Section DHS 109.15 - Treatment of spousesNotwithstanding ss. DHS 109.13 and 109.14, when the spouse of a SeniorCare participant files an application or review of eligibility for SeniorCare under s. DHS 109.14(7), or requests a new benefit period, and is required under s. DHS 109.12(1) to be in the same fiscal test group as the participant, the eligibility of the spouse for benefits and services under s. DHS 109.13 and the duration of the spouse's benefit period shall be determined in the following manner, unless both the participant and the participant's spouse jointly file a request for a new benefit period under s. DHS 109.14:
(1) The department shall determine the eligibility of the spouse under s. DHS 109.11, and, if eligible for SeniorCare, determine the beginning eligibility date of the spouse's benefit period according to s. DHS 109.14.(2) If the department under sub. (1) determines the spouse is eligible for SeniorCare the spouse's benefit period shall end on the same date as the participant's benefit period ends. (3) If the department determines the spouse is ineligible for SeniorCare, the benefits and services that the participant spouse may receive during the participant's current benefit period may not be affected.(4) If the income of the spouse was not used to determine the SeniorCare benefit for the participant spouse, both of the following apply: (a) The department shall determine the annual income for the fiscal test group for the 12-month period beginning with the month the application request for the spouse is received.(b) The benefit and services under s. DHS 109.13 that the spouse may receive shall be determined as follows: 1. 'Annual income exceeds 240% of poverty line.' a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, the spouse may receive spend-down services under s. DHS 109.13(4) (a) 2.b. When determining whether the spouse meets the SeniorCare spend-down under s. DHS 109.13(4) (c), the amount of the SeniorCare spend-down shall be prorated. The prorated amount shall be the annual spend-down amount under s. DHS 109.13(4) (b) multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12. Only prescription drug costs of the spouse may count towards meeting the prorated spend-down. c. If the spouse meets the prorated spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13(3) (b). When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13(3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12. d. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13(2) (b).2. `Annual income between 160-240% of poverty line.' a. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13(3) (b).b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13(3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13(3) (c) multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12. c. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13(2) (b).3. `Annual income less than 160% of poverty line.' a. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13(2).(5) If the income of the spouse was used to determine the SeniorCare benefit for the participant, the department shall determine the benefit as follows: (a)Annual income exceeds 240% of poverty line. 1. `Participant has not met spend-down.' If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, and the participant has not met the spend-down by the date the spouse becomes eligible for SeniorCare, the spouse may receive spend-down services under s. DHS 109.13(4).2. `Participant has met spend-down.' a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family and the participant met the spend-down before the spouse becomes eligible for SeniorCare, or the participant and spouse meet the spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13(3).b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13(3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13(2) (b).(b)Annual income between 160-240% of poverty line. 1. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13(3).2. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13(3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13(3) (c) multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13(2) (b).(c)Annual income less than 160% of poverty line. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13(2).Wis. Admin. Code Department of Health Services DHS 109.15
CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (4) (b) 1. c. and 2. b. and (5) (a) 2. b. and (b) 2. Register October 2004 No. 586, eff. 11-1-04.