Section DHS 103.03 - Non-financial conditions for eligibility In order to be eligible for MA, a person shall meet both non-financial conditions for eligibility in this section and financial conditions for eligibility under s. DHS 103.04. The non-financial conditions for eligibility are:
(1) BadgerCare PLUS-RELATEDNESS OR SSI-RELATEDNESS.(a)Requirement. To be non-financially eligible for MA, an applicant shall be BadgerCare Plus-related or SSI-related.(b)BadgerCare Plus-related persons. In this subsection, "BadgerCare Plus-related" means a person who meets one of the following conditions:1. The person is pregnant and meets the conditions specified in s. 49.471 (4) (a)1, 1g., or 1m., Stats.2. The person is a child under age 19 who meets the conditions specified in s. 49.471 (4) (a)3, 3g., 3m. or 7., Stats., and under par. (f).2m. The person is an unborn child as defined in s. 49.471 (1) (k), Stats., and meets the conditions under par. (f).3. The person is a caretaker relative or a caretaker relative's spouse if the spouse resides with the caretaker relative's child who meets the conditions specified in s. 49.471 (4) (a) 4 or 7., Stats.4. The person is a foster child under 19 years of age living in a foster home licensed under s. 48.62, Stats., or a group home licensed under s. 48.625, Stats., is a child under the care of a subsidized guardianship under s. 48.623, Stats., or is a child in an adoption assistance placement under s. 48.975, Stats.5. The person is a former foster care recipient and meets the conditions specified under s. 49.471 (4) (a)5, Stats.6. The person meets the conditions to receive family planning services under s. 49.45 (24s), Stats.7. The person is diagnosed with tuberculosis and meets the conditions under s. 49.46 (1) (a)15., Stats.8. The person is at least 19, but under 21 years of age and resides in an intermediate care facility, skilled nursing facility, or inpatient psychiatric hospital and meets the conditions under s. 49.47 (4), Stats.(c)SSI-related persons. In this subsection, "SSI-related person" means a person who meets one of the following conditions: 1. The person is age 65 or over; or2. The person is blind or disabled.(d)Verification of blindness or disability. Except as provided under par. (e), the blindness or disability claimed under par. (c) 2. shall be verified in one of the following ways:1. By presentation of a current old age and survivors disability insurance (OASDI) disability award notice;2. By presentation of a current medicare card indicating blindness or disability; or3. By receipt of a disability determination made by the department's bureau of social security disability insurance, along with current medical reports.(e)Presumption of disability in an emergency.1. Under emergency circumstances, a person may be presumed disabled for purposes of demonstrating SSI-relatedness and be eligible for MA without the verification required under par. (d).2. When an emergency need for MA exists, the department shall make a preliminary disability determination within 7 days of the date a completed disability determination form is received.3. An emergency need for MA shall exist when the applicant is:a. A patient in a hospital;b. Seriously impaired and the attending physician states the applicant will be unable to work or return to normal functioning for at least 12 months;c. In need of long-term care and the nursing home will not admit the applicant until MA benefits are in effect; ord. Unable to return home from a nursing home unless in-home service or equipment is available and this cannot be obtained without MA benefits. Note: Copies of the disability determination form may be obtained from the county or tribal income maintenance agency.
(f)BadgerCare Plus eligibility. To be non-financially eligible for BadgerCare Plus, a person shall meet all of the following conditions: 1. The person meets one of the conditions in par. (b).2. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and does not have health insurance coverage that meets both of the following criteria:a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is provided under the state of Wisconsin employee health plan.b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person's residence.2m. The person is an unborn child and the unborn child's mother does not have health insurance coverage that covers services provided in a service area that is within a reasonable driving distance from the person's residence.3. Except as provided in subd. 5m., the person is a child age 1 through 5 with household income over 191% of the federal poverty line or age 6 through 18 with household income over 156% of the federal poverty line, and the person does not have access to coverage under a group health insurance plan that meets all of the following criteria: a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.b. The health insurance coverage would begin within 3 calendar months following the BadgerCare Plus application filing date, the BadgerCare Plus annual renewal month, or the start date of the employment through which the child can access the health insurance coverage.c. The employer of the person's parent, step-parent or other caretaker relative residing with the person, when the person is under 19 years of age.cm. