43.5 Core Plan Enrollment Begin Dates

43.5.1 Filing Date 43.5.2 Enrollment Date

43.5.2.1 Retroactive Eligibility/Backdating

43.5.1 Filing Date

The filing date for a Core Plan application is established only when an application with a name, address and valid signature is submitted and the application processing fee is paid (whichever is later). The signature can be provided electronically through the phone or by using the online ACCESS Apply for Benefits tool. See Chapter 25.5 for the policy regarding valid signatures. For all applications and renewals, a notice of decision must be issued within 30 calendar days after the filing date. If an application is not processed with sufficient time to allow the applicant 10 calendar days to provide verification, the processing timeframe must be extended. An extension can be granted, in 10 day increments, to allow the applicant additional time to provide requested verification. Notification must be provided for any delays that extend the application processing beyond the 30-day processing period. Note: The EBD Medicaid application filing date can be used as the Core Plan filing date, if:

A Core Plan application is received and the application fee is paid within 30 days after the EBD Medicaid denial notice is issued; and
All required verification is submitted prior to the deadline.

If the applicant is eligible to enroll in the Core Plan, s/he can also choose a later coverage begin date. This option affords a longer certification period for individuals who did not incur any medical expenses while the EBD Medicaid application was being processed.

Example 1: Virginia applies for EBD Medicaid on September 1st. On September 30th, her EBD Medicaid application is processed and it is determined that her income is over the program limits for EBD Medicaid. A six month deductible (September through February) is established. She contacts the ESC to apply for the BadgerCare Plus Core Plan on October 15th and pays her application fee on October 25th. She submitted all required verification timely. When Virginia’s Core Plan application is approved on November 20th, her enrollment in the Core Plan is approved to begin on October 15th, since that is the date her Core Plan enrollment would have begun if she had applied for the Core Plan and paid the application fee on September 1st. The October 15th enrollment date takes into consideration the 30 days allowed for processing the application had the agency received the application and the fee on September 1st.

Example 2: Bill applies for EBD Medicaid on September 25th. On November 30th, DDB issued a decision that he is not disabled. He decides to appeal the decision. He seeks Core Plan coverage by calling the IM agency and pays the application fee on December 23rd. Bill meets the Core Plan eligibility criteria and is eligible to enroll effective November 1st since that is the date his Core Plan enrollment would have begun if he had applied for the Core Plan and paid the application fee on September 25th. The November 1st enrollment date takes into consideration the 30 days allowed for processing the application had the IM agency received the application and the fee on September 25th. However, Bill can choose to enroll in the Core Plan effective November 15th, December 1st, December 15th, or January 1st. The choice will depend on whether medical expenses were incurred during that time versus a longer certification period.

43.5.2 Enrollment Date

Enrollment in the Core Plan begins on the next available enrollment period (always the 1st or the 15th of the month) after:

All eligibility requirements have been met; and
Eligibility has been confirmed and transmitted.

Eligibility must be confirmed at least two business days prior to the next enrollment period in order for enrollment in the Core Plan to occur on that date. If eligibility is timely confirmed after the cut-off date, enrollment begins on the next available 1st or 15th enrollment date.

Example 3: Phil applied for Core Plan on June 15th and his eligibility was timely confirmed on July 14th. Enrollment begins on August 1st because enrollment was confirmed after the cutoff date and there are not two business days before the next enrollment period.

43.5.2.1 Retroactive Eligibility/Backdating

There is no retroactive eligibility or backdating allowed in the Core Plan, unless an agency delay in application processing would otherwise result in a loss of coverage, or a member with income below 133% of the FPL was disenrolled for failure to verify income and later verifies the income for the back months was below 133% of the FPL. (See 43.11.3)

43.5.2.2 Late Processing

Core Plan enrollment will never occur retroactively. Coverage will be granted retroactively when:

Solely due to agency delay, enrollment in the Core Plan is confirmed after the 30 day application processing period; and
The enrollment date was actually impacted by the agency delay.

Example 4: Dawn applied for Core Plan on June 10th and due to agency delay, her eligibility was confirmed on July 28th. Enrollment begins August 1st. If the application had been processed timely, her enrollment would have begun on July 15th. Retroactive coverage will be granted from July 15th through July 31st.

Example 5: Phil applied for Core Plan on June 15th and his eligibility was confirmed on July 28th. Enrollment begins August 1st. Although there was an agency delay, had the agency confirmed the case timely by July 14, enrollment would have begun on August 1st. Retroactive coverage is not granted

43.5.3 Certification Period

Once enrollment has been confirmed, the certification period is continuous for 12 calendar months unless the individual:

Turns age 65;
Moves out of the state of Wisconsin;
Is admitted to an Institution for Mental Disease ( IMD );
Becomes incarcerated;
Becomes eligible for Medicare;
Meets the non-financial criteria for BadgerCare Plus or Medicaid (pregnancy, children in the home, disability, etc.)
Attains health insurance coverage

Changes in income and/or marital status do not affect a member’s eligibility during the 12 month certification period. This policy ends when the Core Plan ends on December 31, 2013.

New Spouse

If a member gets married during the 12 month certification period and the new spouse applies for the Core Plan, an application fee (43.4.2) and Health Needs Assessment (43.6.3) is not required for the new spouse. The new spouse’s application for Core Plan is treated as a "person add” (Process Help 3.2) and a separate eligibility determination is done for the new spouse. The financial eligibility for the new spouse is based on both spouses’ income as of the new spouse’s application date. If eligible, the new spouse is enrolled in the same HMO (if applicable) as the current member throughout the duration of the certification period for the current member. The review date for the new spouse is aligned with the current member’s review date. If the new spouse is not eligible, the current member remains enrolled until the end of the 12 month certification period. At that time a review must be completed to determine if the couple is eligible taking into account all the income in the household.

This page last updated in Release Number: 13-02

Release Date: 10/25/13

Effective Date: 10/01/13