Section 49.472. Medical assistance purchase plan.

 

(1)   Definitions. In this section:

(a) “Earned income" has the meaning given in 42 USC 1382a (a) (1).

(am) “Family" means an individual, the individual's spouse and any dependent child, as defined in s. 49.141 (1) (c) , of the individual.

(b) “Health insurance" means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.

(c) “Independence account" means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which an individual began receiving medical assistance under this section.

(d) “Medical assistance purchase plan" means medical assistance, eligibility for which is determined under this section.

(e) “Unearned income" has the meaning given in 42 USC 1382a (a) (2).

(2)   Waivers and amendments. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.

(3)   Eligibility. Except as provided in sub. (6) (a) , an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:

(a) The individual's family's net income is less than 250 percent of the poverty line for a family the size of the individual's family. In calculating the net income, the department shall apply all of the exclusions specified under 42 USC 1382a (b).

(b) The individual's assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under 42 USC 1382b (a) or assets accumulated in an independence account. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.

(c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under 42 USC 1396d (q) (2) (B) and (D).

(e) The individual is legally able to work in all employment settings without a permit under s. 103.70 .

(f) The individual maintains premium payments calculated by the department in accordance with sub. (4) , unless the individual is exempted from premium payments under sub. (4) (b) or (5) .

(g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals.

(h) The individual meets all other requirements established by the department by rule.

(4)   Premiums.

(a) Except as provided in par. (b) and sub. (5) , an individual who is eligible for medical assistance under sub. (3) and receives medical assistance shall pay a monthly premium to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:

1. The premium for any individual may not exceed the sum of the following:

a. Three and one-half percent of the individual's earned income after the disregards specified in subd. 2m.

b. One hundred percent of the individual's unearned income after the deductions specified in subd. 2.

2. In determining an individual's unearned income under subd. 1. , the department shall disregard all of the following:

a. A maintenance allowance established by the department by rule. The maintenance allowance may not be less than the sum of $20, the federal supplemental security income payment level determined under 42 USC 1382 (b) and the state supplemental payment determined under s. 49.77 (2m) .

b. Medical and remedial expenses and impairment-related work expenses.

2m. If the disregards under subd. 2. exceed the unearned income against which they are applied, the department shall disregard the remainder in calculating the individual's earned income.

3. The department may reduce the premium by 25 percent for an individual who is covered by private health insurance.

(b) The department may waive monthly premiums that are calculated to be below $10 per month. The department may not assess a monthly premium for any individual whose income level, after adding the individual's earned income and unearned income, is below 150 percent of the poverty line.

(5)   Community options participants. From the appropriation under s. 20.435 (4) (bd) , the department may pay all or a portion of the monthly premium calculated under sub. (4) (a) for an individual who is a participant in the community options program under s. 46.27 (11) .

(6)   Insured persons.

(a) Notwithstanding sub. (4) (a) 3. , from the appropriation accounts under s. 20.435 (4) (b) , (gm) , or (w) , the department shall, on the part of an individual who is eligible for medical assistance under sub. (3) , pay premiums for or purchase individual coverage offered by the individual's employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.

(b) If federal financial participation is available, from the appropriation accounts under s. 20.435 (4) (b) , (gm) , or (w) , the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under sub. (3) .

(7)   Department duties. The department shall do all of the following:

(a) Determine eligibility, or contract with a county department, as defined in s. 49.45 (6c) (a) 3. , or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with sub. (3) .

(b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.

1999 a. 9 , 185 ; 2001 a. 16 ; 2003 a. 33 ; 2009 a. 2 ; 2011 a. 10 , 32 ; 2015 a. 55 ; 2015 a. 197 s. 51 . Cross-reference: See also chs. DHS 103 and 107 and s. DHS 103.087 , Wis. adm. code.