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person's residence.d. The health insurance policy is through the child's employer, the employer of the child's spouse when the spouse is residing with the child, or the employer of the child's parent, step-parent or other caretaker relative residing with the child.3m. If the person is an unborn child, the unborn child's mother does not have access to coverage under a group health insurance plan that meets all of the following criteria: a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.b. The health insurance coverage would begin within 3 calendar months following the BadgerCare Plus application filing date, the BadgerCare Plus annual renewal month, or the start date of the employment through which the mother can access the health insurance coverage.c. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person's residence.d. The health insurance policy is through the mother's employer or the employer of the mother's spouse when the spouse is residing with the mother.e. When the mother is under 19 years old, the health insurance coverage is through the employer of the mother's parent, step-parent, or other caretaker relative residing with the mother.4. Except as provided in subd. 5. or 5m., if the person did not, at any time in the 12 months immediately preceding application for BadgerCare Plus, have access to employer-subsidized health care coverage or a state employee health plan and is any of the following:a. A child ages 1 through 5 with household income over 191% of the federal poverty level.b. A child ages 6 through 18 with household income over 156% of the federal poverty line.4g. The child under subd. 4. is ineligible for BadgerCare Plus the first day of the month that the employer's plan would have provided coverage for the child if the family had been enrolled in the plan. The child remains ineligible for each month that coverage would have been available up to 18 12 months from the month the failure to enroll in the plan occurred if the health insurance plan meets all of the following criteria: a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person's residence.c. The health insurance policy is through the child's employer, the employer of the child's spouse when the spouse is residing with the child, or the employer of the child's parent, step-parent or other caretaker relative residing with the child.4r. Except as provided in subd. 5., if the person is an unborn child, the unborn child's mother did not, at any time in the 12 months immediately preceding application for BadgerCare Plus, have access to employer-subsidized health care coverage, or a state employee's health plan. The unborn child is ineligible for BadgerCare Plus the first day of the month that the employer's plan would have provided coverage for the unborn child's mother if the family had been enrolled in the plan. The unborn child remains ineligible for each month that coverage would have been available up to 12 months from the month the failure to enroll in the plan occurred if the health insurance plan meets all of the following criteria:a. The health insurance coverage is provided by an employer that pays 80% of the premium or coverage is available under the state of Wisconsin employee health plan.b. The health insurance covers services provided in a service area that is within a reasonable driving distance from the person's residence.c. The health insurance policy is provided through the mother's employer, the employer of the mother's spouse when the spouse is residing with the mother, or the employer of the mother's parent, step-parent or other caretaker relative residing with the child, if the mother is under 19 years of age.5. The 12 month period in subds. 4. and 4m. does not apply if one of the following statements is true about access to employer-subsidized health care coverage: b. The person's employer discontinued health care coverage for all employees.c. A member or members of the family were eligible for other health insurance coverage or MA at the time the employee failed to enroll in the employer-subsidized health care coverage and no member of the group was eligible at that time for BadgerCare Plus with an assistance group income above 156% of the federal poverty line.e. Any other reason determined by the department to be a good cause reason.6. The person is not eligible for MA under BadgerCare Plus-related or SSI-related criteria in this chapter.7. A person required to pay a premium under s. DHS 103.085(1) has made the first payment.8. A person has not chosen to receive BadgerCare Plus-related or SSI-related MA through a spend-down, as described in s. DHS 103.08 (2) (a), or has chosen to end a spend-down period at any time prior to the date at which the expenditure or obligation of excess income has been achieved.(fm)Exemption from health insurance coverage requirements. A child is exempt from the health insurance coverage requirements in sub. (1) (f) 2., 3., and 4., if they meet any of the following criteria: 1. The child is younger than 19 years old, has met a deductible, and is in the deductible period.2. The child is in an extension.3. The person is age 18 and was in foster care, subsidized guardianship, or court-ordered kinship care on the date they turned 18 years old.4. The child is pregnant.