Release 07-01

7.1 Health Insurance Conditions of Eligibility

To prevent the crowd out of private insurance, BadgerCare Plus (BC+) benefits may be denied or terminated for individuals who have access to certain employer sponsored health insurance policies when those individuals:


  1. Have countable household  income that exceeds 150 percent of the FPL; or are eligible under the BC+ Prenatal Program at any income level and,

  2. Are not in an exempt category (transitional grandfathered, pregnant women, continuously eligible newborns and youths exiting out of home care); and,

  3. Do not have a ”r;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:


  1. Continuously Eligible Newborns;

  2. Children under age 19 who have met a deductible  (exempt only during the deductible period);

  3. Youths who Exited Out-of-Home Care.

  4. Transitionally Grandfathered members.

  5. Pregnant women, other than BC+ Prenatal Program, are exempt from the policies for past and current access and current coverage. See (7.5) for the policy on dropped coverage for this group.

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


Access to health insurance includes:


  1. Past Access.

  2. Current Access.

  3. Coverage.

  4. Dropped Coverage.

  5. Cooperation with Health Insurance Premium Payment (HIPP) requirements.


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


This page last updated in Release Number: 07-01

Release Date: 10/29/07

Effective Date: 02/01/08