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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
The following exceptions apply when one spouse (hereafter referred to as Spouse 2) is determined eligible after the participating spouse’s (hereafter referred to as Spouse 1) benefit period has begun.
In all of these situations, Spouse 1’s eligibility and benefit period does not change, unless s/he chooses to reapply (5.16.11).
If Spouse 2 becomes eligible after Spouse 1’s benefit period has begun, Spouse 2’s benefit period ends on the same date that Spouse 1’s benefit period ends.
The participation level for Spouse 2 depends on whether:
Spouse 2 was married and living with Spouse 1
at the time of Spouse 1’s application (5.16.9.1).
If spouse 1’s eligibility was determined at
level 2a or 2b, then refer to (5.16.9.1)
If spouse 1’s eligibility was determined at
level 3 then
refer to (5.16.9.1.2)
Met spenddown (5.16.9.1.2.1)
Unmet spend (5.16.9.1.2.2)
Or
Spouse 2 was not included in the FTG
( e.g. single or not living with Spouse 1) at the time of Spouse 1’s application.
(5.16.9.2), but the are
now residing together.
If spouse 1’s eligibility was determined at
level at level 2a or 2b, refer to (5.16.9.2.1)
If spouse 1’s eligibility was determined at
level 3, refer to (5.16.9.2.2)
If Spouse 2’ s participation level is determined after Spouse 1’s and Spouse 2 was included in the original FTG (married and living with Spouse 1 at the time of Spouse 1’s application) the participation level for Spouse 2 is determined based on annual income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. information provided on Spouse 1’s application.
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Example: Tyler and Anne are married and live together. Tyler has significant prescription drug expenses and applies for SC. Anne takes no prescription drugs and does not request SC when Tyler applies in March. Tyler’s participation level is based on a FTG of two. Tyler is found eligible, and his benefit period begins April 1st.
In September, Anne is diagnosed with a health problem and begins taking prescription drugs. She applies for SC on September 15th. The same income information provided in March is used to determine Anne’s eligibility, even though Tyler has since obtained a part-time job and has additional income.
Anne’s benefit period is from October 1st through March 31st so her benefit period ends at the same time as Tyler’s. They will report the income from Tyler’s part-time job when their SC eligibility is reviewed in March. |
Spouse 2’s deductible is prorated if the couple’s gross annual income is between 160% and 240% of the FPL, and Spouse 2 becomes SC eligible after Spouse 1’s benefit period has begun. To prorate the deductible, multiply the required deductible amount ($500/$850) by the number of months in Spouse 2’s benefit period and divide by 12.
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Example: Mary and Jim apply for SC in January. They have an annual income of $22,000, which is between 160% and 200% of the FPL for a FTG of two (8.1.14). Their income places them in Level 2a ($500 deductible).
Jim is determined eligible for SC, but Mary’s eligibility for SC is denied because she is 64. Mary is refunded her enrollment fee. Jim’s 12-month benefit period begins February 1st. Jim has a $500 deductible.
In June, Mary will turn 65. At adverse action in the month of May, CARES Client Assistance for Re-employment & Economic Support will process this case through batch. At that time, the application status is updated if the applicant who is turning 65 is:
A letter is sent to Mary notifying her that if she still wishes to participate in SC, she must submit her $30 annual enrollment fee. If Mary’s enrollment fee is received before July 1st, she will be determined eligible beginning July 1st.
Mary’s benefit period begins August 1st, and ends January 31st, when Jim’s benefit period ends. Mary’s deductible is prorated. Since there are six months in her benefit period, $500 is multiplied by six and the total is divided by 12.
$500 x 6=$3,000/12=$250
Mary’s deductible is $250. Once Mary meets the $250 deductible by purchasing covered prescription drugs, she is eligible to purchase covered prescription drugs at the co-payment amounts through the remainder of her benefit period.
Jim’s eligibility and benefit period are not affected. If the couple’s income were between 200% and 240% of the FPL, the example would be the same except that the $500 deductible would be $850. |
If the couple’s income is greater than 240% of the FPL and Spouse 2 becomes eligible after Spouse 1’s benefit period has begun, the procedure differs according to whether the spenddown has been met at the time Spouse 2’s eligibility begins.
When Spouse 2 is added before Spouse 1 has met the spenddown, covered prescription drug purchases of both spouses will count toward the remaining spenddown requirement.
After the spenddown has been met, both spouses begin to participate at Level 2b, and each will have a deductible requirement. The deductible for Spouse 1 is $850. The deductible for Spouse 2 is prorated (5.16.9.2.1).
Participants will get a discount off the retail price for most covered prescription drugs during the deductible period.
After a spouse has met his/her deductible, s/he purchases covered prescription drugs at the co-payment amounts for the remainder of the benefit period.
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Example: Reginald and Elizabeth’s joint income is $32,976, which is $3,000 more than 240% of the FPL for a FTG of two. Elizabeth applies in December and is determined eligible for SC effective January 1st. Only Elizabeth’s covered prescription drug costs are applied toward the spenddown.
