7.1 Health Insurance Conditions of Eligibility

7.1.1 Health Insurance Conditions of Eligibility for under Non-MAGI Rules

7.1.2 Health Insurance Conditions of Eligibility Under MAGI Rules

7.1.1 Health Insurance Conditions of Eligibility under Non-MAGI rules

To prevent the crowd out of private insurance, BadgerCare Plus benefits may be denied or terminated for individuals who have eligibility determined under non-MAGIApply to households whose eligibility is determined using BadgerCare Plus relationship rules (prior to March 31, 2014) to budget income for a household prior to transitioning to MAGI BadgerCare Plus budgeting rules. rules and have access to certain employer sponsored health insurance policies when those individuals:

Are adult parents and caretaker relatives with household income above 133% of the FPL (through March 31, 2014).

Are infants under age 1 with household incomes over 300% of the FPL, children ages 1 through 5 with household incomes over 185% of the FPL and children ages 6 through 18 with household incomes over 150% of the FPL,
Are pregnant women eligible under the BadgerCare Plus Prenatal Program at any income level,
Are not in an exempt category (see list below) and,
Do not have a good cause reason for failure to enroll in an employer sponsored health insurance plan.

Individuals exempt from the policies related to health insurance access and coverage are:

Continuously Eligible Newborns,
Children under age 19 who have met a deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. (exempt only during the deductible period),
Infants less than 1 year old with household income at or below 300% of the FPL,
Children ages 1 through 5 (up to age 6) with household income at or below 185% of the FPL,
Children ages 6 to 18 with household income at or below 150% of the FPL,
Former Foster Care Youth (FFCYFormer Foster Care Youth, formerly known as Youths Exiting Out of Home Care (YEOHC). Young adults between the ages of 18 and 21 (through 12/31/13) or 18 and 26 (effective 1/1/14) who were placed in Foster Care, court-ordered Kinship Care, or subsidized guardianship in Milwaukee County at the time they turned 18.),
Pregnant women, other than those in the BadgerCare Plus Prenatal Program,
Parents and caretakers who are blind or disabled (including MAPP Disabled), as determined by the DDB, or through the Presumptive Disability process (MEH 5.9), and
Parents, caretaker relatives, and children who are in an Extension.

BadgerCare Plus Prenatal Program members are subject to different policies related to health insurance coverage. Refer to (7.4.1) (7.5) for the policies regarding the rules for current coverage and dropping coverage under the BadgerCare Plus Prenatal Program.

Access to health insurance includes:

Past Access. (7.2)
Current Access. (7.3)
Coverage. (7.4)
Dropped Coverage. (7.5)

IM workers are not responsible for determining current or past access to health insurance. The process will be done through the EVHI database. See 9.9.6.1.

7.1.2 Health Insurance Conditions of Eligibility under MAGI rules

To prevent the crowd out of private insurance, BadgerCare Plus benefits may be denied or terminated for individuals who have eligibility determined under MAGIModified Adjusted Gross Income. MAGI rules are used to determine BadgerCare Plus eligibility for new applicants beginning in 2014 and for existing members as of March 31, 2014, or their next regularly scheduled renewal, whichever is later. MAGI rules are based on tax relationships and family relationships, and they consider taxable income and whether children and tax dependents are required to file. rules and have access to certain employer sponsored health insurance policies when those individuals:

Are children ages 1 through 5 with household incomes over 191% of the FPL and children ages 6 through 18 with household incomes over 156% of the FPL,
Are pregnant women eligible under the BadgerCare Plus Prenatal Program at any income level,
Are not in an exempt category (see list below) and,
Do not have a good cause reason for failure to enroll in an employer sponsored health insurance plan.

Individuals exempt from the policies related to health insurance access and coverage are:

Continuously Eligible Newborns,
Children under age 19 who have met a deductible (exempt only during the deductible period),
Infants less than 1 year old with household income at or below 306% of the FPL,
Children ages 1 through 5 (up to age 6) with household income at or below 191% of the FPL,
Children ages 6 to 18 with household income at or below 156% of the FPL,
Former Foster Care Youth,
Pregnant women, other than those in the BadgerCare Plus Prenatal Program,
Parents and caretaker relatives, including those who are blind or disabled (including MAPP Disabled), as determined by the DDB, or through the Presumptive Disability process (MEH 5.9),
Childless adults, and
Parents, caretaker relatives, and children who are in an Extension.

Access to health insurance includes:

Past Access. (7.2)
Current Access. (7.3)
Coverage. (7.4)
Dropped Coverage. (7.5)

IM workers are not responsible for determining current or past access to health insurance. The process will be done through the EVHI database. See 9.9.6.1.

This page last updated in Release Number: 14-01

Release Date: 02/07/14

Effective Date: 02/01/14