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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 are BC specific non-financial requirements:
Meet general MA non-financial requirements (1.1.2).
A child under age 19, parents living with children
under age 19, or a spouse living with parents of children under the age
of 19.
Do not have health insurance coverage (5.7.3.4)
now or in the three calendar months prior to the BC request.
Do not have access to health insurance coverage
(5.7.3.5) now or in the past 18 months.
Pay a premium if the family income exceeds 150% of the FPL (8.1.11).
There is no requirement that a parent be the caretaker of a deprived child. Do not deny BC for failure to furnish or verify information necessary to establish deprivation.
When the natural or adoptive parents of a child do not live together, and have joint custody, either parent can apply for BC. If both parents are applying, only one parent can be determined eligible at a time. See 3.5.3.2 if there is any question about who is the primary person, including if there is an arrangement where the minor spends equal time in each household.
Cooperation with HIPP is a BC non-financial eligibility requirement (6.3.7).
Is covered or has been covered in the three calendar
months prior to the BC request by any health insurance plan, and
The health insurance plan meets the standards of a Health Insurance Portability and Accountability Act ( HIPAA ) standard plan (6.3.2).
The policyholder does not need to live in the home. The plan can be individual or family coverage. The person or employer’s share of the premium has no affect. Someone with coverage in a location other than where they are living is still insured. It does not matter if it is another county or another state.
Coverage includes employer based and any other health insurance coverage. It does not include MA, Medicare Managed Care (aka Medicare Choice Plus), Medicare, Medicare Supplemental policies, HIRSP, WisconCare, General Relief, General Assistance, or Family Health Plan coverage. The Family Health Plan is a government sponsored safety net coverage run by Marshfield clinics.
Consider self-employed people, including farmers, as covered by health insurance and if the:
Individual purchased a plan that covers him or
herself, or
The business is incorporated and s/he is an employee of the corporation, and has health insurance through the corporation.
Good Cause - Good cause exists if the owner of any self- employment enterprise lost health insurance in the previous three months prior to the eligibility determination if:
The operation provides health insurance coverage
to the individual, and
That operation drops health insurance coverage
for all employees of the
operation, and
The farm or self-employment operation lists the health insurance costs as a business expense/loss on their tax forms. The expense/loss must be listed on the self-employment tax forms.
This means that the self-employed person, who meets all the above criteria and who drops his/her health insurance coverage in the month prior to application for BC, does not have to wait three months before eligibility can begin.
Collect insurance coverage information from the client and through CARES. EDS verifies insurance information.
If the client does not know if the non-custodial parent has a health insurance plan that provides coverage for anyone in the household, assume they do not have one.
If the client does not know if s/he or someone other than the non-custodial parent has health insurance, ask for the information and consider it questionable until s/he provides the information.
CARES will send coverage information to EDS, only if the insurance information is complete in CARES. EDS will verify insurance coverage information. If EDS verifies insurance coverage exists, and sends that information to CARES. You will receive an alert if EDS finds that there is verified coverage through a HIPAA standard plan (6.3.2). Review the insurance information for accuracy, and in cases involving past coverage, check with the clients as to whether there was good cause for losing coverage. BC eligibility will end at the end of the month following adverse action for those clients with HIPAA insurance coverage currently in effect or in the three prior calendar months.
If a person has good cause for dropping or losing his/her employer provided insurance coverage in the previous three months, s/he may be eligible. Good cause reasons are:
Loss of employment, other than a voluntary termination.
Loss of employment due to the employee’s incapacitation.
Change to a new employer that does not offer coverage.
End of COBRA continuation.
Coverage ends due to death, divorce or age.
Coverage ends due to reduced (voluntary or involuntary)
hours of employment.
Discontinuation of health benefits to all employees by the client’s employer. See 5.7.3.4.1 for self-employed.
If you have an unusual situation where coverage ended in the last three months for a reason beyond the control of the family, contact the CARES Call Center. Medicaid staff will determine if good cause exists and the Call Center will notify you. It is not good cause if a person drops coverage because of the cost.
Clients who have lost their insurance coverage due to involuntary loss of employment, and meet all other eligibility requirements, are eligible for BC. Begin his/her BC eligibility the day after the last day of the insurance coverage or the application date, whichever is later.
If s/he opts to take COBRA coverage, do not begin his/her BC eligibility until the COBRA coverage has ended because it has reached the 18th month. Do not begin BC eligibility the day after COBRA coverage has ended if the coverage ended because of voluntary termination or the client did not pay the premiums.
