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State of Wisconsin |
Release 25-02 |
The following exceptions apply when one spouse (hereafter referred to as Spouse 2) is determined eligible after the participating spouse’s (hereafter referred to as Spouse 1) benefit period has begun.
In all of these situations, Spouse 1’s eligibility and benefit period does not change, unless he or she chooses to reapply (see Section 33.11 Re-Application).
If Spouse 2 becomes eligible after Spouse 1’s benefit period has begun, Spouse 2’s benefit period ends on the same date that Spouse 1’s benefit period ends.
The participation level for Spouse 2 depends on whether:
See 33.9.4 Addition of a Spouse Summary Table
If Spouse 2’ s participation level is determined after Spouse 1’s and Spouse 2 was included in the original FTG (married and living with Spouse 1 at the time of Spouse 1’s application) the participation level for Spouse 2 is determined based on annual income information provided on Spouse 1’s application.
| Example 1: |
Tyler and Anne are married and live together. Tyler has significant prescription drug expenses and applies for SeniorCare. Anne takes no prescription drugs and does not request SeniorCare when Tyler applies in March. Tyler’s participation level is based on a FTG of two. Tyler is found eligible, and his benefit period begins April 1st. In September, Anne is diagnosed with a health problem and begins taking prescription drugs. She applies for SeniorCare on September 15th. The same income information provided in March is used to determine Anne’s eligibility, even though Tyler has since obtained a part-time job and has additional income. Anne’s benefit period is from October 1st through March 31st so her benefit period ends at the same time as Tyler’s. They will report the income from Tyler’s part-time job when their SeniorCare eligibility is reviewed in March. |
Spouse 2’s deductible is prorated if the couple’s gross annual income is between 160% and 240% of the FPL, and Spouse 2 becomes SeniorCare eligible after Spouse 1’s benefit period has begun. To prorate the deductible, multiply the required deductible amount ($500 or $850) by the number of months in Spouse 2’s benefit period and divide by 12.
| Example 2: |
Mary and Jim apply for SeniorCare in January. They have an annual income between 160% and 200% of the FPL for a FTG of two (see Section 39.11 SeniorCare Income Limits and Participation Levels). Their income places them in Level 2a with a $500 deductible. Jim is determined eligible for SeniorCare, but Mary’s eligibility for SeniorCare is denied because she is 64. Mary is refunded her enrollment fee. Jim’s 12-month benefit period begins February 1st. Jim has a $500 deductible. In June, Mary will turn 65. At adverse action in the month of May, CARES will process this case through batch. At that time, the application status is updated if the applicant who is turning 65 is:
A letter is sent to Mary notifying her that if she still wishes to participate in SeniorCare, she must submit her $30 annual enrollment fee. If Mary’s enrollment fee is received before July 1st, she will be determined eligible beginning July 1st. Because Mary paid her enrollment fee on July 5th, Mary’s benefit period begins August 1st, and ends January 31st, when Jim’s benefit period ends. Mary’s deductible is prorated. Since there are six months in her benefit period, $500 is multiplied by six and the total is divided by 12. $500 x 6=$3,000/12=$250 Mary’s deductible is $250. Once Mary meets the $250 deductible by purchasing covered prescription drugs, she is eligible to purchase covered prescription drugs at the co-payment amounts through the remainder of her benefit period. Jim’s eligibility and benefit period are not affected. If the couple’s income were between 200% and 240% of the FPL, the example would be the same except that the $500 deductible would be $850. |
If the couple’s income is greater than 240% of the FPL and Spouse 2 becomes eligible after Spouse 1’s benefit period has begun, the procedure differs according to whether the spenddown has been met at the time Spouse 2’s eligibility begins.
When Spouse 2 is added before Spouse 1 has met the spenddown, covered prescription drug purchases of both spouses will count toward the remaining spenddown requirement.
After the spenddown has been met, both spouses begin to participate at Level 2b, and each will have a deductible requirement. The deductible for Spouse 1 is $850. The deductible for Spouse 2 is prorated (33.9.3.1 FTG Changes at Level 2a and 2b).
Participants will get a discount off the retail price for most covered prescription drugs during the deductible period.
