Section DHS 103.04 - Asset and income limits The nonexempt assets and budgetable income of the MA group or, when applicable, the fiscal test group, shall be compared to the following asset and income limits established in this section to determine the eligibility of the MA group:
(1) CATEGORICALLY NEEDY.(a) The MA group or fiscal test group shall first be tested against the categorically needy standard. Persons who meet the non-financial eligibility conditions and who meet the income and asset standards specified in this subsection shall be determined eligible as categorically needy in accordance with s. 49.46 (1) (e), Stats., and shall receive MA benefits in accordance with s. 49.46 (2), Stats., and chs. DHS 101 to 108.(b) The BadgerCare Plus-related categorically needy income standard for MA applicants shall be the appropriate standard as specified in s. DHS 103.03 (1) (a).(c) The SSI-related categorically needy income standard shall be the maximum SSI payment including state supplement that a single person or a couple, as appropriate, could receive in Wisconsin under s. 49.77, Stats., or federal title XVI of the social security act of 1935, as amended. The SSI-related categorically needy asset standard shall be the same as specified in section 1613 of title XVI of the social security act of 1935, as amended.(2) MEDICALLY NEEDY. If the MA group or fiscal test group is not eligible as categorically needy, the medically needy standard shall be applied. SSI-related persons who meet non-financial conditions for eligibility and meet the income and assets criteria set forth in s. 49.47 (4) (b) and (c), Stats., and this chapter shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 through 108.(3) EXCESS INCOME CASES. (a) In this subsection, "spend-down period" means the period during which excess income may be expended or obligations to expend excess income may be incurred for the purpose of obtaining BadgerCare Plus-related or SSI-related MA eligibility, as described under s. DHS 103.08(2) (a).(b) When an SSI-related fiscal test group is found ineligible as medically needy and excess income is the only reason, the group may expend or incur obligations to expend the excess income above the appropriate medically needy income limit pursuant to s. 49.47 (4) (c)2, Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.(bg) When a child is found ineligible for BadgerCare Plus-related MA solely under s. DHS 103.03 (1) (f), the BadgerCare Plus-related fiscal test group may expend or incur obligations to expend the excess income above the appropriate income limit pursuant to s. 49.471 (7) (b)2, Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.(br) When a pregnant woman is found ineligible for BadgerCare Plus-related MA solely under s. DHS 103.03 (1) (f), the BadgerCare Plus-related fiscal test group may expend or incur obligations to expend the excess income above the appropriate income limit pursuant to s. 49.471 (7) (b)1, Stats., and this chapter. If after incurred medical expenses are deducted, the remaining income is equal to or less than the income limit, the MA group shall be determined medically needy and shall receive MA benefits in accordance with s. 49.47 (6), Stats., and chs. DHS 101 to 108 for the balance of the spend-down period.(c) Health insurance premiums actually incurred or paid, plus any medical service recognized by state law received by a member of the MA or fiscal test group shall be counted toward fulfilling the excess income expenditure or incurrence requirement when the service is prescribed or provided by a medical practitioner who is licensed by Wisconsin or another state and if either or both of the following conditions are met: 1. The service is received during the spend-down period; or2. The expense was incurred prior to the spend-down period and a fiscal test group member is still legally responsible for the debt and is consistently making payments, in which case the payments made during the spend-down period shall be counted.(d) No medical costs that are incurred and are to be paid or have been paid by a person other than the applicant or members of the fiscal test group may be counted toward fulfilling the excess income expenditure or incurrence requirement. No expense for which a third party is liable, including but not limited to medicare, private health insurance, or a court-ordered medical support obligation, may be used to meet the expenditure of excess income requirement.(4) SPECIAL FINANCIAL STANDARDS FOR INSTITUTIONALIZED PERSONS. The categorically needy and medically needy asset standards shall be the same for institutionalized persons as for non-institutionalized persons, except that in determining initial eligibility under s. DHS 103.075 for an institutionalized individual with a community spouse the asset standard shall be the regular SSI-related MA group size one asset standard as provided under s. 49.47 (4) (b)3g, Stats., plus the community spouse resource allowance as provided under s. 49.455 (6) (b), Stats. The eligibility standards against which an institutionalized person's income is tested shall be the following:(a)Categorically needy standard. The categorically needy standard for an institutionalized person shall be an amount equal to 3 times the federal share of the SSI payment for one person living in that person's own home.