(1) DEFINITIONS. In this section, unless the context requires otherwise: (a) “BadgerCare Plus” means the Medical Assistance program described in this section. (b) “Caretaker relative” means an individual who is maintaining a residence as a child’s home, who exercises primary responsibility for the child’s care and control, including making plans for the child, and who is any of the following with respect to the child: 1. A blood relative, including those of half-blood, and including first cousins, nephews, nieces, and individuals of preceding generations as denoted by prefixes of grand, great, or great-great. 2. A stepfather, stepmother, stepbrother, or stepsister. 3. An individual who is the adoptive parent of the child’s parent, a natural or legally adopted child of such individual, or a relative of an adoptive parent. 4. A spouse of any individual named in this paragraph even if the marriage is terminated by death or divorce. (c) “Child” means an individual who is under the age of 19 years. “Child” includes an unborn child. (cm) “Disabled” means, when referring to an adult, meeting the disability standard for eligibility for federal supplemental security income under 42 USC 1382c (a) (3). (d) “Essential person” means an individual who satisfies all of the following: 1. Is related to an individual receiving benefits under this section. 2. Is otherwise nonfinancially eligible, except that the individual need not have a minor child under his or her care. 3. Provides at least one of the following to an individual receiving benefits under this section: a. Child care that enables a caretaker to work outside the home for at least 30 hours per week for pay, to receive training for at least 30 hours per week, or to attend, on a full-time basis as defined by the school, high school or a course of study meeting the standards established by the state superintendent of public instruction for the granting of a declaration of equivalency of high school graduation under s. 115.29 (4). b. Care for anyone who is incapacitated. (e) “Family” means all children for whom assistance is requested, their minor siblings, including half brothers, half sisters, stepbrothers, and stepsisters, and any parents of these minors and their spouses. (f) “Family income” has the meaning given for “household income” under 42 CFR 435.603 (d). (g) “Group health plan” has the meaning given in 42 USC 300gg-91 (a) (1). (h) “Health insurance coverage” has the meaning given in 42 USC 300gg-91 (b) (1), and also includes any arrangement under which a 3rd party agrees to pay for the health care costs of the individual. (i) “Parent” has the meaning given in s. 49.141 (1) (j). (j) “Recipient” means an individual receiving benefits under this section. (k) “Unborn child” means an individual from conception until he or she is born alive for whom all of the following requirements are met: 1. The unborn child’s mother is not eligible for medical assistance under this subchapter, except that she may be eligible for benefits under s. 49.45 (27). 2. The income of the unborn child’s mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 300 percent of the poverty line. 3. Each of the following applicable persons who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings: a. The unborn child’s mother. b. The spouse of the unborn child’s mother. c. Members of the unborn child’s mother’s family. 4. The unborn child’s mother provides medical verification of her pregnancy, in the manner specified by the department. An unborn child’s eligibility for coverage under this section does not begin before the first day of the month in which the unborn child’s mother provides the medical verification. 5. The unborn child and the mother of the unborn child meet all other applicable eligibility requirements under this chapter or established by the department by rule except for any of the following: a. The mother is not a U.S. citizen or an alien qualifying for Medicaid under 8 USC 1612. b. The mother is an inmate of a public institution. c. The mother does not provide a social security number, but only if subd. 5. a. applies. (2) WAIVER AND STATE PLAN AMENDMENTS. The department shall request a waiver from, and submit amendments to the state Medical Assistance plan to, the secretary of the federal department of health and human services to implement BadgerCare Plus. If the state plan amendments are approved and a waiver that is substantially consistent with the provisions of this section, excluding sub. (2m), is granted and in effect, the department shall implement BadgerCare Plus beginning on January 1, 2008, the effective date of the state plan amendments, or the effective date of the waiver, whichever is latest. If the state plan amendments are not approved or if a waiver that is substantially consistent with the provisions of this section, excluding sub. (2m), is not granted, BadgerCare Plus may not be implemented. If the state plan amendments are approved but approval is not continued or if a waiver that is substantially consistent with the provisions of this section, excluding sub. (2m), is granted but not continued in effect, BadgerCare Plus shall be