Release 13-02

7.1 Health Insurance Conditions of Eligibility

7.1.1 Health Insurance Conditions of Eligibility Through December 31, 2013

7.7.2 Health Insurance Conditions of Eligibility Effective January 1, 2014

7.1.1 Health Insurance Conditions of Eligibility Through December 31, 2013

Note:The following policy is only effective until December 31, 2013.

 

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.

  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 at or below 300% of the FPL,

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

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

  6. Former Foster Care Youth (FFCY),

  7. Pregnant women, other than those in the 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), and

  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 9.9.6.1.

7.1.2 Health Insurance Conditions of Eligibility Effective January 1, 2014

Note: The following policy will be effective for all BadgerCare Plus (BC+) applicants and members effective January 1, 2014.

 

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

  1. 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,
  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 at or below 306% of the FPL,

  4. Children ages 1 through 5 (up to age 6) with household income at or below 191% of the FPL,

  5. Children ages 6 to 18 with household income at or below 156% of the FPL,

  6. Former Foster Care Youth,

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

  8. 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),

  9. Childless adults, and

  10. 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 9.9.6.1.

 

 

 

 

 

his page last updated in Release Number: 13-02

Release Date: 10/25/13

Effective Date: 10/01/13