After a spouse has met his or her deductible, he or she purchases covered prescription drugs at the co-payment amounts for the remainder of the benefit period.
| Example 3: |
Reginald and Elizabeth’s joint income is $3,000 more than 240% of the FPL for a FTG of two. Elizabeth applies in December and is determined eligible for SeniorCare effective January 1. Only Elizabeth’s covered prescription drug costs are applied toward the spenddown. In March, Reginald turns 65 and is determined eligible for SeniorCare beginning April 1. His benefit period ends December 31, when Elizabeth’s ends. Since Elizabeth has not yet met the spenddown when Reginald’s eligibility begins, both spouses’ covered prescription expenses are applied toward the remaining spenddown amount, beginning April 1. In June, Elizabeth and Reginald meet the spenddown. Elizabeth has a $850 deductible, but Reginald’s deductible is prorated. Since there are nine months in his benefit period, $850 is multiplied by nine and the total is divided by 12. $850 x 9 = $7,650/12 = $638 Reginald’s deductible is $638. Once Reginald meets the $638 deductible, he purchases covered prescription drugs at the copayment amounts through the remainder of his benefit period. Once Elizabeth meets her $850 deductible, she purchases covered prescription drugs at the copayment amounts through the remainder of the benefit period. |
When a second spouse is added after the spenddown has been met, the eligibility and benefit period for Spouse 1 is not affected.
If Spouse 2’s income was included in Spouse 1’s determination and the spenddown has been met, the deductible for Spouse 2 is prorated (33.9.2.1). Participants will get a discount off the retail price for most covered prescription drugs during the deductible period.
After a spouse has met his or her deductible, he or she purchases covered prescription drugs at the co-payment amounts for the remainder of the benefit period.
| Example 4: |
Bob and Bernice’s joint income is $1,000 more than 240% of the FPL for a FTG of two. Bernice applies in December and is determined eligible for SeniorCare effective January 1. Bob does not apply because he is not yet 65 years old. Only Bernice’s covered prescription drug costs are applied toward the spenddown amount of $1,000. Bernice meets the spenddown requirement in April. She then begins purchasing covered prescription drugs that count toward her $850 deductible. In June, she has $100 left before she will meet her deductible. In May, Bob turns 65 and is determined eligible for SeniorCare. His eligibility begin date is June 1. His benefit period ends December 31, when Bernice’s ends. Since Bernice has already met the spenddown requirement, Bob will begin participating at Level 2b. His deductible will be prorated. Since there are seven months in his benefit period, $850 is multiplied by seven and the total is divided by 12. $850 x 7 = $5,950/12 = $496 Bob’s deductible is $496. After he meets the $496 deductible by purchasing covered prescription drugs, he purchases covered prescription drugs at copayment amounts for the remainder of his benefit period. Bernice’s eligibility and benefit period are not affected. Once she meets her deductible by purchasing another $100 in covered prescription drugs, she purchases covered prescription drugs at the copayment amounts for the remainder of her benefit period. |
When a married SeniorCare participant applies after Spouse 1’s benefit period has begun, and Spouse 2 was not included in the FTG when the participation level for Spouse 1 was determined:
| Example 5: |
Jim is a SeniorCare participant from September through August. Because he was not married and living with a spouse when he applied, Jim’s benefit level was based on a FTG of one. In January, Jim marries Helen. Helen applies for SeniorCare in February. Jim’s eligibility is not redetermined when Helen applies. Helen’s participation level is determined based on a FTG of two. Income is estimated for Helen prospectively for the 12-month period beginning in February. Helen’s benefit period begins in March, if she met all eligibility requirements in February. Helen’s benefit period ends in August, when Jim’s benefit period ends. |
Spouse’s 2 deductible is prorated (33.9.3.1 FTG Changes at Level 2a and 2b) when income for Spouse 2, based on a FTG of two, is determined to be above 160% but less than or equal to 240% of the FPL and Spouse 2 is added to the case after Spouse 1’s benefit period has begun.
| Example 6: |
Will is married, but he and his wife Grace were separated at the time he applied for SeniorCare. Will applies for SeniorCare in October. Will’s benefit level is based on a FTG of one, using only his income. Will’s gross annual income is less than 160% of the FPL for a FTG of one. Will is determined to be SeniorCare eligible at Level 1 beginning November 1. His 12-month benefit period ends the following October. Will does not pay a deductible or spenddown. He purchases covered prescription drugs at the copayment amounts. Grace returns home in January. She applies for SeniorCare in February and is determined eligible beginning March 1. Grace’s benefit level is determined based on a FTG of two. Their joint income is between 200% and 240% of the FPL for a FTG of two. Her benefit period ends October 31st, when Will’s benefit period ends. Since there are eight months in her benefit period, Grace’s deductible amount is prorated. The deductible amount of $850 is multiplied by eight and then divided by 12. $850 x 8=$6,800/12=$567 Grace’s deductible amount is $567. After she has met her deductible, she purchases covered prescription drugs at the copayment amounts for the remainder of the benefit period. Will’s eligibility and benefit period are not affected. |
Spouse 2’s spenddown is prorated only if:
To prorate Spouse 2’s spenddown, multiply the amount of income exceeding 240% FPL by the number of months of Spouse 2’s benefit period and divide by 12. The result is equal to the prorated spenddown amount of Spouse 2. Only covered prescription drug costs of Spouse 2 count toward the prorated spenddown.