(g)Medicaid purchase plan non-financial eligibility. To be non-financially eligible for the medicaid purchase plan a person shall meet the conditions described in par. (c) for SSI-related persons and shall be age 18 or older and the person shall meet any of the following conditions: 1.a. The person shall be employed.b. The person shall be enrolled in a department-certified health and employment counseling program.c. The health of the person participating in the medicaid purchase plan for at least 6 months shall have deteriorated to the point that he or she is unable to participate under subd. 1. a. or b. and the county agency has waived the requirement for a period up to 6 calendar months. The county agency may waive the requirement if the person is hospitalized, injured or suffers any other health setback. The county agency may waive the requirement as long as it had not granted a waiver of the requirement twice within the 36 months immediately preceding the current waiver request. The waiver periods shall be non-consecutive. The person shall supply proof of health difficulties. In addition to the discretion the county agency has to grant a waiver, the department may grant a temporary waiver of the work requirement upon a showing of good cause.2. The person meets SSI-related non-financial eligibility requirements under par. (c) as verified under par. (d) and s. 49.472 (3) (c), Stats.3. The applicant meets the eligibility requirements described in s. DHS 103.087.(h)Medicaid purchase plan health and employment counseling eligibility.1. 'Initial eligibility.' To be eligible for the health and employment counseling program within the medicaid purchase plan, a person shall complete an employment plan. a. The employment plan shall be reviewed by a screening agency and approved by the department before the person receives approval from the department as a participant.b. The screening agency shall refer the person to community resources as appropriate to meet all employment plan requirements. The screening agency may assist the person in completing the written employment plan or providing any other services required under the plan.c. A notice of participation status shall be sent by the department to the person, the screener and the appropriate county or tribal economic support office.2. 'Period of eligibility.' a. A person may participate in a health and employment counseling program for a period of up to nine consecutive calendar months and for any allowable periods of extension described under subd. 3.b. Upon completion of a period of eligibility, a person shall be ineligible for a health and employment counseling program for a period of 6 consecutive calendar months. Following the 6-month period, a person may begin a new period of eligibility, but a given person may only use 2 periods of eligibility within a period of 5 consecutive calendar years.c. Participation in a health and employment counseling program approved by the department meets the eligibility requirement in par. (g) 1. b.3. 'Extending eligibility.' a. If a person is not employed at the end of the period of eligibility, the person may request an extended period of eligibility from the department. The extended period of eligibility shall be valid for a period of three consecutive calendar months.b. The extended period of eligibility shall be approved by the department.c. The person may not request more than one extension of eligibility per period of eligibility.d. After participation in a health and employment counseling [program] ends, a person may continue to receive services from an agency that also provides screening services, in accordance with the agency's rules.4. 'Retroactive eligibility.' a. A person may request retroactive participation in a health and employment counseling program for a period of up to three months if the person demonstrates he or she met all eligibility requirements of the employment plan during those months.b. Any retroactive months of eligibility requested by the person shall count toward the period of eligibility as described in this paragraph.c. The department shall approve requested months of retroactive eligibility.(2) CITIZENSHIP. U.S. citizenship shall be a requirement for eligibility for MA, except that the following persons who are not U.S. citizens may also be eligible for MA:(a) A U.S. National from American Samoa or Swains Island.(b) A citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau who meets all of the following requirements:1. Has declared, or someone legally responsible for the individual has declared, that the individual has a satisfactory immigration status.2. Has provided satisfactory documentary evidence of their status.3. Has their status verified with the U.S. Department of Homeland Security.4. Is lawfully residing in the U.S.