MEH 5.7.3 Non-Financial Requirements

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 Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. exceeds 150% of the FPL (8.1.11).

Cooperate in verifying earnings and access to employer-provided health insurance. (5.7.3.6)

5.7.3.1 Deprivation

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.

5.7.3.2 Joint Custody

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.

5.7.3.3 Health Insurance Premium Payment ( HIPP )

Cooperation with HIPP is a BC non-financial eligibility requirement (6.3.7).

5.7.3.4 Insurance Coverage

A person is ineligible for BC, when s/he:

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 (WisconCare was discontinued effective 7/25/03 by the 2003/2005 Budget Bill) , General Relief, General Assistance, or Family Health Plan coverage. The Family Health Plan is a government sponsored safety net coverage run by Marshfield clinics.

5.7.3.4.1 Self-Employed

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 either the self-employment tax forms or self employment health insurance deduction line on the IRS 1040.

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.

5.7.3.4.2 Coverage Process

Collect insurance coverage information from the client and through CARES Client Assistance for Re-employment & Economic Support. 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.

5.7.3.4.3 Coverage Good Cause Reason

If a person has good cause for dropping or losing his/her 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 (either employer-provided insurance or other private health insurance) 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.

5.7.3.5 Insurance Access

Clients are ineligible for BC if they have access to health insurance through a household member’s employer. 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.

5.7.3.5.1 Current Access

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.

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.

5.7.3.5.2 Past Access

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.

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.

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.

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.

5.7.3.5.3 Future Access

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.

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.

5.7.3.5.4 Self-Employment

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 access.

5.7.3.5.5 Access Process

See 5.7.3.6 for verifying access to employer-provided health insurance.

5.7.3.5.6 Access Good Cause Reasons

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.

5.7.3.6 Verifying earnings and access to employer provided health insurance.

Every employed member of the family or individuals legally responsible for an eligible member of the family must provide verification from his/her employer:

Of earnings;
Whether or not the employer provides health care coverage.
The amount that the employer pays, if any, toward the cost of the health care coverage premium.

Self employed members of the family or individuals legally responsible for an eligible member of the family must provide verification or earnings.

5.7.3.6.1 When verification is required.

This verification is required at:

BC Application and Review
Person Add - if employed and part of the BC fiscal test group.
When someone in the BC fiscal group gets a new job.
When a case with an employed person cascades from other MA subprograms to BC.

Verification will be required in these circumstances unless the person has already been subjected to the verification requirement, for the same employer, within the last 12 months. This means that there are some situations where employment information may not be required for BC at review if the information has already been verified in the last 12 months. Although the information may be needed for other programs it is not required for BC.

Example: Chuck starts a new job in May 2004. The next BC review is due in October 2004. A new hire auto-update generates both the EVF- E and the EVF-H that are returned with verification of the employment. The data is autopopulated in CARES on 06/03/04. There is no requirement to verify employment information from the same job at the October 2004 review for BC eligibility since it has been verified within the past 12 months. The next time the individual is required to verify this employment for BadgerCare eligibility is at the October 2005 eligibility review.

Do not apply the preceeding verification requirements for the following individuals.

Full time students under age 19.
Part time students working less than 30 hours per week and under age 19.
Test Children under age 19.
Children under age 18 not living with a parent
18 year olds not living with a parent and not living with their child.

5.7.3.6.2 Verification Methods

5.7.3.6.2.1 Employer Verification Forms

The applicant/recipient will receive a CARES generated cover letter indicating that additional information needs to be verified and that the EVF-E and/or H are attached. The EVF will be sent directly to the customer requesting verification of earnings or access to health insurance.

One or both of the Employer Verification Forms (EVF-E) or (EVF-H) will be mailed to the applicant when:

A New Hire Auto Update occurs
The eligibility worker triggers the appropriate EV form from the AGEV screen.
The BadgerCare earnings or access to the health insurance verification conditions occur.