In March, Reginald turns 65 and is determined eligible for SC beginning April 1st. His benefit period ends December 31st, when Elizabeth’s ends. Since Elizabeth has not yet met the spenddown when Reginald’s eligibility begins, both spouses’ covered prescription expenses are applied toward the remaining spenddown amount, beginning April 1st.
In June, Elizabeth and Reginald meet the spenddown. Elizabeth has a $850 deductible, but Reginald’s deductible is prorated. Since there are nine months in his benefit period, $850 is multiplied by nine and the total is divided by 12.
$850 x 9 = $7,650/12 = $638
Reginald’s deductible is $638. Once Reginald meets the $638 deductible, he purchases covered prescription drugs at the co-payment amounts through the remainder of his benefit period. Once Elizabeth meets her $850 deductible, she purchases covered prescription drugs at the co-payment amounts through the remainder of the benefit period. |
When a second spouse is added after the spenddown has been met, the eligibility and benefit period for Spouse 1 is not affected.
If Spouse 2’s income was included in Spouse 1’s determination and the spenddown has been met, the deductible for Spouse 2 is prorated (5.16.9.2.1). Participants will get a discount off the retail price for most covered prescription drugs during the deductible period.
After a spouse has met his/her deductible, s/he purchases covered prescription drugs at the co-payment amounts for the remainder of the benefit period.
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Example: Bob and Bernice’s joint income is $ 30,976, which is $1,000 more than 240% of the FPL for a FTG of two. Bernice applies in December and is determined eligible for SC effective January 1st. Bob does not apply because he is not yet 65 years old. Only Bernice’s covered prescription drug costs are applied toward the spenddown amount of $1,000.
Bernice meets the spenddown requirement in April. She then begins purchasing covered prescription drugs that count toward her $850 deductible. In June, she has $100 left before she will meet her deductible.
In May, Bob turns 65 and is determined eligible for SC. His eligibility begin date is June 1st. His benefit period ends December 31st, when Bernice’s ends. Since Bernice has already met the spenddown requirement, Bob will begin participating at Level 2b. His deductible will be prorated. Since there are seven months in his benefit period, $850 is multiplied by seven and the total is divided by 12.
$850 x 7 = $5,950/12 = $496
Bob’s deductible is $496. After he meets the $496 deductible by purchasing covered prescription drugs, he purchases covered prescription drugs at co-payment amounts for the remainder of his benefit period.
Bernice’s eligibility and benefit period are not affected. Once she meets her deductible by purchasing another $100 in covered prescription drugs, she purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period. |
When a married SC participant applies after Spouse 1’s benefit period has begun, and Spouse 2 was not included in the FTG when the participation level for Spouse 1 was determined:
The gross annual income test for Spouse 2 is based
on a FTG of two, and
Gross annual income for Spouse 2 is determined
prospectively beginning with the month Spouse 2’s request is received, and
The eligibility and benefit period for Spouse 1 is not affected, unless s/he chooses to reapply.
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Example: Jim is a SC participant from September through August. Because he was not married and living with a spouse when he applied, Jim’s benefit level was based on a FTG of one.
In January Jim marries Helen. Helen applies for SC in February. Jim’s eligibility is not re-determined when Helen applies.
Helen’s participation level is determined based on a FTG of two. Income is estimated for Helen prospectively for the 12-month period beginning in February.
Helen’s benefit period begins in March, if she met all eligibility requirements in February. Helen’s benefit period ends in August, when Jim’s benefit period ends. |
Spouse’s 2 deductible is prorated (5.16.9.2.1) when income for Spouse 2, based on a FTG of two, is determined to be above 160% but less than or equal to 240% of the FPL and Spouse 2 is added to the case after Spouse 1’s benefit period has begun.
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Example: Will is married, but he and his wife Grace were separated at the time he applied for SC.
Will applies for SC in October. Will’s benefit level is based on a FTG of one, using only his income. Will’s gross annual income is $13,176, which is less than 160% of the FPL for a FTG of one.
Will is determined to be SC eligible at Level 1 beginning November 1st. His 12-month benefit period ends the following October. Will does not pay a deductible or spenddown. He purchases covered prescription drugs at the co-payment amounts.
Grace returns home in January. She applies for SC in February and is determined eligible beginning March 1st. Grace’s benefit level is determined based on a FTG of two. Their joint income is determined to be $27,656, which is between 200% and 240% of the FPL for a FTG of two. Her benefit period ends October 31st, when Will’s benefit period ends.
Since there are eight months in her benefit period, Grace’s deductible amount is prorated. The deductible amount of $850 is multiplied by eight and then divided by 12.
