(1) DEFINITIONS. In this section: (b) “Child” means a person who is born and who is under the age of 19. (c) “Employer-subsidized health care coverage” means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80 percent of the cost, excluding any deductibles or copayments that may be required under the plan. (d) “Family” means a unit that consists of at least one child and his or her parent or parents, all of whom reside in the same household. “Family” includes the spouse of an individual who is a parent if the spouse resides in the same household as the individual. (e) “Parent” has the meaning given in s. 49.141 (1) (j). (f) “State plan” means the state child health plan under 42 USC 1397aa (b). (g) “Unborn child” means a person from the time of conception until it is born alive. (2) WAIVERS. (a) 1. The department of health services shall request a waiver from the secretary of the federal department of health and human services to permit the department of health services to implement, beginning not later than July 1, 1998, or the effective date of the waiver, whichever is later, a health care program under this section. If a waiver that is consistent with all of the provisions of this section, excluding sub. (4) (a) 3m. and (ap) and provisions related to sub. (4) (ap), is granted and in effect, the department of health services shall implement the program under this section, subject to subd. 2. The department of health services may not implement the program under this section unless a waiver that is consistent with all of the provisions of this section, excluding sub. (4) (a) 3m. and (ap) and provisions related to sub. (4) (ap), is granted and in effect. 2. The department may not implement sub. (4) (ap) or provisions related to the coverage under sub. (4) (ap) unless a state plan amendment authorizing the coverage under sub. (4) (ap) is approved by the federal department of health and human services. (b) If the department of health services determines that it needs a waiver to require the verification specified in sub. (4) (a) 3m., the department shall request a waiver from the secretary of the federal department of health and human services and may not implement the verification requirement under sub. (4) (a) 3m. unless the waiver is granted. If a waiver is required and is granted, the department of health services may implement the verification requirement under sub. (4) (a) 3m. as appropriate. If a waiver is not required, the department of health services may require the verification specified in sub. (4) (a) 3m. for eligibility determinations and annual review eligibility determinations made by the department, beginning on January 1, 2004. (3) ADMINISTRATION. Subject to sub. (2) (a) 2. , the department shall administer a program to provide the health services and benefits described in s. 49.46 (2) to persons that meet the eligibility requirements specified in sub. (4). The department shall promulgate rules setting forth the application procedures and appeal and grievance procedures. The department may promulgate rules limiting access to the program under this section to defined enrollment periods. The department may also promulgate rules establishing a method by which the department may purchase family coverage offered by the employer of a member of an eligible family or of a member of an eligible child’s household, or family or individual coverage offered by the employer of an eligible unborn child’s mother or her spouse, under circumstances in which the department determines that purchasing that coverage would not be more costly than providing the coverage under this section. (4) ELIGIBILITY. (a) A family is eligible for health care coverage under this section if the family meets all of the following requirements: 1. The family’s income does not exceed 185 percent of the poverty line, except as provided in par. (at) and except that a family that is already receiving health care coverage under this section may have an income that does not exceed 200 percent of the poverty line. The department shall establish by rule the criteria to be used to determine income. 2. The family does not have access to employer-subsidized health care coverage. 3. The family has not had access to employer-subsidized health care coverage within the time period established by the department by rule, but not to exceed 18 months, immediately preceding application for health care coverage under this section. The department may establish exceptions to this time period restriction by rule. 3m. Each member of the family who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings, of whether the employer provides health care coverage for which the family is eligible, and of the amount that the employer pays, if any, towards the cost of the health care coverage, excluding any deductibles or copayments required under the coverage. 4. The family meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements. (am) A child who does not reside with his or her parent is eligible for health care coverage under this section if the child meets all of the following requirements: 1. The child’s income does not exceed 185 percent of the poverty line, except as provided in par. (at) and except that a child that is already receiving health care coverage under this section may have an income that does not exceed 200 percent of the poverty line. The department shall use the criteria established under par. (a) 1. to determine income under this subdivision. 2. The child does not have access to employer-subsidized health care coverage. 3. The child has not had access to employer-subsidized health care coverage within the time period established by the department under par. (a) 3. The department may establish exceptions to this subdivision. 4. The child meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements. (ap) An unborn child whose mother is not eligible for health care coverage under par. (a) or (am) or for medical assistance under s. 49.46 or 49.47, except that she may be eligible for benefits under s. 49.45 (27), is eligible for health care coverage under this section, which shall be limited to coverage for prenatal care, if all of the following requirements are met: 1. The income of the unborn child’s mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 185 percent of the poverty line, except as provided in par. (at) and except that, if an unborn child is already receiving health care coverage under this section, the applicable specified person or persons may have an income that does not exceed 200 percent of the poverty line. The department shall establish by rule the criteria to be used to determine income. 3. The unborn child’s mother provides medical verification of her pregnancy, in the manner specified by the department. 4. The unborn child and the mother of the unborn child meet all other requirements 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. 