Release 12-02

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. Are adult parents and caretaker relatives with household income above 133% of the FPL.


Note: The new income limit of 133% FPL for adults will be applied on or after July 1, 2012, but only when:


Until one of the above circumstances occurs, apply the access and coverage policies to parents and caretakers with household incomes over 150% of the FPL who are not in an Extension.


  1. 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,

  2. Are pregnant women eligible under the BC+ Prenatal Program at any income level,

  3. Are not in an exempt category (see list below) and,

  4. 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:


  1. Continuously Eligible Newborns,

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

  3. Infants less than 1 year old with household income up to 300% of the FPL,

  4. Children ages 1 through 5 (up to age 6) with household income up to 185% of the FPL,

  5. Children ages 6 to 18 with household income up to 150% of the FPL,

  6. Youths who Exited Out-of-Home Care,

  7. Pregnant women, other than those in BC+ Prenatal Program,

  8. 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), or

  9. Parents, caretaker relatives, and children who are in an Extension.

BC+ 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 BC+ Prenatal Program.


Access to health insurance includes:


  1. Past Access. (7.2)

  2. Current Access. (7.3)

  3. Coverage. (7.4)

  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



This page last updated in Release Number: 12-02

Release Date: 10/05/12

Effective Date: 07/01/12