19.2 Premium Calculations

19.2.1 Premium Calculations for Non-MAGI Households

19.2.2 Premium Calculations Effective January 1, 2014

19.2.2.1 Children's Premiums Using MAGI Rules

19.2.2.3 Adults' Premiums Using MAGI Rules

19.2.1 Premium Calculations for Non-MAGI Households

Note: The following policy applies to all BadgerCare Plus members whose eligibility is determined under non-MAGI rules.

Under BadgerCare Plus, premiums for children are initially calculated on an individual basis and then a total for the case is determined. Premiums for adults are based on a percentage of the household income and the amount is the same regardless of the number of adults covered by the premium CARESThis system supports the Income Maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs. will calculate the premium for each case. The general rules for calculating the premium amounts are as follows:

The minimum monthly premium amount for children is $10 per person.
For children with a family income above 300% of the FPL, the individual premium shall not exceed the full per member per month cost of coverage for a child.
For non-pregnant, non-disabled parents and caretaker relatives, including those in BadgerCare Plus Extensions with a family income above 133% of the FPL, premiums will be calculated based on a sliding scale, ranging from 3% of countable household income for individuals above 133% of the FPL to 9.5% of household countable income for individuals at or above 300% of the FPL. Premiums for adults will be calculated based on actual household income and rounded to the nearest dollar. See 48.1 for premium ranges based on family size and income.
Through March 31, 2014, for self-employed parents, stepparents and caretaker relatives, with incomes above 200% of the FPL before subtracting the depreciationA federal income tax deduction for the cost of a business asset that gradually loses value through the wear and tear of use. but below 200% of the FPL after subtracting the depreciation, the caretaker relative's share of the premium shall be 5% of the family’s net income, before subtracting depreciation from the self-employment income.
Through March 31, 2014, for families with income over 300% of the FPL, if at least one member of the case is eligible for BadgerCare Plus as a self-employed adult or as a grandfathered individual, the combined total of all family members’ premiums will be either the total of all children’s premiums, or 5% of the family’s income, whichever amount is greater. One exception is for families that include a child living with a caretaker relative . If the only BadgerCare Plus eligible members are children under 19, the 5% cap does not apply and the family owes the per member per month premiums for the children.
Through March 31, 2014, for families with income below 300% of the FPL, where only children owe a premium or self-employed parents/caretakers owe the 5% premiums, the combined total of all family members’ premiums will be rounded down to the nearest whole dollar amount.
Through March 31, 2014, For families with income at or above 300% of the FPL, premium amounts for cases where only children owe a premium and the 5% premiums for self-employed parents/caretakers will not be rounded.
For pregnant women under age 19 with income over 300% of the FPL, the individual premium shall not exceed the full per member per month cost of coverage for a child with a family income of 300% of the FPL.

Pregnant women may sometimes fall into one of the other premium groups. In those cases, the following rules apply:

Pregnant minors with income between 200% and 300% of the FPL are not charged a premium.
Pregnant minors with income over 300% of the FPL are charged the child’s premium rate.
Pregnant parents, stepparents or caretaker relatives with income between 133% and 200% of the FPL are not charged a premium.
Pregnant self-employed parents, stepparents or caretaker relatives with income between 200% and 300 % of the FPL are not charged a premium.
Pregnant parents, stepparents or caretaker relatives with self-employment income above 300% FPL are not charged a premium and do not have to meet a deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan..

The premium for the BadgerCare Plus group is the total of the individually calculated premiums for the children included in the group. For example, a household with three children and family income between 200% and 210% of the FPL will owe $30, or $10 per eligible child in the family.

Premiums for adults with household income less than or equal to 200% of FPL or in an extension are based on a percentage of the household income and the amount is the same regardless of the number of adults covered by the premium.

19.2.2 Premium Calculations for MAGI Households

The basic approach for determining premiums remains the same for MAGI households: premiums for children are initially calculated on an individual basis and then a total for the case is determined, while premiums for adults in Extensions are based on a percentage of the adult’s assistance group income.However, there are some significant differences to premium amount calculations under MAGI rules. CARES will calculate the premium for each case, but the general rules for calculating the premium amounts are explained below for children and adults.

19.2.2.1 Children's Premiums using MAGI Rules

The minimum monthly premium amount for children is $10 per person.
The maximum monthly premium for a child with income above 301% up to 306% FPL is $97.53.
Each child’s premium amount will be based on their AG’s size and income. Under MAGI rules, it is possible for different children within the same household to have different amounts of income counted and to have a different AG sizes. For this reason, each child’s AG is evaluated separately to determine that AG’s income and group size, which is the basis for determining the FPL percentage of that child’s income. That FPL percentage, in turn, will determine whether a child potentially owes a premium and the amount of the premium.
The premium for the BadgerCare Plus group is the total of the individually calculated premiums combined, not to exceed 5% cap.
The cap will be 5% of the income of the assistance group with the highest income (in terms of dollar amount) in the case. (See 19.3.)

19.2.2.2 Adults' Premiums using MAGI Rules

For non-pregnant, non-disabled parents and caretaker relatives in BadgerCare Plus Extensions with a family income above 133% of the FPL, premiums will be calculated based on a sliding scale, ranging from 3% of countable income for individuals above 133% of the FPL to 9.5% of countable income for individuals at or above 300% of the FPL.
Premiums for adults in extensions will be calculated based on actual income and rounded to the nearest dollar. See 48.1 for premium ranges based on family size and income. When a child is pulled into an adult’s extension, the child does not owe a premium.
Adults in an extension who are married filing jointly, or who are married but not filing taxes, will have a combined premium. Adults in an extension who are married filing separately or are non-marital co-parents will have premiums calculated on an individual basis.

Note: Pregnant minors are not charged a premium.

This page last updated in Release Number: 14-01

Release Date: 02/07/2014

Effective Date: 02/01/2014