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4.4.4.1

Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Persons who are covered by employer health insurance plans that meet the Health Insurance Portability and Accountability Act (HIPAA) standards (and have not demonstrated good cause) will not be eligible for BadgerCare Plus. The eligibility worker will collect insurance information from the household to verify coverage and access. The HIPAA standard will be included in a question to the applicant family asking whether this is a major medical health insurance plan. EDS, Wisconsin Medicaid’s fiscal agent, will then verify coverage through the eligibility exchange system currently in use, and through written and phone contacts with employers. When previously unreported insurance coverage is discovered, EDS will inform the worker who will close BadgerCare Plus coverage.

Persons who have coverage under employer health insurance that meets HIPAA are ineligible for BadgerCare Plus, unless they are able to demonstrate good cause. Persons who have access to employer health insurance that meets HIPAA standards and for which the employer pays 80% or more of the cost are also ineligible for BadgerCare Plus. Persons who have access to employer health insurance that meets HIPAA standards and for which the employer pays at least 40 % but no more than 80% of the cost will be eligible for the health insurance premium purchase under BadgerCare Plus to assure that BadgerCare Plus does not substitute for private coverage.

4.4.4.2

Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. As part of the 2003-2005 Biennial Budget Act, Wisconsin implemented a mandatory employer verification of earnings and health insurance access/coverage at:

• Application for BadgerCare; • Annual Renewal of BadgerCare; • Upon entry into a new job; and, • When a family moved from Medicaid to BadgerCare.

The process involved sending a pre-printed form to recipients asking them to verify with their employer their earnings and their health insurance status. We required the employer to sign the form. When the form was returned, the

WISCONSIN

Effective Date:

Approval Date: 19