discontinued. (2m) APPROVAL TO QUALIFY AS A HEALTH COVERAGE TAX CREDIT PLAN. The department shall seek any necessary federal approvals to ensure that BadgerCare Plus is qualified health insurance under 26 USC 35 (e). Notwithstanding subs. (4) and (5), if BadgerCare Plus is determined to be qualified health insurance under 26 USC 35 (e), the department shall expand eligibility under BadgerCare Plus to include individuals who are eligible individuals under 26 USC 35 (c). Notwithstanding sub. (10) (a) and (b) 1. to 4., individuals who are eligible for coverage under BadgerCare Plus under this subsection shall pay premiums that are equal to the capitation payments that the department would make on behalf of similar individuals with coverage under BadgerCare Plus, or the full per member per month cost of coverage, whichever is appropriate. (3) INELIGIBILITY FOR OTHER M EDICAL A SSISTANCE BENEFITS. (a) 1. Notwithstanding ss. 49.46 (1), 49.465, 49.47 (4), and 49.665 (4), if the amendments to the state plan under sub. (2) are approved and a waiver under sub. (2) that is substantially consistent with the provisions of this section, excluding sub. (2m), is granted and in effect, an individual described in sub. (4) (a) or (5) is not eligible under s. 49.46, 49.465, 49.47, or 49.665 for Medical Assistance or BadgerCare health program benefits. The eligibility of an individual described in sub. (4) (a) or (5) for Medical Assistance benefits shall be determined under this section. 2. Notwithstanding subd. 1., an individual who is eligible for medical assistance under s. 49.46 (1) (a) 3. or 4. may not receive benefits under this section. 3. Notwithstanding subd. 1., an individual described in sub. (4) (a) or (5) who is eligible for medical assistance under s. 49.46 (1) (a) 5., 6m., 14., 14m., or 15. or (d) or 49.47 (4) (a) or (as) may receive medical assistance benefits under this section or under s. 49.46 or 49.47. (b) 1. If an individual over 18 years of age who is eligible for and receiving Medical Assistance benefits under s. 49.46, 49.47, or 49.665 in the month before BadgerCare Plus is implemented loses that eligibility solely due to the implementation of BadgerCare Plus and, because of his or her income, is not eligible for BadgerCare Plus, the individual shall continue receiving for 12 consecutive months the medical assistance he or she was receiving before the implementation of BadgerCare Plus if all of the following are satisfied: a. The individual’s eligibility for the Medical Assistance benefits in the month before the implementation of BadgerCare Plus was based on an application filed before the implementation of BadgerCare Plus. b. The individual continues to pay any premium that he or she was required to pay for the Medical Assistance coverage in the same amount as the amount that was due in the month before the implementation of BadgerCare Plus. c. The individual meets all nonfinancial eligibility requirements under this section. d. The individual continues to be ineligible for BadgerCare Plus because of his or her income. 2. Notwithstanding subd. 1., if at any time during an individual’s 12-month eligibility extension under subd. 1. any criterion under subd. 1. a. to d. is not satisfied, the individual’s eligibility for the extended coverage is terminated and any time remaining in the eligibility period is lost. (4) GENERAL ELIGIBILITY CRITERIA; APPLICABLE BENEFITS. (a) Except as otherwise provided in this section, all of the following individuals are eligible for the benefits described in s. 49.46 (2) (a) and (b), subject to sub. (6) (k) and s. 49.45 (24j): 1. A pregnant woman whose family income does not exceed 200 percent of the poverty line. 1g. A pregnant woman whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line. 1m. A pregnant woman who obtains eligibility under sub. (7) (b) 1. 2. A child who is under one year of age, whose mother was, on the day the child was born, eligible for and receiving medical assistance under subd. 1. or 5. or s. 49.46 or 49.47, and who lives with his or her mother in this state. 2m. A child who is under one year of age, whose mother was determined to be eligible under subd. 1g., and who lives with his or her mother in this state. 3. A child whose family income does not exceed 200 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care. 3g. A child whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care. 3m. A child who obtains eligibility under sub. (7) (b) 2. 4. An individual who satisfies all of the following criteria: a. The individual is a parent or caretaker relative of a dependent child who is living in the home with the parent or caretaker relative or who is temporarily absent from the home for not more than 6 months or, if the dependent child has been removed from the home for more than 6 months, the parent or caretaker relative is working toward unifying the family by complying with a permanency plan under s. 48.38 or 938.38. For purposes of this subdivision, a “dependent child” means an individual who is under the age of 18 or an individual who is age 18 and a full-time student in secondary school or equivalent vocational or technical training if before attaining the age of 19 the individual is reasonably expected to complete the school or training. b. The individual’s family income does not exceed 100 percent of the poverty line before application of the 5 percent income disregard under 42 CFR 435.603 (d). 