$850 x 8=$6,800/12=$567
Grace’s deductible amount is $567. After she has met her deductible, she purchases covered prescription drugs at the co-payment amounts for the remainder of the benefit period. Will’s eligibility and benefit period are not affected. |
Spouse 2’s spenddown is prorated only if:
The income for Spouse 2, based on a FTG of two, is determined to be above 240% of the FPL, and
Spouse 2 becomes eligible after Spouse 1’s benefit
period has begun, and
Spouse 2 was not included in the FTG when the participation level for Spouse # 1 was determined.
To prorate Spouse 2’s spenddown, multiply the amount of income exceeding 240% FPL by the number of months of Spouse 2’s benefit period and divide by 12. The result is equal to the prorated spenddown amount of Spouse 2. Only covered prescription drug costs of Spouse 2 count toward the prorated spenddown.
After the spenddown has been met, the deductible for Spouse 2 is prorated (5.16.9.2.1). Participants will get a discount off the retail price for most covered prescription drugs during the deductible period.
After the deductible is met, s/he purchases covered remainder of the benefit period.
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Example: Tim is married, but his wife Marsha was institutionalized at the time he applied for SC. Marsha was expected to be out of the home for five months.
Tim applies for SC in May. Tim’s benefit level is based on a FTG of one. Tim’s gross annual income is $13,176, which is less than 160% of the FPL for a FTG of one.
Tim is determined to be SC eligible beginning June 1st. His 12-month benefit period ends the following May. Tim does not pay a deductible or spenddown. He purchases covered prescription drugs at the co-payment amounts.
Tim’s wife Marsha returns home in November. She applies for SC in November and is determined eligible beginning December 1st. Marsha’s participation level is determined based on a FTG of two. Their joint income is determined to be $30,976, which is $1,000 above 240% of the FPL for a FTG of two. Her benefit period ends May 31st, when Tim’s benefit period ends.
Since there are six months in her benefit period, Marsha’s spenddown amount is prorated. The spenddown amount of $1,000 is multiplied by six and then divided by 12.
$1,000 x 6=$6,000/12=$500
Marsha’s spenddown amount is $500. After she has met her spenddown, she then has a prorated deductible. Since there are six months in her benefit period, $850 is multiplied by six and then divided by 12.
$850x 6=$5,100/12=$425
Marsha pays for covered prescription drugs until she has met the $425 deductible. After Marsha has met the deductible, she purchases covered prescription drugs at the co-payment amounts for the remainder of benefit period.
Tim’s eligibility and benefit period are not affected |
The following table assumes that Spouse 1 and Spouse 2 do not apply for SC at the same time.
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SPOUSE 1's Eligibility |
SPOUSE 2's Eligibility |
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Benefit Period: Begin Date |
First of month following receipt of a valid application and enrollment fee. |
First of month following receipt of a valid application and enrollment fee. Will be later than Spouse 1’s begin date. |
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Benefit Period: End Date |
End of twelfth month of eligibility unless terminated early. |
Same end date as Spouse 1 regardless of when Spouse 2 applies. |
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Participation Level: Married at time of Spouse 1’s application |
FTG of two. Participation Level determined based on annual self-reported income of both spouses. |
FTG of two. Participation Level determined based on annual self-reported income from Spouse 1’s application. Eligibility results will be the same as Spouse 1. |
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Participation Level: Single or not living together at time of Spouse 1’s application. |
Gross annual income test based on a FTG of one. When adding a new spouse, Spouse 1 does not need to reapply until the end of the twelve-month benefit period unless s/he chooses to do so. |
Gross annual income test based on a FTG of two. Participation Level determined based on annual self-reported income of both spouses. Participation Level may be different than Spouse 1’s. Spouse 2 must estimate income at the time s/he applies. Spouse 1’s income remains the same. |
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Deductible: |
Has a $500/$850 deductible based on Participation Level. |
Required deductible is prorated based on number of months of eligibility and amount of deductible. |
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Spenddown: Unmet Original FTG of 2 |
Covered prescription drugs of Spouse 1 used to meet spenddown until Spouse 2 is added. Once spenddown is met, Spouse 1 has a deductible of $850. |
Projected income from Spouse 1’s application will be used to determine Spouse 2’s eligibility. Covered prescription drugs of both spouses are used to meet the spenddown. Once spenddown is met, Spouse 2 has a prorated deductible.
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Spenddown: Met Original FTG of 2 |
No change in spenddown for Spouse 1. |
No new spenddown when Spouse 2 is added. Spouse 2 has a prorated deductible. |
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Spenddown: Unmet Original FTG of 1 |
No change in spenddown for Spouse 1. |
Spouse 2 has a prorated spenddown and deductible. |
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Spenddown: Met Original FTG of 1 |
No change in spenddown for Spouse 1. |
Spouse 2 has a prorated spenddown and deductible. |
Note: If Spouse 1 terminates prior to spouse 2’s request. A new application is required for a new 12- month benefit period.
This page last updated in Release Number: 04-02
Release Date: 04/30/04
Effective Date: 04/30/04