17-01 Version of 7.5 Access and Coverage Overviews
Click here to see this page in full context

17-01 Version of 7.5 Access and Coverage Overviews

  1. 7.5.1 Access and Coverage Overview for New Applicants
  2. 7.5.2 BadgerCare Plus Prenatal Program Insurance Access and Coverage Overview

7.5.1 Access and Coverage Overview for New Applicants

To determine whether or not an individual passes BadgerCare Plus insurance access and coverage requirements, answer the following questions for each individual within a BadgerCare Plus group.

  1. Is the applicant or member a pregnant woman otherwise eligible for the BadgerCare Plus Prenatal Program?
    1. If yes, go to Section 7.5.2 BadgerCare Plus Prenatal Program Insurance Access and Coverage Overview to determine whether she passes the insurance access and coverage requirements.
    2. If no, continue to question 2.
  2. Is the applicant or member:
    1. Age 19 or older,
    2. Pregnant,
    3. Under age one, or
    4. A Former Foster Care Youth
      1. If yes, the applicant or member is not subject to the access and coverage requirements.
      2. If no, continue to question 3.
  3. Is the member a child younger than 19 years old and currently eligible for BadgerCare Plus because a child's 150% deductible was met?
    1. If yes, the member is not subject to the access and coverage requirements during the deductible period.
    2. If no, continue to question 4.
  4.  Is the member in a BadgerCare Plus extension?
    1. If yes, the applicant or member is not subject to the access and coverage requirements.
    2. If no, continue to question 5.
  5.  Is the applicant or member one of the following:
    1. A child one through five years old with household income at or below 191% FPL
    2. A child six through 18 years old with household income at or below 156% FPL
      1. If yes, the applicant or member is not subject to the access and coverage requirements.
      2. If no, continue to question 6.
  6. Do they have access to or coverage under health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult member of the BadgerCare Plus test group?
    1. If yes, continue to question 7.
    2. If no, continue to question 11.
  7. Does the employer pay 80% or more of the premium?
    1. If yes, continue to question 9.
    2. If no, continue to question 8.
  8. Is the employer-provided insurance the Wisconsin state employee health plan (regardless of plan type or premium amount contributed by state or local government)?
    1. If yes, continue to question 9.
    2. If no, continue to question 11.
  9. Is the coverage current or would the coverage begin in any of the three calendar months after one of the following:
    1. The month of BadgerCare Plus application filing date
    2. The annual review month
    3. The employment start date
      1. If yes, continue to question 10.
      2. If no, continue to question 11.
  10. Does the insurance cover services provided in a service area that is within a reasonable driving distance from the individual’s residence?
    1. If yes, the applicant or member is not eligible for BadgerCare Plus benefits.
    2. If no, continue to question 11.
  11. Did the applicant or member have access to employer-provided health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult in the BadgerCare Plus test group in the twelve months prior to the application or review date?
    1. If yes, continue to question 12.
    2. If no, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.
  12. Would the employer have paid 80% or more of the premium (at any time in the last 12 months)?
    1. If yes, continue to question 14.
    2. If no, continue to question 13.
  13.  Would the employer-provided insurance be under the Wisconsin state employee health plan (regardless of plan type or premium amount contributed by state or local government)?
    1. If yes, continue to question 14.
    2. If no, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.
  14. Did the applicant or member have "good cause" for failure to enroll in an employer-sponsored health insurance plan in the 12 months prior to the application (see Section 7.2.2 Good Cause for the Past Access Test)?
    1. If yes, the applicant or member passes the BadgerCare Plus insurance access and coverage requirements.
    2. If no, the applicant or member is ineligible for BadgerCare Plus for 12 months from the date the coverage would have begun unless they become exempt from health insurance/access coverage requirements during that time.

7.5.2 BadgerCare Plus Prenatal Program Insurance Access and Coverage Overview

Use this overview only for the BadgerCare Plus Prenatal Program. The BadgerCare Plus Prenatal Program is for pregnant women who are not eligible for BadgerCare Plus solely due to immigration status or due to being an inmate.

  1. Does she have access to health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult member of the BadgerCare Plus test group?
    1. If yes, continue to question 2.
    2. If no, continue to question 6.
  2. Does the employer pay 80% or more of the premium?
    1. If yes, continue to question 4.
    2. If no, continue to question 3.
  3. Is the employer-provided insurance the Wisconsin state employee health plan (regardless of plan type or premium amount contributed by state or local government)?
    1. If yes, continue to question 4.
    2. If no, continue to question 6.
  4. Would the coverage begin in any of the three calendar months after one of the following:
    1. The month of BadgerCare Plus Prenatal application filing date
    2. The annual review month
    3. The employment start date
      1. If yes, continue to question 5.
      2. If no, continue to question 6.
  5. 5. Does the insurance cover services provided in a service area that is within a reasonable driving distance from the individual’s residence?
    1. If yes, the applicant or member is not eligible for BadgerCare Plus benefits.
    2. If no, continue to question 6.
  6. Did she have access to employer-provided health insurance, including access due to a qualifying event, through a current employer or the current employer of an adult in the BadgerCare Plus test group in the twelve months prior to the application or review date?
    1. If yes, continue to question 7.
    2. If no, continue to question 10.
  7. Would the employer have paid 80% or more of the premium (at any time in the last 12 months)?
    1. If yes, continue to question 9.
    2. If no, continue to question 8.
  8. Would the employer-provided insurance be under the Wisconsin state employee health plan (regardless of plan type or premium amount contributed by state or local government)?
    1. If yes, continue to question 9.
    2. If no, continue to question 10.
  9. Did she have "good cause" for failure to enroll in an employer-sponsored health insurance plan in the 12 months prior to application (see Section 7.2.2 Good Cause for the Past Access Test)?
    1. If yes, continue to question 10.
    2. If no, she is ineligible for the BadgerCare Plus Prenatal Program 12 months from the date the coverage would have begun unless she becomes exempt during that time.
  10. Is the woman covered by any HIPAA health insurance policy (either private or employer provided)?
    1. If yes, continue to question 11.
    2. If no, she passes BadgerCare Plus Prenatal insurance access and coverage requirements.
  11. Does the insurance cover services provided in a service area that is within a reasonable driving distance from the individual’s residence?
    1. If yes, the applicant or member is not eligible for BadgerCare Plus benefits.
    2. If no, they pass BadgerCare Plus Prenatal insurance access and coverage requirements.

This page last updated in Release Number: 17-01
Release Date: 04/11/2017
Effective Date: 04/11/2017