7.3 Current Access to Health Insurance

7.3.1 Introduction
7.3.2 The 80 Percent Current Access Test
7.3.3.The 9.5 Percent Current Access Test

7.3.1 Introduction

Beginning July 1, 2012, there are two Current Access policies in effect:

The 80% Current Access Test.
The 9.5% Current Access Test.

The 80% Current Access Test policies applies to non-exempt children (See 7.1). The 9.5% test applies to adult parents and caretakers until March 31, 2014.

7.3.2 The 80 Percent Current Access Test

Children and BadgerCare Plus Prenatal Program members with access to health insurance, including access due to a qualifying event , through an employed family member who is currently living in the household are not eligible for BadgerCare Plus benefits if:

The access is to a 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 plan through a current employer for which the employer pays at least 80% of the premium or the State of Wisconsin’s health care plan (regardless of plan type, or premium amount contributed by state or local government); and

The applicantA request for BadgerCare Plus coverage. The request must be on the Department's or Federally-facilitated Marketplace’s application, registration form or account transfer (from Federally-facilitated Marketplace) and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process./member is a child under age 19 and the child is not exempt; and

The coverage would begin within three calendar months following:

1. The BadgerCare Plus application filing date ; or
2. Annual review month; or
3. Employment start date

The child or BadgerCare Plus Prenatal Program member who could have been covered by the health insurance plan are ineligible for BadgerCare Plus benefits. Children under 19 years of age 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 Ch. 17)

There are no good cause reasons for not enrolling in a health insurance plan when an individual has current access.

Example 1: Janelle applies for BadgerCare Plus in January for herself and her child. She can enroll in a health insurance plan through her employer in March and her employer pays 80% of the premium. However, since coverage would not begin until May, Janelle does not have "current access” so her child is eligible for BC + until the next eligibility renewal (assuming there are no other changes that resulted in ineligibility). If Janelle’s circumstances remain unchanged, her child will be disenrolled at his or her next review because she had "past access”. Janelle is not eligible because her income is over the limit for the parent and caretaker coverage group.

Example 2: Bill applies for BadgerCare Plus in January for himself and his family. He can enroll in family health insurance through his employer and the employer pays 80% of the premium. Coverage would start in April. Bill chooses not to sign up because he thinks he will be eligible for BadgerCare Plus. His children are not eligible for BadgerCare Plus because Bill can sign up in this month and coverage would begin within the next three calendar months. Bill is not eligible because his income is over the limit for the parent and caretaker coverage group.

7.3.3.The 9.5 Percent Current Access Test

The 9.5% test applies to adult parents and caretakers until March 31, 2014.

For parents and caretakers who are not exempt (See 7.1), an individual with current access to employer sponsored health insurance is not eligible for BadgerCare Plus. An individual has current access to employer sponsored insurance if:

the individual could enroll in and be covered under the plan in the month for which eligibility is being determined, and
the cost of coverage for the employee-only plan does not exceed 9.5% of the monthly household income.

When an employed parent or caretaker has been determined to have current access, the individual's spouse will also be considered to have current access if the employer offers a plan that provides coverage to the spouse, such as employee + spouse or employee + family coverage.

Non-pregnant, non-disabled parents and caretaker relatives with household income above 150% of the FPL will not be eligible for BadgerCare Plus benefits if they have current access or will have access in the next three months to a State Employee’s health care plan, regardless of the amount of the premium. Non-pregnant, non-disabled parents and caretaker relatives with access to state employee health insurance, who have income between 133% and 150% FPL, are only ineligible for BadgerCare Plus if the employee-only premiums are not more than 9.5% of household income.

There are no good cause reasons for not enrolling in a health insurance plan when an individual has current access.

This page last updated in Release Number: 14-01

Release Date: 02/07/14

Effective Date: 02/01/14