5. An individual who, regardless of family income, was born on or after January 1, 1988, and who, on his or her 18th birthday, was in a foster care placement under the responsibility of this state, or at the option of the department, under the responsibility of another state, and enrolled in Medical Assistance under this subchapter or a Medicaid program, as determined by the department. The coverage for an individual under this subdivision ends on the last day of the month in which the individual becomes 26 years of age, unless he or she otherwise loses eligibility sooner. 6. Migrant workers and their dependents who are determined eligible under sub. (6) (f). 7. Individuals who qualify for a medical assistance eligibility extension under s. 49.46 (1) (c) or (cg) when their income increases above the poverty line, except as provided in s. 49.46 (1) (cr). (d) An individual is eligible to purchase coverage of the benefits described in sub. (11) for himself or herself and for his or her spouse and dependent children, at the full per member per month cost of coverage, if all of the following apply: 1. The individual lost his or her employer-sponsored health care coverage as a result of his or her employer’s or former employer’s bankruptcy. 2. After losing his or her employer-sponsored health care coverage, the individual received health care coverage through a voluntary employment benefit association that was established before August 2006. 3. The individual is not otherwise eligible for coverage under this section. 4. The individual is under 65 years of age. (e) If the department obtains approval from the federal department of health and human services to provide an alternate benchmark plan under sub. (11r), to the extent the federal department of health and human services approves, the department may enroll in the alternate benchmark plan under sub. (11r) any individual whose family income exceeds 100 percent of the poverty line, who is either an adult who is not pregnant or a child, and who applies and is otherwise eligible to receive benefits under this section, except that the department shall enroll a child who has a parent who is enrolled in a plan under this section in the same plan as his or her parent. (5) PRESUMPTIVE ELIGIBILITY. (a) In this subsection: 1. “Qualified entity” means an entity that satisfies the requirements under 42 USC 1396r-1a (b) (3) (A), as determined by the department. 2. “Qualified provider” means a provider that satisfies the requirements under 42 USC 1396r-1 (b) (2), as determined by the department. (b) 1. Except as provided in sub. (6) (a) 1., a pregnant woman is eligible for the benefits specified in par. (c) during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman’s family income does not exceed 300 percent of the poverty line and ending on the applicable day specified in subd. 3. 2. Except as provided in sub. (6) (a) 2., a child who is not an unborn child is eligible for the benefits described in s. 49.46 (2) (a) and (b) during the period beginning on the day on which a qualified entity determines, on the basis of preliminary information, that the child’s family income does not exceed any of the following and ending on the applicable day specified in subd. 3., unless the federal department of health and human services approves the department’s request to not extend eligibility to children during this period: a. 150 percent of the poverty line for a child who is 6 years of age or older but has not yet attained the age of 19. b. 185 percent of the poverty line for a child who is one year of age or older but has not yet attained the age of 6. c. 300 percent of the poverty line for a child who is under one year of age. 3. a. If the woman or child applies for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the day on which the department or the county department under s. 46.215, 46.22, or 46.23 determines whether the woman or child is eligible for benefits under sub. (4), except that a child who is not an unborn child is not eligible for benefits described in s. 49.46 (2) (a) and (b) during that time if the federal department of health and human services approves the department’s request not to provide those benefits during that time. b. If the woman or child does not apply for benefits under sub. (4) within the time required under par. (d), the benefits specified in subd. 1. or 2., whichever is applicable, end on the last day of the month following the month in which the provider or entity makes the determination under this paragraph. (c) 1. On behalf of a woman under par. (b) 1. whose family income does not exceed 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits described in s. 49.46 (2) (a) and (b). 