(c) A qualified non-citizen as described in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 USC 1641, who meets all of the following requirements:1. Has declared, or someone legally responsible for the individual has declared, that the individual has a satisfactory immigration status.2. Has provided satisfactory documentary evidence of a qualified non-citizen status.3. Has their qualified non-citizen status verified with the U.S. Department of Homeland Security.4. If subject to the 5-year bar under 8 USC 1613, has been in the United States for 5 years with a qualified non-citizen status.(d) A child under age 19, a pregnant woman or an individual under age 21 residing in an institution for mental disease who is a noncitizen lawfully residing in the U.S. as allowed under 42 USC 1396b (v) (4), who meets all of the following requirements: 1. Has declared, or someone legally responsible for the individual has declared, that the individual has a satisfactory immigration status.2. Has provided satisfactory documentary evidence of lawfully residing in the U.S.3. Has their lawful residence status verified with the U.S. Department of Homeland Security.(2m) LIMITATION ON MEDICAL ASSISTANCE FOR NONCITIZENS. A noncitizen who does not meet the conditions in sub. (2) (a), (b), (c), or (d) may not receive medical assistance benefits except as provided under s. 49.45 (27), Stats.(3) WISCONSIN RESIDENCE. (a)Definitions. In this subsection:1. "Incapable of indicating intent" means:a. The individual's IQ is 49 or less, or the individual has a mental age of 7 or less, based on tests acceptable to the department;b. The individual is found legally incompetent under guardianship statutes; orc. Medical documentation or other documentation acceptable to the department supports a finding that the individual is incapable of indicating intent.2. "Intent to reside" means that a person intends that Wisconsin is the person's place of residence and that the person intends to maintain the residence indefinitely.3. "Physical presence" means living in Wisconsin.(b)Physical presence and intention. An eligible person shall be a Wisconsin resident, as determined under 42 CFR 435.403. Residence shall be based on physical presence, except as provided in an interstate agreement, and on the person's intent to maintain Wisconsin residence indefinitely, except as otherwise provided in pars. (c) to (g).(c)Migrant farm workers. A migrant farm worker who is living in Wisconsin and who entered with a job commitment or to seek employment shall be considered a resident so long as there is no medical assistance being received from another state. In this paragraph, "migrant farm worker" means any person whose primary employment in Wisconsin is in the agricultural field or cannery work, is authorized to work in the United States, who is not immediate family by blood or marriage of the employer, and routinely leaves an established place of residence to travel to another locality to accept seasonal or temporary employment. Members of the migrant farm worker's family who live with the worker in Wisconsin shall also be considered Wisconsin residents.(d)Non-institutionalized persons. The residence of a person under age 21 shall be determined in accordance with the rules governing residence under the AFDC program except that non-institutionalized persons under age 21 whose MA eligibility is based on blindness or disability are residents if they are physically present in Wisconsin.(e)Institutionalized persons.1. For any institutionalized person who is under age 21, or who is age 21 or older and became incapable of indicating intent before age 21, the state of residence is that of: a. The parents or the legal guardian, if one has been appointed, and parental rights have terminated at the time of placement in an institution; orb. The parent applying for MA on behalf of the applicant if the parent resides in another state and there is no appointed legal guardian.2. Institutionalized persons over age 21 are Wisconsin residents when they are physically present with the intent to reside in Wisconsin except that persons who become incapable of indicating intent at or after age 21 are residents of the state in which they are physically present.(f)Out-of-state institutional placements. When a state arranges for a person to be placed in an institution located in another state, the state making the placement is the state of residence irrespective of the person's indicated intent or ability to indicate intent.(g)Establishment of residence. Once established, residence is retained until superseded by a new place of residence.(4) FURNISHING OF A SOCIAL SECURITY NUMBER. (a) All individuals for whom MA benefits are requested shall have a social security number and shall furnish the number to the agency, except an individual who is one of the following: 1. An alien who is requesting medical assistance only for emergency services.2. A child who is eligible for medical assistance under 42 USC 1396a (e) (4). During the time that the child is eligible under 42 USC 1396a (e) (4), the agency shall use the mother's MA identification number.3. An individual who is not eligible to receive a social security number.4. An individual who does not have a social security number and may only be issued a social security number for a valid non-work reason in accordance with 20 CFR 422.104.5. An individual who refuses to obtain a social security number because of well-established religious objections as provided in s. 49.82 (2) (b)3, Stats.