State of Wisconsin Department of Health Services

Release 25-02 April 9, 2025

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7.4 Current Health Insurance Coverage

7.4.1 The Current Coverage Test for Children

The Current Coverage Test policy applies to non-exempt children (see Section 7.1 Health Insurance Conditions of Eligibility). These children who currently have individual or family health insurance coverage through an employed family member currently living in the household and who meets the following criteria are not eligible for BadgerCare Plus:

1. The child is not exempt from access and coverage policies (see Section 7.1 Health Insurance Conditions of Eligibility); and
2. Coverage is provided by an employer; and the employer pays at least 80% of the premium or
3. Coverage is available under the state of Wisconsin employee health plan (regardless of plan type or premium amount contributed by state or local government), and

4. The insurance covers services provided in a service area that is within a reasonable driving distance from the person’s residence.

Example 1

Dave applies for BadgerCare Plus in March for his family. The children's income exceeds 191% of the FPLFederal Poverty Level. Dave is currently covered by family health insurance through his employer and the employer pays 80% of the premium. His children are not eligible for BadgerCare Plus because they are currently covered.

Children under 19 years of age who are ineligible for BadgerCare Plus due to current coverage can become eligible by meeting a deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. (see Chapter 17 Deductibles).

7.4.2 Current Coverage Test for BadgerCare Plus Prenatal Program

Pregnant people who are otherwise eligible only for the BadgerCare Plus Prenatal Program are not eligible for the BadgerCare Plus Prenatal Program if they are currently covered by any health insurance plan which qualifies as minimum essential coverage as defined at 26 USC § 5000A(f)(1). The plan does not have to be employer-sponsored, but the insurance must cover services provided in a service area that is within a reasonable driving distance from the person’s residence.

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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