2. On behalf of a woman under par. (b) 1. whose family income exceeds 200 percent of the poverty line, the department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. only for ambulatory prenatal care services under the benefits under sub. (11). (d) A woman or child who is determined to be eligible under par. (b) shall apply for benefits under sub. (4) on or before the last day of the month following the month in which the qualified provider or entity makes the eligibility determination. (e) A qualified provider or entity that determines that a woman or child is eligible under par. (b) shall do all of the following: 1. Notify the department of that determination within 5 working days after the day on which the determination is made. 2. Notify the woman or child of the requirement under par. (d) at the time of the determination. (f) The department shall provide qualified providers and qualified entities with application forms for the benefits under sub. (4) and information on how to assist women and children in completing the forms. (6) MISCELLANEOUS ELIGIBILITY AND BENEFIT PROVISIONS. (a) 1. Except as provided in subd. 4., any pregnant woman, including a pregnant woman under sub. (5) (b) 1. , is eligible for medical assistance under this section for any of the 3 months prior to the month of application if she met the eligibility criteria under this section in that month. 2. Except as provided in subd. 3. or 4., any child who is not an unborn child, including a child under sub. (5) (b) 2., parent, or caretaker relative whose family income is less than 150 percent of the poverty line is eligible for medical assistance under this section for any of the 3 months prior to the month of application if the individual met the eligibility criteria under this section and had a family income of less than 150 percent of the poverty line in that month. 3. Any individual described in subd. 2. who is not disabled, not elderly, and not pregnant, who is an adult, and whose family income exceeds 133 percent of the federal poverty level is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits. 4. To the extent allowed by the federal department of health and human services, any individual described in subd. 1. or 2. who is not disabled is not eligible for medical assistance under this section for any of the 3 months before the month of application for medical assistance benefits. (b) A pregnant woman who is determined to be eligible for benefits under sub. (4) remains eligible for benefits under sub. (4) for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 365th day after the last day of the pregnancy falls without regard to any change in the woman’s family income. (c) If a child who is eligible for benefits under sub. (4) is receiving inpatient services covered under sub. (4) on the day before his or her 19th birthday and, but for attaining 19 years of age, the child would remain eligible for benefits under sub. (4), the child remains eligible for benefits until the end of the stay for which the inpatient services are being furnished. (d) If an application under this section shows that an individual is an essential person, the individual shall be provided the benefits specified under sub. (4) (a). (f) The medical assistance eligibility provisions for migrant workers and their dependents under s. 49.47 (4) (av) apply to BadgerCare Plus. (g) 1. Except as provided in subd. 2., as a condition of eligibility for coverage under this section, an individual with income shall provide verification, as determined by the department, of that income. 2. Subdivision 1. does not apply to an individual under sub. (4) (a) 5. or a child under the age of 18. (h) Within 10 days after the change occurs, a recipient shall report to the department any change that might affect his or her eligibility or any change that might require premium payment by a recipient who was not required to pay premiums before the change. (i) For purposes of determining eligibility and family income, the department shall include a family member who is temporarily absent from the home for not more than 6 months, as determined by the department. (j) All of the following apply to BadgerCare Plus in the same respect as they apply under s. 49.46: 1. Section 49.46 (2) (c) and (cm), relating to benefits for individuals who are eligible for Medicare. 2. Section 49.46 (2) (d), relating to prohibiting payments for any part of any service payable through 3rd-party liability or any governmental or private benefit system. 3. Section 49.46 (2) (dm), relating to prohibiting payment for services to residents of institutions for mental diseases. 4. Section 49.46 (2) (f) , relating to prohibiting payment for gastric bypass or stapling surgery. (k) For an individual who is eligible for medical assistance under this section and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under sub. (11) (a) or s. 49.46 (2) (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug. (L) The department shall request from the federal department of health and human services approval of a state plan amendment or a waiver of federal law to implement subs. (6) (b) and (7) (b) 1. and ss. 49.46 (1) (a) 1m. and (j) and 49.47 (4) (ag) 2. (7) SPECIAL INCOME PROVISIONS. (b) 1. A pregnant woman whose family income exceeds 300 percent of the poverty line may become eligible for coverage under this section if the difference between the pregnant woman’s family income and the applicable income limit under sub. (4) (a) is obligated or expended for any member of the pregnant woman’s family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision continues without regard to any change in family income for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 365th day after the last day of the woman’s pregnancy falls. Eligibility obtained by a pregnant woman under this subdivision extends to all pregnant women in the pregnant woman’s family. 