eligible by meeting a deductible in backdated months, they are only eligible as a pregnant member until the end of the month in which the pregnancy ends.

For eligibility regarding the BadgerCare Plus Prenatal Program for inmates of a public institution or non-qualifying immigrants, see Section 41.2 BadgerCare Plus Prenatal Program Eligibility Requirements.

Example 1

Janet gives birth on June 30. On July 10, she applies for BadgerCare Plus and requests a BadgerCare Plus deductible period from April through September. Janet paid the full deductible amount, so is certified from April 1 through June 30 (the end of the month in which her pregnancy ended). She should be tested as a parent / caretaker relative effective July 1 if she is living with the newborn or any other child under her care, or if applicable, as a childless adult or under Medicaid for the Elderly Blind or Disabled.

Example 2

Annette applies for BadgerCare Plus as a pregnant woman in May and requests a BadgerCare Plus deductible period from April to September. She gives birth on June 14. Annette paid the full deductible amount and applied prior to the birth of the baby, so she is certified from April 1 through August 31 (the month in which the 60th day following the end of the pregnancy occurs). She should be tested as a parent / caretaker relative effective September 1 if she is living with the newborn or any other child under her care, or if applicable, as a childless adult or under Medicaid for the Elderly Blind or Disabled

17.2.2 Deductible Period

A pregnant member can choose to begin the BadgerCare Plus deductible period as early as three months prior to the month of applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process., and as late as the month after the month of application.

A pregnant member can choose a BadgerCare Plus deductible period which includes a month in which they are ineligible for a non-financial reason, with one exception. A deductible period may not begin with a month in which the pregnant member is non-financially ineligible.

Although excess income is still calculated over a six month period, the individual may only be certified for BadgerCare Plus during the dates when they are non-financially eligible.

Example 1

Luanne applied for BadgerCare Plus as a pregnant woman on June 1 and requested a BadgerCare Plus deductible period from April through September. She gave birth on June 2. Luanne paid the full deductible amount, so is certified from April 1 through August 31 (the month in which the 60th day following the end of the pregnancy falls). Even though the deductible period continues through September, Luanne will remain eligible through September 30 only if she is otherwise nonfinancially eligible for a deductible. For example, if she becomes disabled or pregnant again. If she is non-financially ineligible for a deductible, she should be tested as a parent/caretaker relative effective September 1 if she is living with the newborn or any other child under her care or, if applicable, as a childless adult.

A new deductible period can be established at any time before the current deductible has been met. The person must sign and submit a new application in order for the new deductible period to be established. A new application is required regardless of when the previous deductible period was established or if anyone in the household is eligible for another health care program.

Example 2

Julie is pregnant and due November 15. She applied for BadgerCare Plus April 1. She is eligible for a deductible period from April 1 through September 30. She has not incurred enough expenses to meet the deductible. In July, Julie’s income decreased, and she would like to have a new deductible period from July 1 through December 31. Julie must submit a new, signed application for the IM agency to establish a new deductible period.

A pregnant member who is ineligible due to excess income in some backdated months, but has no excess income in others, does not have to choose to have a BadgerCare Plus deductible. They can choose to be certified in the months they are eligible and to accept the ineligibility of the other months when they had excess income.

Example 3

Rachel is pregnant and applied for BadgerCare Plus in July. She had no income and did not expect any income in the future. She was eligible in July. She also requested BadgerCare Plus eligibility for April to cover some medical expenses she had in April. In April and May, she had income in excess of 300% of the FPL. In June, she would have been eligible because she had no income.

In April and May, her income was over 300% of the FPL by $200 a month. She has two choices:

Choose a BadgerCare Plus deductible period of April through September. After meeting the BadgerCare Plus deductible of $400, she would be certified for BadgerCare Plus from April through September or 60 days past the birth of her baby, with no premium.

Not choose a BadgerCare Plus deductible period. She would not have to meet a BadgerCare Plus deductible. She could be certified immediately for June through 60 days past the birth of her baby but would have to forego BadgerCare Plus for April and May because of the excess income in April and May.

17.2.3 Calculating the Deductible Amount

To calculate the dollar amount of the BadgerCare Plus deductible for a pregnant woman:

Determine the BadgerCare Plus deductible period.
Find the BadgerCare Plus group's total countable income for each month in the deductible period.
If the assistance group's total countable income includes the income of someone other than the pregnant woman, her spouse, or, if she is younger than 19 years old, her parents, subtract the income of that person(s), but do not change the size of the assistance group.
Compare the total income of each month with 300% of the FPL. If any month's income is less than or equal to 300% of the FPL, ignore it. If any month's income is more than the income limit, find the excess income by subtracting the income limit from the income of that month.
Add together the excess income of the months in the deductible period. The result is the pregnant woman’s BadgerCare Plus deductible amount.

When calculating a deductible amount for backdated months, use the actual, not prospective, income received in the backdated months.

This page last updated in Release Number: 22-03
Release Date: 12/05/2022
Effective Date: 12/05/2022