(b) If an applicant who is required to furnish a social security number under par. (a) does not have a social security number, application for the number shall be made by or on behalf of the applicant to the federal social security administration. If there is a refusal to furnish a number or apply for a number, the person for whom there is a refusal is not eligible for MA. The department may not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's social security number.(5) ASSIGNMENT OF MEDICAL SUPPORT. The parent or caretaker relative of a dependent child enumerated in s. 49.19 (1) (a), Stats., shall be deemed to have assigned all rights to medical support to the state as provided in s. 49.45 (19) (a), Stats. If there is a refusal to make the assignment, the person who refuses is not eligible for MA.(6) NOT A PERSON DETAINED BY LEGAL PROCESS. A person detained by legal process is not eligible for MA benefits. For purposes of this subsection, "detained by legal process" means incarcerated because of law violation or alleged law violation, which includes misdemeanors, felonies, and delinquent acts. A person who returns to the court after observation, is found not guilty of a law violation by reason of mental deficiency and is subsequently committed to a mental institution shall not be considered detained by legal process.(7) NOT A PERSON RESIDING IN AN INSTITUTION FOR MENTAL DISEASES. A person 21 to 64 years of age who resides in an institution for mental diseases (IMD) is not eligible for MA benefits, unless the person is 21 years of age, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident of the IMD since then. An IMD resident 21 to 64 years of age may be eligible for MA benefits while on convalescent leave from the IMD.(8) NOT AN INELIGIBLE CARETAKER RELATIVE. A caretaker relative enumerated in s. 49.19 (1) (a), Stats., with whom a dependent child as defined in s. 49.19 (1) (a), Stats., is living when the income and resources of the MA group or fiscal test group exceed the limitations of ss. 49.19 and 49.77, Stats., or title XVI of the social security act of 1935, as amended, is not eligible unless the caretaker relative is SSI-related in accordance with sub. (1) (c), or is a woman who is medically verified to be pregnant.(9) NOT A STRIKER. A person on strike is not eligible. When the striker is a caretaker relative, all members of the MA group who are 18 years of age or older shall be ineligible except that if the member of the MA group who is on strike is medically verified pregnant or, if the MA group includes a medically verified pregnant woman, the pregnant woman continues to be eligible during her pregnancy and through the month in which the 60th day following the end of pregnancy falls. In this subsection, "striker" means anyone who on the last day of the month is involved in a strike or a concerted effort with other employees to stop work, including a stoppage of work due to the expiration of a collective bargaining agreement, or any concerted slowdown or other concerted interruption of operations by employees.Wis. Admin. Code Department of Health Services DHS 103.03
Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (b) 1., Register, February, 1988, No. 386, eff. 3-1-88; emerg. r. and recr. (7), eff. 8-1-88; r. and recr. (7), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (7), eff. 6-1-89; am. (7), Register, February, 1990, No. 410, eff. 3-1-90; am. (1) (b) 1., 2. and 4, (2), (3) (b) and (9), r. and recr. (4), Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (1) (a) and (b) 3., eff. 7-1-99; am. (1) (a) and (b) 3. and cr. (1) (f), Register, March, 2000, No. 531, eff. 4-1-00; cr. (1) (g) and (h), Register, November, 2000, No. 539, eff. 12-1-00; correction in (1) (b) 1. made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.Amended by, CR 21-067: am. (intro.), cr. (1) (g) 4., (h) 5. Register March 2022 No. 795, eff. 4-1-22, am. (intro.), r. (1) (g) 4., (h) 5. eff. the first day of the month after the emergency period, as defined in 42 USC 1320b-5(g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (intro.) made under s. 35.17, Stats., and correction in (1) (g) 4., (h) 5. made under ss. 13.92(4) (b) 4, 35.17, Stats., Register March 2022 No. 795, eff. 4/1/2022Amended by, CR 23-046: am. (1) (title), (a), (b) (title), (intro.), 1., 2., cr. (1) (b) 2m., am. (1) (b) 3., 4., cr. (1) (b) 5. to 8, am. (1) (f) (title), (intro.), 1., r. and recr. (1) (f) 2., cr. (1) (f) 2m., am. (1) (f) 3. (intro.), r. and recr. (1) (f) 3. a., b., cr. (1) (f) 3. cm., d., 3m., r. and recr. (1) (f) 4., cr. (1) (f) 4g., 4r., am. (1) (f) 5. (intro.), c., r. (1) (f) 5. d., am. (1) (f) 6., 8., cr. (1) (fm), renum. (2) to (2) (intro.) and am., cr. (2) (a) to (e), (2m), am. (4) (a) 1., 2., cr. (4) (a) 3. to 5., am. (4) (b) Register April 2024 No. 820, eff. 5-1-24; correction in (1) (b) 1., (f) 5. made under s. 35.17, Stats., and correction in numbering of (1) (f) cm. and (fm) 1. to 4. made under s. 13.92 (4) (b) 7Register April 29 No. 820, eff. 5/1/2024