4. a. applies. (at) 1. a. Except as provided in subd. 1. b., the department shall establish a lower maximum income level for the initial eligibility determination if funding under s. 20.435 (4) (jz) , (p), and (x) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding. b. The department may not lower the maximum income level for initial eligibility unless the department first submits to the joint committee on finance a plan for lowering the maximum income level. If, within 14 days after the date on which the plan is submitted to the joint committee on finance, the cochairpersons of the committee do not notify the secretary that the committee has scheduled a meeting for the purpose of reviewing the plan, the department shall implement the plan as proposed. If, within 14 days after the date on which the plan is submitted to the committee, the cochairpersons of the committee notify the secretary that the committee has scheduled a meeting to review the plan, the department may implement the plan only as approved by the committee. cm. Notwithstanding s. 20.001 (3) (b), if, after reviewing the plan submitted under subd. 1. b., the joint committee on finance determines that the amounts appropriated under s. 20.435 (4) (jz), (p), and (x) are insufficient to accommodate the projected enrollment levels, the committee may transfer appropriated moneys from the general purpose revenue appropriation account of any state agency, as defined in s. 20.001 (1), other than a sum sufficient appropriation account, to the appropriation account under s. 20.435 (4) (b) to supplement the health care program under this section if the committee finds that the transfer will eliminate unnecessary duplication of functions, result in more efficient and effective methods for performing programs, or more effectively carry out legislative intent, and that legislative intent will not be changed by the transfer. 2. If, after the department has established a lower maximum income level under subd. 1., projections indicate that funding under s. 20.435 (4) (jz) , (p), and (x) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185 percent of the poverty line. 3. The department may not adjust the maximum income level of 200 percent of the poverty line for persons already receiving health care coverage under this section or for applicable persons specified in par. (ap) 1. with respect to an unborn child already receiving health care coverage under this section. (b) Notwithstanding fulfillment of the eligibility requirements under this subsection, no person is entitled to health care coverage under this section. (c) No person may be denied health care coverage under this section solely because of a health condition of that person, of any family member of that person, or of the mother of an unborn child. (d) An unborn child’s eligibility for coverage under par. (ap) shall not begin before the first day of the month in which the unborn child’s mother provides the medical verification required under par. (ap) 3. (4g) DISEASE MANAGEMENT PROGRAM. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (4m), the department shall develop and implement, for individuals who are eligible under sub. (4), disease management programs. These programs shall have at least the following characteristics: (a) The use of information science to improve health care delivery by summarizing a patient’s health status and providing reminders for preventive measures. (b) Educating health care providers on health care process improvement by developing best practice models. (c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering. (d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care. (e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions. (4m) PHYSICAL HEALTH RISK ASSESSMENT. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible under sub. (4) to receive a physical health risk assessment as part of the first physical examination the individual receives under Badger Care. (5) LIABILITY FOR COST. (ac) In this subsection, “cost” means total cost-sharing charges, including premiums, copayments, coinsurance, deductibles, enrollment fees, and any other cost-sharing charges. (ag) Except as provided in pars. (am), (b), and (bm), a family, a child who does not reside with his or her parent, or the mother of an unborn child, who receives health care coverage under this section shall pay a percentage of the cost of that coverage in accordance with a schedule established by the department by rule. The department may not establish or implement a schedule that requires a contribution, including the amounts required under par. (am), of more than 5 percent of the income of the family, child, or applicable persons specified in sub. (4) (ap) 1. towards the cost of the health care coverage provided under this section. (am) Except as provided in pars. (b) and (bm), a child, a family member, or the mother of an unborn child, who receives health care coverage under this section shall pay the following cost-sharing amounts: 1. A copayment of $1 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b). 2. A copayment of $3 for each prescription of a drug that bears a brand name, as defined in s. 450.12 (1) (a). (b) The department may not require a family, child who does not reside with his or her parent, or applicable persons specified in sub. (4) (ap) 1. , with an income below 150 percent of the poverty line, to contribute to the cost of health care coverage provided under this section. (bm) If the federal department of health and human services notifies the department of health services that Native Americans may not be required to contribute to the cost of the health care coverage provided under this section, the department of health services may not require Native Americans to contribute to the cost of health care coverage under this section. (c) The department may establish by rule requirements for wage withholding as a means of collecting a family’s or an unborn child’s mother’s share of the cost of the health care coverage under this section. (5m) INFORMATION ABOUT BADGER CARE RECIPIENTS. The department shall obtain and share information about Badger Care health care program recipients as provided in s. 49.475. (7) EMPLOYER VERIFICATION FORMS; FORFEITURE AND PENALTY ASSESSMENT. (a) 1. Notwithstanding sub. (4) (a) 3m., the department shall mail information verification forms to the employers of the individuals required to provide the verifications under sub. (4) (a) 3m. to obtain the information specified. 2. An employer that receives a verification form shall complete the form and return it to the department, by mail, with a postmark that is not more than 30 working days after the date on which the department mailed the form to the employer. 3. As an alternative to the method under subd. 2., an employer may, within 30 working days after the date on which the department mailed the form to the employer, return the completed form to the department by any electronic means approved by the department. The department must be able to determine, or the employer must be able to verify, the date on which the form was sent to the department electronically. (b) 1. Subject to subd. 3., an employer that does not comply with the requirements under par. (a) 2. or 3. shall be required to pay a forfeiture of $50 for each verification form not returned in compliance with par. (a) 2. or 3. 2. Subject to subd. 3., whenever the department imposes a forfeiture under subd. 1., the department shall also levy a penalty assessment of $50. 3. An employer with fewer than 250 employees may not be required to pay more than $1,000 in forfeitures and penalty assessments under this paragraph in any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in forfeitures and penalty assessments under this paragraph in any 6-month period. 4. All penalty assessments collected under subd. 2. shall be credited to the appropriation account under s. 20.435 (4) (jz) and all forfeitures collected under subd. 1. shall be credited to the common school fund. (c) An employer may contest an assessment of forfeiture or penalty assessment under par. (b) 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.
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