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• Applicants who have access to coverage under family health insurance subsidized by an employer at 80% or more of the premium cost will not be eligible for BadgerCare Plus. • Applicants who were covered during the six months prior to application under employer family health insurance plans meeting HIPPA standards for family coverage will be ineligible for BadgerCare Plus. However, exceptions will be made where prior coverage ended due to reasons unrelated to the availability of BadgerCare Plus. These reasons include, but are not limited to:

 Loss of employment due to factors other than voluntary termination;  Change to a new employer that does not offer family coverage;  Change of address so that the individual is now outside the employer- sponsored insurance plan’s service territory;  Discontinuation of health benefits to all employees by the applicant’s employer; and  Expiration of COBRA coverage period.

• The Department intends to purchase family coverage made available by the employer of members of an eligible family when the employer’s contribution is greater than 40% but less than 80%. This will only occur when the Department determines that purchasing the employer coverage would be more cost-effective than providing the coverage directly under BadgerCare Plus. The cost effectiveness will compare the cost to the State to buy in to the employer's plan versus the cost to directly provide coverage to the recipient. • The Wisconsin Medicaid fiscal agent will notify the applicant, employer, insurance company, if necessary and the involved certifying agency of the cost-effectiveness decision and terms of the agreement. • The Wisconsin Medicaid fiscal agent will establish a communication protocol with each employer regarding notification of the applicant’s employment, coverage levels and premium amounts. • The Wisconsin Medicaid fiscal agent will monitor employers’ health insurance plans for open enrollment periods and will conduct an employer telephone inquiry to obtain the necessary cost-effectiveness information to facilitate insurance buy-in when available. • The Wisconsin Medicaid fiscal agent will gather information regarding the applicant’s access to and/or participation in the employer’s health insurance plan beyond the previous six-month period for informational purposes only. EDS and Department staff will monitor this information for crowd-out impact.

WISCONSIN

Effective Date:

Approval Date: 57