2. A child who is not an unborn child, whose family income exceeds 150 percent of the poverty line, and who is ineligible under this section solely because of sub. (8) (b), or whose family income exceeds 300 percent of the poverty line, may obtain eligibility under this section if the difference between the child’s family income and 150 percent of the poverty line is obligated or expended on behalf of the child or any member of the child’s family for medical care or any other type of remedial care recognized under state law or for personal health insurance premiums or for both. Eligibility obtained under this subdivision during any 6month period, as determined by the department, continues for the remainder of the 6-month period and extends to all children in the family. 3. For a pregnant woman to obtain eligibility under subd. 1., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the pregnant woman’s monthly family income and the monthly family income that is 300 percent of the poverty line. For a child to obtain eligibility under subd. 2., the amount that must be obligated or expended in any 6-month period is equal to the sum of the differences in each of those 6 months between the child’s monthly family income and the monthly family income that is 150 percent of the poverty line. (d) In addition to applying other income counting requirements the department shall do all of the following: 1. When calculating the family income of a member of a household who is not disabled, include the income of all adults residing in the home for at least 60 consecutive days but exclude the income of a grandparent in a household containing 3 generations, unless the grandparent applies for or receives benefits as a parent or caretaker relative under this section. 2. When determining the size of a family for purposes of determining income eligibility, exclude from family size an adult whose income is included in a calculation of family income solely under subd. 1. 3. Apply this paragraph only to the extent the federal department of health and human services approves the income eligibility calculation methods, if approval is required. (e) For the purpose of determining family income, the department shall apply the regulations defining a household under 42 CFR 435.603 (f) . To determine the family size for a pregnant woman, the department shall include the pregnant woman and the number of babies she is expecting. (8) HEALTH INSURANCE COVERAGE AND ELIGIBILITY. (a) 1. Except as provided in subd. 2., any individual who is otherwise eligible under this section and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for BadgerCare Plus and if the department determines that it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor’s behalf. 2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with subd. 1., the failure does not affect the minor’s eligibility under this section. (b) Except as provided in pars. (c), (cg), (cr), (ct), and (d), an individual whose family income exceeds 150 percent of the poverty line is not eligible for BadgerCare Plus if any of the following applies: 1. The individual has individual or family health insurance coverage that is any of the following: a. Coverage provided by an employer and for which the employer pays at least 80 percent of the premium. b. Coverage under the state employee health plan under s. 40.51 (6). 2. The individual, in the 12 months before applying, had access to the health insurance coverage specified in subd. 1. 3. The individual could be covered under the health insurance coverage specified in subd. 1. if the coverage is applied for, and the coverage could become available to the individual in the month in which the individual applies for benefits under this section or in any of the next 3 calendar months. (c) An unborn child, regardless of family income, is not eligible for BadgerCare Plus if any of the following applies: 1. The unborn child or the unborn child’s mother has individual or family health insurance coverage. 2. The unborn child or the unborn child’s mother, in the 12 months before applying, had access to the health insurance coverage specified in par. (b) 1. 