State of Wisconsin Department of Health Services

Release 25-01 February 10, 2025

View History

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 women who are otherwise eligible only for the BadgerCare Plus Prenatal Program are not eligible for the BadgerCare Plus Prenatal Program if they are covered by any HIPAAHIPAA is the Health Insurance Portability and Accountability Act. A HIPAA Standard Plan is any group health care plan that provides medical care to covered individuals and/or their dependents directly or through insurance, reimbursement, or by some other means. Medical care means amounts paid for diagnosis, cure, mitigation (moderation), treatment or prevention of disease; or amounts paid for the purpose of affecting any structure or function of the body. A policy that pays for a doctor's services in either an in-patient or outpatient setting qualifies as a HIPAA plan. The amount or type of benefits paid; co-insurance, deductibles, caps, etc., do not matter as long as the plan meets the HIPAA Standard Plan criteria. The health care plan cannot be limited to a single type of covered service or only accessible in a very defined circumstance. Plans limited to accident, disability, vision, long term care or dental are not examples of HIPAA plans. health insurance policy. 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 woman’s residence.

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

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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