Clients are ineligible for BC if they have access to health insurance through a household member’s employer. EDS verifies insurance access using the current employer’s information from CARES. Insurance access means a family member living in the household is employed:
And can sign up for an employer-subsidized family health care plan which
meets the HIPAA standard plan (6.3.2)
definition, and for which the employer
pays 80% or more of the cost of the premium for the plan. Consider
all members of the household that could be covered by that employer’s
policy to have access; or
By a unit of state government and can sign up for the State’s health care plan which meets the HIPAA standard plan (6.3.2) definition. Consider those who could be covered by the State’s health care plan to have access. It does not matter if the plan is family or individual, or what premium amount that state government would pay.
Access includes the ability to sign up and be covered in the current month. It also includes if s/he had the ability to sign up and be covered in any or all of the 18 months prior to the application or redetermination of BC eligibility.
If the client had access any time in the past 18 months, those who had access are ineligible for 18 months. There are three different situations to consider when determining whether access exists.
BC clients are not exempt from being required to sign up with an employers’ health plan when members of the household receive MA or have other insurance coverage.
If a family could sign up this month and be covered this month (employer pays 80% or more), then all members of the family who could be covered are ineligible for BC.
Start of Ineligibility Period: Start the ineligibility period after giving timely notice.
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Example: Tom applies September 10, 2001. EDS discovers in early October that Tom can enroll his family under his employer’s health plan at any time and coverage would start immediately. He is given timely notice and closes at the end of October. The ineligibility period starts November 2001. |
If a family could have signed up (or been signed up for) and been covered through employer provided family coverage (at 80% or more) through the current employer in the past 18 months, they are ineligible.
Do not deny the group’s eligibility based on access if anyone in the household was covered by MA (but not BC) or another health insurance plan at the time the group could have been enrolled in the employer’s plan.
Start of Ineligibility Period: If a family could have signed up for family coverage through an employer group health plan, the members with access remain ineligible for 18 months from the month coverage could have started. The ineligibility period may cover a period when the client received BC. See the second example.
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Example 1: Jim applies for BC in July 2001. In October 2000, Jim’s employer had an open enrollment health insurance period with coverage starting in January 2001. He did not enroll. Jim’s children were eligible for MA in October, so he remains eligible. |
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Example 2: Kim applies for BC in November 2000, and is approved. No one else in her household had MA eligibility or insurance coverage during the last three months. EDS finds in February 2001, Kim could have signed up with her employer’s health plan in February 2000, and coverage would have been available March 2000. She did not sign up and will not get another chance to sign up until February 2002. The ineligibility period starts March 1, 2000 for Kim and the children. Do not consider the BC she received from November to February to be incorrect benefits. |
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Example 3: The
same circumstances as the above, except the children were covered by health
insurance in February 2000. The children’s coverage allows Kim to
be eligible. Note: If Kim is still on BC next February, she will be required to sign up with the employer’s plan, even if the children are on MA. |
If the family can sign up for coverage in which the employer pays 80% or more, but it does not start until a later date, s/he must sign up for the coverage. EDS monitors this and notifies you via CARES. If s/he does sign up, continue BC eligibility until the end of the month in which insurance coverage starts. Clients receive the full month to avoid gaps in coverage if a new policy starts after the first of the month.
Even if a client does not sign up for coverage that starts at a later date, continue BC eligibility until the end of the month in which insurance coverage could start.
Start of Ineligibility Period: Start the ineligibility period the month after access to coverage.
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Example: Bob’s employer offers health insurance in January. The coverage will not start until March 1st. Bob does not sign up. Bob’s family remains BC eligible through March 31st. The ineligibility period starts April 1st. |
For self-employment operations in which the owner/operator is applying for BC, do not consider the coverage the operation provided in the past, or could provide, when determining if there is past access.
Insurance access will be determined only by EDS. You will collect insurance access information from the client and through CARES. However, do not verify insurance access information for BC. Accept the client’s statements in determining initial BC eligibility. Do not verify information concerning who could be covered in the household, or whether the coverage meets the HIPAA standards (6.3.2).
Persons who say they have access to employer subsidized-health plans remain eligible for BC until EDS verifies who in the household has access. EDS obtains any insurance information that is needed from the employer directly.
Ask the client if s/he has access to a group health plan. If s/he does, CARES sends that information to EDS upon confirmation. EDS then sends an Employer Verification of Insurance Coverage ( EVIC ) form to the employer who completes it and gives it back to EDS. If a family member does have insurance access, s/he will become ineligible. The case runs through adverse action and closes at the end of the month.
Good cause reasons for not having insurance access are:
Loss of employment.
Change to a new employer that does not offer access.
Access ends due to death, divorce or age.
Reduced hours (voluntary or involuntary) lead to loss of insurance access.
For clients who have lost their insurance access due to involuntary loss of employment, and meet all other eligibility requirements, begin his/her BC eligibility the day after the last day of the insurance access. A client who declined to take COBRA coverage at the time of the involuntary loss of employment did not have access to insurance.
This page last updated in Release Number : 03-03
Release Date: 09/22/03
Effective Date: 09/22/03