3. The unborn child or the unborn child’s mother could be covered under individual or family health insurance coverage if the coverage is applied for, and the coverage could become available to the unborn child or the unborn child’s mother in the month in which the unborn child applies for benefits under this section or in any of the next 3 calendar months. (cg) An individual who is not disabled and not pregnant, who is over 18 years of age, and whose family income exceeds 133 percent of the poverty line is not eligible for BadgerCare Plus if all of the following apply: 1. The individual has any of the following: a. Access to individual or family health coverage provided by an employer in which the monthly premium that an employee would pay for an employee-only policy does not exceed 9.5 percent of the family’s monthly income. b. Access to individual or family health coverage under the state employee health plan. 2. The individual has access to any coverage described in subd. 1. during any of the following times: a. The 12 months before the first day of the month in which an individual applies for and the month in which an individual applies for BadgerCare Plus. b. The 3 months after the last day of the month in which the individual applies for BadgerCare Plus. c. The month including the date of the annual determination of the individual’s eligibility for Medical Assistance. 3. The individual does not have as a reason for not obtaining health insurance any of the good cause reasons under par. (d) 2. a. to e. (cr) 1. Subject to subd. 4., an individual who is any of the following is not eligible for BadgerCare Plus if the criteria under par. (cg) 1. and 2. apply to that individual: a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line. b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line. c. An adult, including a pregnant individual, who is not disabled, who is under 26 years of age; who is eligible to be covered under coverage a parent receives from an employer; and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line. 2. An individual under subd. 1. is not ineligible if any of the good cause reasons described in par. (d) 2. a. to e. is the reason that the individual did not obtain health insurance coverage. 3. An individual under subd. 1. c. is not ineligible if any of the following good cause reasons is the reason the individual did not obtain health insurance coverage: a. The parent of the individual is no longer employed by the employer through which the parent was eligible for coverage, and the parent does not have current coverage. b. The employer of the parent of the individual discontinued providing health benefits to all employees. 4. The department may apply this paragraph to eligibility determinations for BadgerCare Plus only if the federal department of health and human services approves of the conditions to make that individual ineligible, if approval is required. (ct) 1. If the federal department of health and human services approves the department’s request to add private major medical insurance as a type of coverage which causes ineligibility, an individual who is not disabled and not pregnant, who is over 18 years of age, whose family income exceeds 133 percent of the poverty line, and who has coverage provided by private major medical insurance in which the monthly premium does not exceed 9.5 percent of the family’s monthly income is not eligible for BadgerCare Plus. 2. If the federal department of health and human services approves of the conditions to make that individual ineligible for BadgerCare Plus, an individual who is any of the following is not eligible for BadgerCare Plus if he or she has the major medical insurance coverage described under subd. 1.: a. An individual who is not disabled and who is a child, or unborn child, of an individual whose family income is at a level determined by the department but no lower than 133 percent of the poverty line. b. A parent or caretaker relative who is not disabled, not pregnant, and an adult and whose family income is at a level determined by the department but no lower than 100 percent of the poverty line. (d) 1. None of the following is ineligible for BadgerCare Plus by reason of having health insurance coverage or access to health insurance coverage: a. A pregnant woman, except as provided in par. (cr) 1. c. b. A child described in sub. (4) (a) 2. or 2m. c. Except as provided in par. (c), a child who has health insurance coverage, or access to health insurance coverage, as a dependent of an absent parent but who resides outside of the service area of the absent parent’s plan. d. An individual described in sub. (4) (a) 5. e. A child who obtains eligibility under sub. (7) (b) 2. , but only for the remainder of the child’s eligibility period under sub. (7) (b) 2. f. An individual described in sub. (4) (a) 7. g. An adult who is disabled. 