Section 252.16. Health insurance premium subsidies.

 

(1)   Definitions. In this section:

(ar) “Dependent" means a spouse or domestic partner under ch. 770 , an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

(b) “Group health plan" means an insurance policy or a partially or wholly uninsured plan or program, that provides hospital, medical or other health coverage to members of a group, whether or not dependents of the members are also covered. The term includes a medicare supplement policy, as defined in s. 600.03 (28r) , but does not include a medicare replacement policy, as defined in s. 600.03 (28p) , or a long-term care insurance policy, as defined in s. 600.03 (28g) .

(c) “Individual health policy" means an insurance policy or a partially or wholly uninsured plan or program, that provides hospital, medical or other health coverage to an individual on an individual basis and not as a member of a group, whether or not dependents of the individual are also covered. The term includes a medicare supplement policy, as defined in s. 600.03 (28r) , but does not include a medicare replacement policy, as defined in s. 600.03 (28p) , or a long-term care insurance policy, as defined in s. 600.03 (28g) .

(d) “Medicare" means coverage under part A, part B, or part D of Title XVIII of the federal Social Security Act, 42 USC 1395 to 1395hhh .

(e) “Residence" means the concurrence of physical presence with intent to remain in a place of fixed habitation. Physical presence is prima facie evidence of intent to remain.

(2)   Subsidy program. From the appropriation account under s. 20.435 (1) (am) , the department shall distribute funding in each fiscal year to subsidize the premium costs under s. 252.17 (2) and, under this subsection, the premium costs for health insurance coverage available to an individual who has HIV infection and who is unable to continue his or her employment or must reduce his or her hours because of an illness or medical condition arising from or related to HIV infection.

(3)   Eligibility. An individual is eligible to receive a subsidy in an amount determined under sub. (4) , if the department determines that the individual meets all of the following criteria:

(a) Has residence in this state.

(b) Has a family income, as defined by rule under sub. (6) , that does not exceed 300 percent of the federal poverty line, as defined under 42 USC 9902 (2), for a family the size of the individual's family.

(c) Has submitted to the department a certification from a physician, as defined in s. 448.01 (5) , physician assistant, or advanced practice nurse prescriber of all of the following:

1. That the individual has an infection that is an HIV infection.

2. That the individual's employment has terminated or his or her hours have been reduced, because of an illness or medical condition arising from or related to the individual's HIV infection.

(dm) Has, or is eligible for, health insurance coverage under a group health plan or an individual health policy.

(e) Authorizes the department, in writing, to do all of the following:

1. Contact the individual's employer or former employer or health insurer to verify the individual's eligibility for coverage under the group health plan or individual health policy and the premium and any other conditions of coverage, to make premium payments as provided in sub. (4) and for other purposes related to the administration of this section.

1m. Contact the individual's employer or former employer to verify that the individual's employment has been terminated or that his or her hours have been reduced and for other purposes related to the administration of this section.

2. Make any necessary disclosure to the individual's employer or former employer or health insurer regarding the individual's HIV status.

(4)   Amount and period of subsidy.

(a) Except as provided in pars. (b) and (d) , if an individual satisfies sub. (3) , the department shall pay the full amount of each premium payment for the individual's health insurance coverage under the group health plan or individual health policy under sub. (3) (dm) , on or after the date on which the individual becomes eligible for a subsidy under sub. (3) . Except as provided in pars. (b) and (d) , the department shall pay the full amount of each premium payment regardless of whether the individual's health insurance coverage under sub. (3) (dm) includes coverage of the individual's dependents. Except as provided in par. (b) , the department shall terminate the payments under this section when the individual's health insurance coverage ceases or when the individual no longer satisfies sub. (3) , whichever occurs first. The department may not make payments under this section for premiums for medicare, except for premiums for coverage for part D of Title XVIII of the federal Social Security Act, 42 USC 1395 to 1395hhh .

(b) The obligation of the department to make payments under this section is subject to the availability of funds in the appropriation account under s. 20.435 (1) (am) .

(d) For an individual who satisfies sub. (3) and who has a family income, as defined by rule under sub. (6) (a) , that exceeds 200 percent but does not exceed 300 percent of the federal poverty line, as defined under 42 USC 9902 (2), for a family the size of the individual's family, the department shall pay a portion of the amount of each premium payment for the individual's health insurance coverage. The portion that the department pays shall be determined according to a schedule established by the department by rule under sub. (6) (c) . The department shall pay the portion of the premium determined according to the schedule regardless of whether the individual's health insurance coverage under sub. (3) (dm) includes coverage of the individual's dependents.

(5)   Application process. The department may establish, by rule, a procedure under which an individual who does not satisfy sub. (3) (b) , (c) 2. or (dm) may submit to the department an application for a premium subsidy under this section that the department shall hold until the individual satisfies each requirement of sub. (3) , if the department determines that the procedure will assist the department to make premium payments in a timely manner once the individual satisfies each requirement of sub. (3) . If an application is submitted by an employed individual under a procedure established by rule under this subsection, the department may not contact the individual's employer or health insurer unless the individual authorizes the department, in writing, to make that contact and to make any necessary disclosure to the individual's employer or health insurer regarding the individual's HIV status.

(6)   Rules. The department shall promulgate rules that do all of the following:

(a) Define family income for purposes of sub. (3) (b) .

(b) Establish a procedure for making payments under this section that ensures that the payments are actually used to pay premiums for health insurance coverage available to individuals who satisfy sub. (3) .

(c) Establish a premium contribution schedule for individuals who have a family income, as defined by rule under par. (a) , that exceeds 200 percent but does not exceed 300 percent of the federal poverty line, as defined under 42 USC 9902 (2), for a family the size of the individual's family. In establishing the schedule under this paragraph, the department shall take into consideration both income level and family size.

1989 a. 336 ; 1991 a. 269 ; 1993 a. 16 ss. 2587 , 2588 ; 1993 a. 27 ss. 386 to 389 ; Stats. 1993 s. 252.16; 1993 a. 491 ; 1995 a. 27 ; 1997 a. 27 ; 2001 a. 38 ; 2005 a. 187 ; 2007 a. 20 ; 2009 a. 28 ; 2011 a. 161 . Cross-reference: See also ch. DHS 138 , Wis. adm. code.