The applicant/recipient is responsible for taking the EVF to the employer; ensuring that the employer completes and signs the form. The customer returns the form within the specified timeframe to the address indicated on the form. An EVF-E and/or H will be sent for each employment sequence subject to verification requirements.

EDS receives the EVF-E and EVF - H form, scans it and validates it. The scanning processes creates a data stream for CARES as well as an electronic image of the paper form.

The data stream sent to CARES will autopopulate data on AFEI/AFWG/AFAC. Sometimes CARES will not be able to process the data and the worker will be alerted that an exception has occurred. The notice will indicate what follow-up may be required. (i.e. contacting the customer or employer)

5.7.3.6.2.2 Pay Stub Letter

Many customers have stated that they would prefer to verify wages using check stubs instead of contacting their employer to complete the EVF-E.

The "check stub letter"may be offered if the customer indicates that they intend to provide verification other than the EVF-E as proof of their wages. The contents of this letter indicate what items need to be verified by the client. This letter can be viewed on CNHS/CNHD once the letter is mailed out to the client. Overdue verification alerts for the Check Stub letter will appear in the same manner as overdue verification notifications for EVF forms (5.7.3.6.2).

5.7.3.6.2.3 Verification for Self Employed

Verify income for self employment using tax forms or the Self-Employment Income Reporting Form (SEIRF).

5.7.3.6.2.4 Other forms of earnings and health insurance verification.

Acceptable verification of earnings and health insurance is not limited to the EVF-E, EVF-H or the "check stub letter." Other types of verifications will be accepted to the extent that they verify the necessary information. Pay stubs for the correct time period or a letter from the employer are acceptable forms of verification.

5.7.3.6.3 Verification not completed or returned timely

If verfication has not been returned timely and wage/health insurance information has not been verified by the local agency, all programs requiring that information will be denied or terminated for lack of information./

5.7.3.6.3.1 Employer Verification Forms not completed or returned timely

If the EVFs have not been returned timely and wage/health insurance information has not been verified by the local agency, all programs requiring that information will be denied or terminated for lack of verification. Family MA will not close when the wage/insurance information has not been verified unless the information is questionable.

Forms returned but not signed.

If the employer has not signed the EVF-E, and wage information has not been verified by the local agency, all programs requiring that information will be denied or terminated for lack of verification. Family MA will not close when the wage/insurance information has not been verified unless the information is questionable
If the employer has not signed the EVF-H, only BC will close. At the option of the agency, when a form lacks a signature the worker may contact the employer to ensure that the information on the form came from the employer.
If the employer states they did indeed complete the form and the information is correct, the worker can update CARES to indicate the form was completed by the employer and continue to process the case.

If an applicant/recipient indicates they are unable to return a completed form because the employer is not filling out the form, the worker should pursue alternate ways to verify the information, documenting these attempts in case comments.

Examples of situations where the employer may not return an accurate and complete EVF:

Employer refuses to complete the form.
Employer does not refuse but has not completed the form within the processing timeframe.
Employer charges a fee to complete the form.
Employer threatens to fire employee/applicant or affect his/her work place environment in a negative way if employer has to complete the form.
Any other reason the local agency deems to be reasonable.

5.7.3.6.3.2 Special Circumstances

If a BadgerCare recipient needs medical services, but cannot obtain that care without a Forward card, agencies may use telephone contacts with employers in these situations to speed the verification process. The Employer Verification Form process is not meant to impede the quick delivery of services when needed.

If a recipient returns the emloyment earnings verification or insurance access verification to the local agency, the agency can either verifiy the employer information or date stamp the information and mail the information to the central P.O. box.

If local agencies verify the employer information over the phone or have the centrally generated form returned to the county be sure to notify the client since the form will still ask them to send it to the central P.O. Box.

This page last updated in Release Number : 05-02

Release Date: 05/10/05

Effective Date: 05/10/05

Policy History for 5.7.3 NONFINANCIAL REQUIREMENTS

Release 06-04

5.7.3 NONFINANCIAL REQUIREMENTS