2. An individual under par. (b) 2., or an individual who is an unborn child or an unborn child’s mother under par. (c) 2., is not ineligible if any of the following good cause reasons is the reason that the individual did not obtain the health insurance coverage under par. (b) 1. to which they had access: a. The individual’s employment ended. b. The individual’s employer discontinued health insurance coverage for all employees. c. One or more members of the individual’s family were eligible for other health insurance coverage or Medical Assistance under s. 49.46 or 49.47 at the time the employee failed to enroll in the health insurance coverage under par. (b) 1. and no member of the family was eligible for coverage under this section at that time or, if one or more members of the individual’s family were eligible for coverage under this section at that time, family income did not exceed 150 percent of the poverty line or the individual qualified for a medical assistance eligibility extension as provided in sub. (4) (a) 7. d. The individual’s access to health insurance coverage has ended due to the death or change in marital status of the subscriber. dg. The insurance is owned by someone not residing with the family and continuation of the coverage is beyond the family’s control. dr. The insurance only covers services provided in a service area that is beyond a reasonable driving distance. e. Any other reason that the department determines is a good cause reason. (e) If a pregnant woman has health insurance coverage and her family income exceeds 200 percent of the poverty line, the woman is required, as a condition of eligibility, to maintain the health insurance coverage. (9) EMPLOYER VERIFICATION OF INSURANCE COVERAGE. (a) 1. Except as provided in subd. 2., for an applicant or recipient with a family income that exceeds 150 percent of the poverty line, the department shall verify insurance coverage and access information directly with the employer through which the applicant or recipient may have health insurance coverage or access to coverage. 2. Subdivision 1. does not apply to any of the following: a. A pregnant woman. b. A child described in sub. (4) (a) 2. or 2m. c. An individual described in sub. (4) (a) 5. (b) An employer that receives a request from the department for insurance coverage and access to coverage information shall supply the information requested by the department in the format specified by the department within 30 calendar days after receiving the request. (c) 1. Subject to subds. 2. and 3., an employer that does not comply with the requirements under par. (b) shall be required to pay, within 45 days after the requested information was due, a penalty equal to the full per member per month cost of coverage under BadgerCare Plus for the individual about whom the information is requested, and for each of the individual’s family members with coverage under BadgerCare Plus, for each month in which the individual and the individual’s family members are covered before the employer provides the information. 2. An employer with fewer than 250 employees may not be required to pay more than $1,000 in penalties under this paragraph that are attributable to any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in penalties under this paragraph that are attributable to any 6-month period. 3. Notwithstanding subd. 1., an employer shall not be subject to any penalties if the employer, at least once per year, timely provides to the department, in the manner and format specified by the department, information from which the department may determine whether the employer provides its employees with access to health insurance coverage. 4. All penalty assessments collected under this paragraph shall be credited to the appropriation accounts under s. 20.435 (4) (jw) and (jz). (d) An employer may contest a penalty assessment under par. (c) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by ch. 227. (10) COST SHARING. (a) Copayments. Except as provided in s. 49.45 (18) (am) 2. and (b) 2., all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to a person eligible for medical assistance under s. 49.46, 49.468, or 49.47. (b) Premiums. 1. Except as provided in subds. 1m. and 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income. 1m. Except as provided in subd. 4., a recipient who is an adult parent or adult caretaker relative; who is not disabled, pregnant, or American Indian; and whose family income exceeds 133 percent of the federal poverty line shall pay a premium for coverage under BadgerCare Plus in an amount determined by the department that is based on a formula in which costs decrease for those with lower family incomes and that is no less than 3 percent of family income but no greater than 9.5 percent of family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4. , the premium may not exceed 5 percent of family income calculated before depreciation was deducted. If the department intends to impose a premium under this subdivision after December 31, 2013, the department shall request from the federal department of health and human services any necessary approval to continue imposing premiums under this subdivision. 2. Except as provided in subds. 3m. and 4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line. 3m. A recipient who is a child, who is not disabled, and whose family income is at a level determined by the department that is at least 150 percent of the poverty line shall pay a premium in an amount determined by the department. The department may apply this subdivision only to the extent the federal department of health and human services approves applying a premium to those individuals, if approval is required. 