State of Wisconsin Department of Health Services

Release 25-01 February 10, 2025

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7.1 Health Insurance Conditions of Eligibility

To prevent the crowd out of private insurance, BadgerCare Plus benefits may be denied or terminated for certain groups who have current health insurance coverage or have access (or have had access in the past) to certain employer-sponsored health insurance policies.

The following groups are subject to the policies related to employer-sponsored health insurance access and coverage:

• Children ages one through five with household incomes over 191% of the FPL
• Children ages six through 18 with household incomes over 156% of the FPL

  Note	If a child qualifies for continuous coverage, their benefits cannot be terminated during the 12-month continuous coverage period because of health insurance coverage. Their benefits can only be denied or terminated during application or renewal.

• Pregnant persons eligible under the BadgerCare Plus Prenatal Program at any income level

However, persons in these groups who have access to health insurance coverage may still be eligible if they have a good cause reason for failure to enroll in an employer-sponsored health insurance plan (see section 7.2.2 Good Cause for the Past Access Test and Section 7.3.2 Good Cause for the Current Access Test).

The following groups are exempt from the policies related to employer-sponsored health insurance access and coverage:

• Infants younger than one year old
• Children younger than 19 years old who are in a continuous coverage period
• Children younger than 19 years old who have met a deductible (exempt only during the deductible period)
• Children who are in an extension
• Children ages one through five with household income at or below 191% of the FPL
• Children ages six to 18 with household income at or below 156% of the FPL
• Former Foster Care Youth
• Pregnant persons and pregnant minors, other than those in the BadgerCare Plus Prenatal Program
• All adults 19 years old or older

BadgerCare Plus Prenatal Program members are subject to different policies related to health insurance coverage (See section 7.4. Current Health Insurance Coverage).

Health insurance conditions that impact eligibility include:

• Past access (see Section 7.2 Past Access to Health Insurance)
• Current access (see Section 7.3 Current Access to Health Insurance)
• Coverage (see Section 7.4 Current Health Insurance Coverage)

IM workers are not responsible for determining current or past access to health insurance. The process is done through the Employer Verification of Health Insurance database (see Section 9.9.7.1 Employer Verification of Health Insurance [EVHI] Database).

Childless adults are not eligible for BadgerCare Plus if they are enrolled in any part of Medicare except Medicare Part B Immunosuppressive Drug Benefit (Part B-ID).

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The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10171