Section DHS 103.085 - Conditions for continuation of eligibility for BadgerCare Plus(1) PREMIUMS. (a)Authority. Subject to s. 49.471 (10) (b)2, Stats., and this section, a child under the age of 19 eligible for BadgerCare Plus may be required to pay a premium.(b)Applicability. 1. A child under age 19 eligible for BadgerCare Plus with budgetable income at or below 201% of the poverty line is not required to pay a premium toward the cost of the health care coverage.2. Except as provided in subd. 3., 4., or 5., a child under age 19 eligible for BadgerCare Plus with budgetable income above 201% of the poverty line shall pay a premium toward the cost of the health care coverage.3. A BadgerCare Plus applicant group does not owe a premium for the first month of BadgerCare Plus unless a member of the BadgerCare Plus fiscal test group was an MA recipient in the previous month.4. A BadgerCare Plus applicant group does not owe a premium for the first month of BadgerCare Plus unless a member of the BadgerCare Plus fiscal test group was a BadgerCare Plus recipient in the previous 12 months.5. A child under the age of 19 shall not be required to pay a premium if any of the following apply: a. The child is a Native American or an Alaskan Native.b. The child is under age 1.c. The child is pregnant.d. The child is eligible under s. 49.471 (4) (a)5, Stats.e. The child is eligible under s. 49.471 (4) (a)7, Stats.f. The child is eligible under s. 49.471 (7) (b)2, Stats.(c)Amounts. A child eligible for BadgerCare Plus required under this subsection to pay a premium shall pay the amount indicated in the schedule provided in Table 103.085, except as provided under par. (cm). Income for each child's BadgerCare Plus fiscal test group shall be determined according to s. DHS 103.07. Table 103.085 BadgerCare Premium Schedule |
Monthly Income as a Percentage of the Poverty Line | Monthly Premium |
From | To |
Above 201% | 210.99% | $ 10 |
211% | 220.99% | $ 10 |
221% | 230.99% | $ 10 |
231% | 240.99% | $ 15 |
241% | 250.99% | $ 23 |
251% | 260.99% | $ 34 |
261% | 270.99% | $ 44 |
271% | 280.99% | $ 55 |
281% | 290.99% | $ 68 |
291% | 300.99% | $ 82 |
301% | 306% | $ 97.53 |
(cm)Caps on premiums. Families must pay either the combined premiums for all of the children required to pay or an amount equal to five percent of the family's countable monthly income, whichever is less.(d)Payment. 1. All children otherwise eligible for BadgerCare Plus in a family who are required to pay a premium under this section shall pay the premium amount in full to the agency before the agency may certify the children's initial eligibility for BadgerCare Plus.2. Premiums are due by the 10th of the month prior to the month for which the premium is required.3. If no payment is received by the end of the month for which the premium is required, the department shall terminate the group's eligibility for BadgerCare, effective at the end of the month.4. The department shall allow a variety of premium payment methods. A group may choose one of the following methods for premium payment:b. Electronic funds transfer (EFT).c. Direct payment by check or money order.(e)Refunds. The department shall issue a refund for a premium which has been paid when the premium is for one of the following:2. A month that the child's budgetable income drops to or below 200% of the poverty line and the change in income that brought the child's budgetable income to or below 200% of the poverty line was reported within 10 days of the date the change occurred.3. A month which requires a lower premium amount due to a change in circumstances which was in effect for the entire month so long as the change was reported within 10 days of the date it occurred. In a case where the change was not reported within 10 days of the date it occurred, the effective date of the lower premium amount due is the first day of the month in which the change was reported.(f)Consequence of failure to pay BadgerCare premiums. A child required to pay a premium shall be ineligible for re-enrollment for the period specified in sub. (3) when the group fails to pay its premium within the time specified in par. (d).(3) RE-ENROLLMENT RESTRICTION. (a)Period of ineligibility. A BadgerCare Plus group that fails to make a premium payment under sub. (1) is not eligible for BadgerCare Plus for a period of at least 3 consecutive calendar months following the date that BadgerCare Plus eligibility ends, unless one of the circumstances in par. (b) applies. Eligibility is restored as described in par. (c). After 3 calendar months, the child shall be eligible for BadgerCare Plus if otherwise eligible.(b)Reasons restriction on re-enrollment may not apply. The restriction on re-enrollment under this section does not apply for any of the following reasons: 1. The failure to pay premiums was due to a circumstance beyond the group's control, provided that all past due premiums have been paid in full. A circumstance beyond the group's control includes any of the following:a. A problem with an electronic funds transfer from a bank account to the BadgerCare Plus program.b. A problem with an employer's wage withholding.c. An administrative error in processing the premium.d. A fair hearing decision.2. The child's income decreases to at or below 201% of the poverty line.3. Payment is received in full for all owed premiums before the end of the three-month restrictive re-enrollment period.4. Any other circumstance affecting payment of the premium which the department determines is beyond the group's control, but not including insufficient funds.(c)Resuming BadgerCare eligibility. Eligibility for BadgerCare shall resume in the following manner for persons with a re-enrollment restriction that ended due to a reason described in par. (b):1. For a child with a reason under par. (b) 1. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for any months that the group had been closed during the restriction period, provided that payment of any outstanding premiums owed is made and the child was otherwise eligible for BadgerCare Plus in those months.2. For a child with a reason under par. (b) 3. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for any calendar months that the child's BadgerCare Plus fiscal test group's income was at or below 201% of the poverty line and the child was otherwise eligible for BadgerCare Plus in those months.3. For a child with a reason under par. (b) 4. for the re-enrollment restriction not to apply, BadgerCare Plus eligibility shall be restored for all months that the child had been ineligible during the restriction period, provided that payment of any outstanding premiums owed is made and the child is otherwise eligible for BadgerCare Plus in those months.Wis. Admin. Code Department of Health Services DHS 103.085
Emerg. cr. eff. 7-1-99; cr. Register, March, 2000, No. 531, eff. 4-1-00; correction in (5) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.Amended by, CR 20-039: renum. (3) (b) (intro.) and 1. to (3) (b) (intro.) and am., r. (3) (b) 2., (6) Register October 2021 No. 790, eff. 11/1/2021Amended by, CR 23-046: am. (title), (1) (a), (b) 1. to 4., cr. (1) (b) 5., am. (1) (c), r. and recr. Table 103.085, cr. (1) (cm), am. (1) (d) 1., r. (1) (d) 5., am. (1) (e) (intro.), r. (1) (e) 1., am. (1) (e) 2., (f), r. (2), am. (3) (a), (b) (intro.), r. and recr. (3) (b) 1. to 3., am. (3) (c) 1., r. and recr. (3) (c) 2. cr. (3) (c) 3., r. (4), (5) Register April 2024 No. 820, eff. 5-1-24; correction in (1) (c) made under s. 35.17, Stats., Register April 29 No. 820, eff. 5/1/2024