45.2 Badgercare Plus basic Eligibility criteria

45.2.1 Core Plan Waitlist Bypass for Basic Members Diagnosed with Cancer

45.2.1.1 Processing Core Plan Waitlist Bypass Cases

Eligibility to enroll in the Basic Plan is limited to individuals who are on the Core Plan Waitlist (Waitlist). Individuals are placed on the Waitlist once s/he applies for the Core Plan and, based on information provided, is determined to be potentially eligible for Core Plan coverage. Individuals must meet the following Core Plan financial and non-financial eligibility criteria to qualify for the Core Plan Waitlist and BadgerCare Plus Basic Plan:

Wisconsin residency;
Age 19-64;
U.S. citizenship or qualifying immigration status ;
Income at or below 200% of the FPL ($1,805 for a single person and $2,428.33 for a married couple);
Not pregnant and no dependent minor children under age 19 living in the home;
Not disabled;
Not entitled to Medicare, Medicaid or BadgerCare Plus for families;
Does not have access to health insurance through a current employer in the month of application or subsequent three months;
Did not have access to health insurance through a current employer in the 12 months prior to application, unless there is a good cause reason for not signing up;
Is not currently covered by a health insurance policy (through employer or individual policy); and
Has not been covered by a health insurance policy in the 12 months prior to application, unless there is a good cause reason for losing the coverage, such as a recent layoff.

Basic Plan coverage does not count as health insurance coverage for the purposes of the Core Plan rules, once an individual is invited to enroll in the Core Plan.

Participation or non-participation in the Basic Plan does not affect an individual’s status on the Core Plan Waitlist.

45.2.1 Core Plan Waitlist Bypass for Basic Members Diagnosed with Cancer

Any person who is enrolled in the BadgerCare Plus Basic Plan and is confirmed by a physician to have a diagnosis of any cancer type, excluding non-melanoma skin cancers, will not be subject to the Core Plan enrollment cap. These individuals are eligible to be removed from the waitlist and apply for the Core Plan. If the member is eligible for the Core Plan, s/he will be enrolled on the next first or fifteen of the month. The member must be currently enrolled in the Basic Plan before s/he can be approved to bypass the waitlist and apply for the Core Plan.

EXAMPLE 1: Joe is on the Core Plan Waitlist. On July 7th he submitted his $130 premium payment to enroll in the Basic Plan. His enrollment will begin on August 1st. On July 10th his physician submitted the Core Plan Medical Bypass form to the ESC. Since Joe’s Basic Plan enrollment will not begin until August 1st he is not allowed to apply for Core Plan before August 1st. Joe applies for the Core Plan on August 4th and is determined eligible, so his Core Plan enrollment begins August 15th.

EXAMPLE 2: Mary is on the Core Plan Waitlist and submitted her $130 premium to enroll in the Basic Plan on June 6th. She was enrolled in the Basic Plan beginning July 1st. On July 8th, her physician submitted the Core Plan Medical Bypass form to the ESC. Mary applied for the Core Plan and was determined eligible on July 10th. Her Core Plan enrollment date will be July 15th.

Basic members who bypass the Core Plan waitlist are not required to pay the Core Plan processing fee. If it is determined that the member does not meet the Core Plan enrollment criteria, including providing all required verification, enrollment for the Core Plan is denied and enrollment in the Basic Plan is terminated.

45.2.1.1 Processing Core Plan Waitlist Bypass Cases

Wisconsin Basic Plan providers will be notified to fax the completed Core Plan Medical Bypass form (F-00292) for newly diagnosed members to the Enrollment Services Center (ESC).

Note: Any applications received in local IM or tribal agencies should be faxed to the ESC at 1-888-409-1982 immediately upon receipt to prevent any delay in eligibility determination or treatment for the applicant .

Upon receipt of the completed form, the ESC will check for completeness and accuracy as follows.

Confirm in interChange that member is currently enrolled in the BadgerCare Plus Basic Plan. If the member is enrolled in any other health care plan except Family Planning Only Services ( FPOS ), Well Woman Program (WWP) or TB MA, or if the member is inactive in BC+ Basic and has no other BC+ or Medicaid Plan coverage, send written notification (NOTICE OF DENIAL) to the member explaining why they are not eligible to enroll in the BadgerCare Plus Core Plan.
Ensure all required information is present and that the diagnosis is cancer. Allow all cancer diagnoses excluding non-melanoma skin cancers (just "melanoma” is acceptable). Do not allow conditions that appear not to be cancer (e.g. multiple sclerosis, epilepsy).
Review physician’s signature and credentials. Only Doctors of Medicine (MD) and osteopaths (DO) are acceptable.
Review the date of physician’s signature to ensure the physician’s confirmation of the cancer diagnosis was made while the member was enrolled in the Basic Plan.

If a waitlist bypass is approved, the ESC will attempt to contact the member to complete the Core Plan application process by phone. If member cannot be reached by phone within two business days, send the F-00287 to notify the member s/he can bypass the waitlist and to contact the ESC by phone to complete the Core Plan application.

Process the application following the normal procedures, including the HNA, and obtain all required verification. A processing fee is not required.

During the application process, determine if the member meets eligibility criteria for Medicaid or the BadgerCare Plus Standard or Benchmark Plans. Eligibility for any of these programs would preclude enrollment into Core.

If it is determined that the member meets all eligibility criteria for the Core Plan, s/he will be enrolled in the Core Plan on the next first or fifteenth of the month. If it is determined that the member does not meet all eligibility criteria for the Core Plan, Core Plan eligibility will be denied and enrollment in the Basic plan will be terminated at the end of the current month. Any Basic Plan premiums paid for future months should be refunded.

A copy of the completed waitlist bypass form should be shared with the DHS Nurse Consultant by fax at: (608) 250-6563.

This page last updated in Release Number: 10-02

Release Date: 10/15/07

Effective Date: 01/01/08