(b)Medically needy standard. An institutionalized person shall be determined medically needy in accordance with requirements under 42 CFR 435.1007.(5) IRREGULAR CASES; MIXTURE OF BadgerCare PLUS AND SSI-RELATEDNESS. When there is a mixture in an MA group of BadgerCare Plus-relatedness and SSI-relatedness, each individual will be tested using the appropriate modified adjusted gross income rules under sub. (7) or SSI-related standards.(6) BadgerCare PLUS. (a) An individual who meets the requirements of s. DHS 103.03 (1) (f) and (2) to (9) and the income limits in this subsection is eligible for BadgerCare Plus.(b) For all children under age 19, pregnant women and individuals requesting only family planning services under s. 49.45 (24s), Stats., in BadgerCare Plus fiscal test groups, the income limit is 306% of the poverty line.(7) SPECIAL BadgerCare PLUS BUDGETING PROCEDURES. (a)MAGI budgeting rules. MAGI rules shall be used to determine eligibility for BadgerCare Plus. For eligibility determinations, all of the following apply: 1. MAGI rules in this section shall be used to determine financial eligibility for individuals who are BadgerCare Plus-related individuals under s. DHS 103.03 (1) (b), except for individuals under s. DHS 103.03 (1) (b) 4. and 5., and who are non-financially eligible for BadgerCare Plus under s. DHS 103.03(f).2. MAGI shall be determined by doing all of the following:a. Identifying the members of each individual's BadgerCare Plus fiscal test group per sub. (7) (b), and determining the group size.b. Adding the countable income per sub. (7) (d) of all members of the individual's BadgerCare Plus fiscal test group per sub. (7) (c).c. Comparing the total income of each individual's BadgerCare Plus fiscal test group to the federal poverty line for that group's size.(b)BadgerCare Plus fiscal test group. Persons are included in an individual's BadgerCare Plus fiscal test group based on whether the individual meets any of the following conditions:1. 'Tax rules.' If the individual expects to file a federal tax return and will not be claimed as a tax dependent of another person, the person's BadgerCare Plus fiscal test group shall consist of the tax filer, the tax filer's spouse, and any dependents the tax filer is claiming. All of the following rules apply to the BadgerCare Plus fiscal test group:a. If there is a pregnant woman in the group, the BadgerCare Plus fiscal test group shall include the number of expected babies.b. Whether the individual is a tax filer, a dependent of a tax filer, and who is a tax dependent of the individual is based on the individual's plans for the same calendar year's taxes in which eligibility is being determined.c. A tax filer may claim persons living outside their home as their tax dependents.d. A tax filer may claim a deceased child as a tax dependent in the tax year the child died.e. A tax filer may file jointly with a deceased spouse in the tax year the spouse died.f. A BadgerCare Plus fiscal test group shall include deployed military members who are spouses or tax dependents of the tax filer.g. A BadgerCare Plus fiscal test group shall include the individual's spouse if living with the individual, even if they are filing taxes separately.h. A BadgerCare Plus fiscal test group shall include the individual's spouse when they are living apart if they are filing taxes jointly.i. A BadgerCare Plus fiscal test group shall not include the individual's spouse, if they are living apart and are filing taxes separately or not planning to file taxes.j. A tax dependent's BadgerCare Plus fiscal test group shall include the same individuals as the tax filer's, even if the tax dependent is also a tax filer, except that a BadgerCare Plus fiscal test group will be based on par. (b) 2. if the person is under age 19, lives with one parent and is being claimed as a tax dependent by a parent outside of the home; the person is being claimed as a tax dependent by someone who is not their parent or spouse; or the person is under age 19, lives with both parents and the parents are not filing taxes jointly.2. 'Relationship rules.' If a person meets an exception in par. (b) 1. j. of this section or they are not tax filers or tax dependents, the person's BadgerCare Plus fiscal test group shall include of any of the following people living in the same home: a. If the person is under 19, the person's parents, spouse, siblings under age 19, and children.b. If the person is over age 19, the person's spouse and children under age 19.c. If there is a pregnant woman in the group, the number of expected infants.d. Deployed military members.3. 