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State of Wisconsin |
Release 26-01 |
When a member no longer meets the eligibility requirements of their current health care program due to a change, their existing coverage must be maintained while eligibility for all other health care programs is being determined.
| Example 1 | Anders is enrolled in SSI-Related Medicaid and QMB. On July 13, he reports an income increase, bringing his countable income to 115% FPL, which is over the income limit for both SSI-Related Medicaid and QMB. While the income verification is requested and his eligibility for other benefits is being determined, Anders’s existing benefits are maintained. On July 22, Anders is determined eligible for an unmet Medicaid deductible and SLMB. Anders’ SSI-Related Medicaid and QMB end August 31, and the Medicaid deductible and SLMB begin September 1. |
| Example 2 | Ella is enrolled in MAPP. Outside of CWW, she is also enrolled in IRIS. On November 2, she reports that she received an inheritance that puts her over the $15,000 asset limit for MAPP. Because she is enrolled in IRIS, eligibility must be determined for other health care, including Waiver Medicaid. Ella is married and spousal impoverishment policies apply to the Waiver Medicaid determination. Verification is requested for the additional financial information (and spousal signature) needed to determine if Ella is eligible for Waiver Medicaid under spousal impoverishment rules. Ella’s MAPP coverage is maintained for December while eligibility for Waiver Medicaid is determined. On November 23, Ella is determined eligible for Waiver Medicaid. Ella’s MAPP coverage ends December 31, and Waiver Medicaid begins January 1. |
Health care eligibility must be promptly redetermined between regular renewals whenever information is received about a change in a member’s circumstances that may affect their eligibility. Requests for information or verification must be limited to information related to the change. During redeterminations of eligibility due to a change in circumstances, the member must remain enrolled in their prior health care assistance group without disruption until enough information is available to determine all health care eligibility.
When an individual is enrolled in a new health care certification period on a case, new 12-month certification periods will be established for all eligible health care members in the household, with some exceptions.
New certification periods will be established for existing eligible members when an individual is enrolled in health care following a change in circumstances, person-add, new program request, or renewal. For example, new certification periods can be established when a person joins the household and is enrolled in health care, changes health care categories, or a previously ineligible person becomes eligible due to a change (for example, a reduction in income puts them under the program limit).
New certification periods will not be established for an existing member when:
| Example 3 | Margaret and Phillip are enrolled in BadgerCare Plus as childless adults with a certification period of January 1, through December 31. On July 2, 11-year-old William joins the household and requests health care. William does not have continuous coverage from another case. William is enrolled in BadgerCare Plus with continuous coverage from July 1 through July 31 of the following year. Margaret and Phillip are now eligible for BadgerCare Plus as caretakers and will also start a new certification period from August 1 through July 31 of the following year. |
| Example 4 | Diego and Sofia are enrolled in BadgerCare Plus and their 4-year-old daughter Gabriella is enrolled in Medicaid from February 1, through January 31. On August 8, Diego’s 12-year-old daughter Isabella joins the household and requests health care. Isabella has had BadgerCare Plus on another case since January. Her BadgerCare Plus enrollment ends on the other case, and she is determined eligible on Diego’s case. Isabella is enrolled in BadgerCare Plus with a new continuous coverage period from September 1, through August 31. Diego and Sofia, remain eligible for BadgerCare Plus and start a new certification period from September 1, through August 31. Gabriella remains eligible in Medicaid and starts a new certification period from September 1, through August 31. |
| Example 5 | Bill and Carrie are enrolled in BadgerCare Plus as parents and their 12-year-old daughter Kiley is disabled and enrolled in SSI-Related Medicaid. Their certification period is January 1, through December 31. Kiley is determined to no longer be disabled on June 5. There was no other change. Kiley transitions from SSI-Related Medicaid to BadgerCare Plus with a new certification period of July 1, through June 30. A new 12-month certification period is established for Bill and Carrie from July 1, through June 30. |
| Example 6 | Edith is enrolled in SSI-Related Medicaid from January 1, through December 31. In July, Edith gets married and requests health care for her husband, Chester. Chester is eligible and enrolled in SSI-Related Medicaid. Edith continues to be eligible. Because someone is newly opening for a health care certification period, a new 12-month certification period is established for Edith and Chester. |
| Example 7 | Dimitri is enrolled in SSI-Related Medicaid from July 1 through June 30. In October, Dimitri gets married and requests health care for his wife, Polina. Polina is neither a US citizen nor a qualifying immigrant and is found ineligible. Dimitri’s SSI-Related Medicaid certification period does not change. |
New certification periods will not be established for members enrolled in time-limited health care benefits, including:
| Example 8 | Matthew and his child Lee are enrolled in BadgerCare Plus from January 1, 2025, through December 31, 2025. Lilly, Lee’s mother, is enrolled in BadgerCare Plus as a pregnant individual with a renewal date of September 30, 2025. In May, their other child Silas joins the household. Lilly remains pregnant. Silas’s information is verified and there is no other change. Silas is enrolled in BadgerCare Plus from May 1, 2025, through May 31, 2026. A new 12-month certification period is established for Matthew and Lee from June 1, 2025, through May 31, 2026. Lilly’s certification period does not change. |
However, a new time-limited health care benefit will result in other members getting a new 12-month certification period.