4. None of the following shall pay a premium, except as provided in subd. 3m.: a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line. b. A child who is eligible under sub. (4) (a) 2. or 2m. c. A child whose family income does not exceed 200 percent of the poverty line. d. A pregnant woman whose family income does not exceed 200 percent of the poverty line. e. A child who obtains eligibility under sub. (7) (b) 2. f. An individual who is eligible under sub. (4) (a) 5. g. An individual described in sub. (4) (a) 7. 5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) either does not pay a premium when due or requests that his or her coverage under this section be terminated, the recipient’s coverage terminates. If the recipient is an adult, the recipient is not eligible for BadgerCare Plus for 12 consecutive calendar months following the date on which the recipient’s coverage terminated, except for any month during that 12-month period when the recipient’s family income does not exceed 133 percent of the poverty line. If the recipient is a child, the recipient is not eligible for BadgerCare Plus for 3 consecutive calendar months, or up to 12 consecutive calendar months if the federal department of health and human services approves, following the date on which the recipient’s coverage terminated, except for any month during that period when the recipient’s family income does not exceed 150 percent of the poverty line. This period of ineligibility for a child does not apply to any child who has paid the outstanding premiums. (11) BENCHMARK PLAN BENEFITS AND COPAYMENTS. Except as provided in sub. (11r) and s. 49.45 (24j), recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments: (a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription. (b) Physicians’ services, including one annual routine physical examination, with a copayment of no more than $15 per visit. (c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the ser- vices provided and a copayment of no more than $50 per admission for psychiatric services. (d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75. (e) Laboratory and X-ray services, including mammography. (f) Home health services, limited to 60 visits per year. (g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided. (h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided. (i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided. (j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided. (k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6). (L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided. (m) Transportation to obtain medical care, as medically necessary, and, to the extent permitted under federal law, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided. (n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit. (o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit. (p) Early childhood developmental services, for children under 6 years of age. (q) Smoking cessation treatment, for pregnant women only. (r) Prenatal care coordination, for pregnant women at high risk only. (s) Early and periodic screening and diagnosis, and all services included in the definition of “medical assistance” under 42 USC 1396d (a) that are found necessary by this screening and diagnosis, for recipients under 21 years of age. (11m) PROVIDER PAYMENTS AND REQUIREMENTS. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs. (11r) ALTERNATE BENCHMARK PLAN BENEFITS AND COPAYMENTS. (a) If the department chooses to provide the alternate benchmark plan under this subsection, the department shall provide to the recipients described under sub. (4) (e) coverage for benefits similar to those in a commercial, major medical insurance policy. (b) The department may charge copayments to recipients receiving coverage under the alternate benchmark plan under this subsection that are higher than copayments charged to recipients receiving coverage under the standard plan under s. 49.46 (2) . The department may not charge to a recipient of coverage under the alternate benchmark plan under this subsection whose family income is at or below 150 percent of the poverty line a copayment that exceeds 5 percent of the individual’s family income for all members of the family. (c) 1. The department may only provide coverage under the alternate benchmark plan under this subsection to the extent the alternate benchmark plan is approved by the federal department of health and human services. 2. If the department is providing coverage under the alternate benchmark plan under this subsection the department may discontinue coverage under the benchmark plan under sub. (11) for those individuals eligible for the alternate benchmark plan under this subsection. 3. The department may provide services to individuals enrolled in the alternate benchmark plan under this subsection through a medical home initiative similar to an initiative described under s. 49.45 (24j). (12) RULES; NOTICE OF EFFECTIVE DATE. (a) 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria. 2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision. (b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is substantially consistent with the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.
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