'Former foster care youth.' A former foster care youth's BadgerCare Plus fiscal test group shall only include the person, except that if the person's spouse is also a former foster care youth, the BadgerCare Plus fiscal test group shall include the spouse.4. 'Family planning services.' For family planning services, the BadgerCare Plus fiscal test group shall only include the one person.(c)Budgeting income for the BadgerCare Plus fiscal test group.1. The MAGI-based countable income defined in par. (d) of all persons in the BadgerCare Plus fiscal test group shall be included when determining eligibility except that the income of a child under age 19 or a tax dependent of a group member is only counted if the child or tax dependent is expected to be required to file a tax return for the current year.2. If a person's income is budgeted for the BadgerCare Plus fiscal test group, his or her deductions will be counted for that group.3. If a person is filing a joint tax return with his or her spouse, the person's deductions may offset the spouse's income even if the person has no income.(d)MAGI-based countable income. MAGI-based countable income means income calculated using the same financial methodologies used to determine MAGI, subject to any of the following exceptions: 1. MAGI-based countable income will include any Social Security benefits, tax-exempt Interest, and foreign earned income.2. Taxable lump sum payments are only counted in the month received.3. Educational scholarships, awards, or fellowships used for educational purposes are not counted, even if taxable.4. American Indian/Alaska Native specified income at 42 CFR 435.603 (e) (3) is not counted.(8) MEDICAID PURCHASE PLAN FINANCIAL ELIGIBILITY CRITERIA.(a) A person who meets the requirements of s. DHS 103.03 (1) (g) and (2) to (9) and the income and asset limits described in this subsection is eligible for the medicaid purchase plan.(b) The person's total net family income is less than 250% of the federal poverty line as determined by the person's family size. Net income is calculated using the standard SSI disregards and exemptions. The income disregards are the following: 1. Sixty-five dollars and one-half of the family's remaining earned income. If the family does not have any unearned income, $85 and one-half of the family's remaining earned income.2. Twenty dollars of any unearned income.3. Impairment-related work expenses.4. Medical and remedial expenditures and long-term care costs in excess of $500 per month incurred by the individual or, if the individual and spouse are living together, the spouse.(c) The person has non-exempt assets less than the asset limit described under s. 49.472 (3) (b), Stats.(d) If the person leaves the medicaid purchase plan and subsequently re-enrolls in the program, the person's independence account and any interest, gains, or dividends from that account are disregarded for purposes of subsequent eligibility determinations.(9) SPECIAL MEDICAID PURCHASE PLAN BUDGETING PROCEDURES. (a)Medicaid purchase plan group. Any of the following persons who reside in the home with the applicant or recipient shall be included in determining the family size of the person applying for the medicaid purchase plan, with this family size used in calculating the person's financial eligibility under this section: 2. The applicant's spouse.3. Any dependent child of the applicant as described in s. 49.141, Stats.(b)Medicaid purchase plan fiscal test group. The income of any person listed in par. (a) 1. or 2. shall be included when determining financial eligibility of the applicant.(c)Medicaid purchase plan coverage. 1. Medical assistance under the medicaid purchase plan applies to the applicant or recipient only.2. The monthly premium for the medicaid purchase plan is calculated using only the income of the applicant or recipient.Wis. Admin. Code Department of Health Services DHS 103.04
Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (4) (intro.), Register, March, 1993, No. 447, eff. 4-1-93; correction in (1) (a) made under s. 13.93(2m) (b) 7, Stats., Register, April, 1999, No. 520; emerg. am. (3) (a), eff. 7-1-99; am. (3) (a) and cr. (6) and (7), Register, March, 2000, No. 531, eff. 4-1-00; cr. (8) and (9), Register, November, 2000, No. 539, eff. 12-1-00; corrections in (1) (b), (2), (3) (b) and (5) (e) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.Amended by, correction in (3) (b) made under s. 13.92(4) (b) 7, Stats., Register July 2015 No. 715, eff.8/1/2015.Amended by, correction in (1) (b) made under s. 13.92(4) (b) 7, Stats., Register January 2021 No. 781, eff. 2/1/2021Amended by, CR 20-039: am. (7) (d) Register October 2021 No. 790, eff. 11/1/2021Amended by, CR 23-046: am. (1) (b), (2), (3) (a), (b), cr. (3) (bg), (br), renum. (5) (a) to (5) and am., r. (5) (b) to (e), am. (6) (title), (a), (b), r. and recr. (7), cr. (8) (b) 4. Register April 2024 No. 820, eff. 5-1-24; correction in (5) (title) made under s. 13.92 (4) (b) 2, Stats., and correction in (7) (b) (intro.), 1. j., 2., (c) 1., made under s. 35.17, Stats., Register April 29 No. 820, eff. 5/1/2024