| Example 9 | Deepak, Fatima, and their son Ravi are enrolled in BadgerCare Plus from July 1, 2025, through June 30, 2026. In August 2025, Fatima’s pregnancy is reported, and she moves from BadgerCare Plus as a parent to BadgerCare Plus as a pregnant individual through May 31, 2026. There are no other changes, and Deepak and Ravi remain eligible. A new 12-month certification period is established for Deepak and Ravi from September 1, 2025, through August 31, 2026. |
If a child would be negatively impacted or move to a CHIP category of health care because of a change, person-add, or new program request during their 12-month continuous coverage period, the child will not get a new 12-month certification period. They will remain in their current period. However, other eligible household members can get new 12-month certification periods. Households may also have different health care renewal dates. See BadgerCare Plus Handbook, Section 1.2.10 Certification Period Changes for Children in Continuous Coverage Periods for examples.
If an individual opens for a new certification period for Wisconsin Well Woman Medicaid, Katie Beckett Medicaid, the SeniorCare Prescription Drug Program, or benefits outside of the CARES eligibility system, new 12-month certification periods will not be established for existing members on the case.
For more information regarding changes in circumstances for Katie Beckett members, see Section 29.3 Katie Beckett Medicaid Changes in Circumstances.
When a member enrolled in BadgerCare Plus or other health care program not based on disability no longer meets the requirements of their current health care category due to a change in circumstances, the IM agency must determine if they qualify for Medicaid based on disability if any of the following are true:
Prior coverage is maintained while the Medicaid Disability Application Form, F-10112 (MADA), Authorization to Disclose Information to Disability Determination Bureau, F-14014 (ADDD), and any other necessary information (including an Asset Assessment, if appropriate) are requested. If the member is otherwise eligible for EBD Medicaid types after the MADA, ADDD, and all necessary information is collected, the prior coverage continues to be maintained while the Disability Determination Bureau (DDB) makes the determination of disability.
| Example 10 | Hoai is enrolled in BadgerCare Plus and IRIS. On March 20, he reports an income increase from his part-time job that puts him over the limit for BadgerCare Plus. He does not have a disability determination and is not married. Because he is enrolled in a long-term care program, BadgerCare Plus must be maintained until it is determined if Hoai is eligible for Medicaid based on disability. On March 21, a request for asset information and the MADA and ADDD are sent to Hoai. Hoai provides the requested asset information and disability application forms by the due date, and he meets the eligibility criteria for Medicaid Purchase Plan (MAPP) if determined disabled by the DDB. On April 10, Hoai’s disability application is sent to the DDB. Hoai’s BadgerCare Plus coverage (and IRIS enrollment) will be maintained until the DDB makes a decision, as long as he remains otherwise eligible for MAPP or another form of full-benefit Medicaid based on disability. A notice is sent informing Hoai that he is now subject to EBD reporting rules, and his existing coverage will be maintained while the DDB is making their decision. On July 10, the DDB returns a decision that Hoai’s disability application is approved for Medicaid. His BadgerCare Plus ends on July 31 and he is enrolled in MAPP effective August 1. He remains enrolled in IRIS. |
If health care coverage was maintained during a redetermination of eligibility and the member’s enrollment changes to a new health care program or has a reduction in premium, liability, or cost-share for a current health care program, their eligibility may need to be redetermined for the month(s) that coverage was maintained.
After redetermination, if a member’s enrollment changes from a limited-benefit to a full-benefit health care program, their eligibility in the new program may need to be redetermined for the months that coverage was maintained and in any month in which the member may be eligible for the new health care program.
After redetermination, if a member becomes eligible for SLMB, SLMB+, or QDWI, eligibility will be determined in the new MSP program retroactively back to the date their prior benefits were maintained. Normally, an individual cannot qualify for SLMB+ if they are enrolled in full-benefit Medicaid, but in this circumstance the overlap is allowed.
| Example 11 | Tim applied for health care on October 2. He was denied for SSI-Related Medicaid due to being over the asset limit and he opened for SLMB. On February 3, he reports a reduction in assets. Verification is requested with a due date of February 23. His SLMB coverage is maintained for March. Verification is received on February 19. His asset decrease makes him eligible for SSI-Related Medicaid with a new certification period starting April 1. However, because the asset reduction was reported in February and verified timely, his eligibility for SSI-Related Medicaid must also be tested retroactively for February and March. |
Eligibility must be retroactively determined in situations where health care coverage was maintained for one household member, and, after the redetermination of eligibility, another household member that was previously not eligible for health care is newly eligible. Eligibility is determined back to the date the change was reported.
| Example 12 | Jim and his wife, Bonnie, both applied for health care on October 2. Bonnie was denied for being over assets for MAPP, but Jim opened for MAPP. On February 3, Jim and Bonnie report a reduction in joint assets. Verification is requested with a due date of February 23. Jim’s MAPP coverage is maintained for March. Verification is received on February 19. The asset decrease makes both Jim and Bonnie eligible for MAPP on April 1. However, because the asset reduction was reported in February and verified timely, eligibility for Bonnie’s MAPP must also be tested retroactively for February and March. |
This page last updated in Release Number: 25-04
Release Date: 12/10/2025
Effective Date: 12/10/2025
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030