After the spenddown has been met, the deductible for Spouse 2 is prorated (33.9.3.1 FTG Changes at Level 2a and 2b). Participants will get a discount off the retail price for most covered prescription drugs during the deductible period.
After the deductible is met, he or she purchases covered remainder of the benefit period.
| Example 7: |
Tim is married, but his wife Marsha was institutionalized at the time he applied for SeniorCare. Marsha was expected to be out of the home for five months. Tim applies for SeniorCare in May. Tim’s benefit level is based on a FTG of one. Tim’s gross annual income is less than 160% of the FPL for a FTG of one. Tim is determined to be SeniorCare eligible beginning June 1. His 12-month benefit period ends the following May. Tim does not pay a deductible or spenddown. He purchases covered prescription drugs at the copayment amounts. Tim’s wife Marsha returns home in November. She applies for SeniorCare in November and is determined eligible beginning December 1. Marsha’s participation level is determined based on a FTG of two. Their joint income is $1,000 above 240% of the FPL for a FTG of two. Her benefit period ends May 31, when Tim’s benefit period ends. Since there are six months in her benefit period, Marsha’s spenddown amount is prorated. The spenddown amount of $1,000 is multiplied by six and then divided by 12. $1,000 x 6=$6,000/12=$500 Marsha’s spenddown amount is $500. After she has met her spenddown, she then has a prorated deductible. Since there are six months in her benefit period, $850 is multiplied by six and then divided by 12. $850x 6=$5,100/12=$425 Marsha pays for covered prescription drugs until she has met the $425 deductible. After Marsha has met the deductible, she purchases covered prescription drugs at the copayment amounts for the remainder of benefit period. Tim’s eligibility and benefit period are not affected. |
The following table assumes that Spouse 1 and Spouse 2 do not apply for SeniorCare at the same time.
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SPOUSE 1's Eligibility | SPOUSE 2's Eligibility |
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Benefit Period: Begin Date |
First of month following receipt of a valid application and enrollment fee. |
First of month following receipt of a valid application and enrollment fee. Will be later than Spouse 1’s begin date. |
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Benefit Period: End Date |
End of twelfth month of eligibility unless terminated early. |
Same end date as Spouse 1 regardless of when Spouse 2 applies. |
| Participation Level:
Married at time of Spouse 1’s application |
FTG of two. Participation Level determined based on annual income of both spouses. |
FTG of two. Participation Level determined based on annual income from Spouse 1’s application. Eligibility results will be the same as Spouse 1. |
| Participation Level:
Single or not living together at time of Spouse 1’s application. |
Gross annual income test based on a FTG of one. When adding a new spouse, Spouse 1 does not need to reapply until the end of the twelve-month benefit period unless he or she chooses to do so. |
Gross annual income test based on a FTG of two. Participation Level determined based on annual income of both spouses. Participation Level may be different than Spouse 1’s. Spouse 2 must estimate income at the time he or she applies. Spouse 1’s income remains the same. |
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Deductible: |
Has a $500/$850 deductible based on Participation Level. |
Required deductible is prorated based on number of months of eligibility and amount of deductible. |
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Spenddown: Unmet Original FTG of 2 |
Covered prescription drugs of Spouse 1 used to meet spenddown until Spouse 2 is added. Once spenddown is met, Spouse 1 has a deductible of $850. |
Projected income from Spouse 1’s application will be used to determine Spouse 2’s eligibility. Covered prescription drugs of both spouses are used to meet the spenddown. Once spenddown is met, Spouse 2 has a prorated deductible.
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Spenddown: Original FTG of 2 |
No change in spenddown for Spouse 1. |
No new spenddown when Spouse 2 is added. Spouse 2 has a prorated deductible. |
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Spenddown: Unmet Original FTG of 1 |
No change in spenddown for Spouse 1. |
Spouse 2 has a prorated spenddown and deductible. |
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Spenddown: Original FTG of 1 |
No change in spenddown for Spouse 1. |
Spouse 2 has a prorated spenddown and deductible. |
| Note | If Spouse 1's eligibility is terminated prior to Spouse 2's request, a new application is required for a new 12-month benefit period. |
This page last updated in Release Number: 19-01
Release Date: 4/19/2019
Effective Date: 4/19/2019
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