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) and to the extent approved by the federal government shall exclude medical and remedial expenditures and long-term care costs in excess of $500 per month that would be incurred by the individual in absence of coverage under the medical assistance purchase plan or a Medicaid long-term care program.
(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), assets accumulated in an independence account, and, to the extent approved by the federal government, assets from retirement benefits accumulated from income or employer contributions while employed and receiving medical assistance under this section or state-funded benefits under s. 46.27, 2017 stats. 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 under sub. (4) (am) and, if applicable and to the extent approved by the federal government, premium payments calculated by the department in accordance with sub. (4) (bm), unless the individual is exempted from premium payments under sub. (4) (dm).
(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. To the extent approved by the federal government, an individual shall prove gainful employment and earned income to the department by providing wage income or prove in-kind work income by federal tax filing documentation. To qualify as gainful income, the amount of in-kind income shall be equal to or greater than the minimum amount for which federal income tax reporting is required.
(h) The individual meets all other requirements established by the department by rule.
(4) Premiums.
(am) To the extent approved by the federal government and except as provided in pars. (dm) and (em), an individual who receives medical assistance under this section shall pay a monthly premium of $25 to the department.
(bm) To the extent approved by the federal government, in addition to the $25 monthly premium under par. (am), an individual who receives medical assistance under this section and whose individual income exceeds 100 percent of the poverty line for a single-person household shall pay 3 percent of his or her adjusted earned and unearned monthly income under par. (cm) that is in excess of 100 percent of the poverty line.
(cm) For the purposes of par. (bm), an individual's adjusted earned and unearned monthly income is calculated by subtracting from the individual's earned and unearned monthly income his or her actual out-of-pocket medical and remedial expenses, long-term care costs, and impairment-related work expenses.
(dm) The department shall temporarily waive an individual's monthly premium under par. (am) and, if applicable, par. (bm) when the department determines that paying the premium would be an undue hardship on the individual.
(em) If the department determines that a state plan amendment or waiver of federal Medicaid law is necessary to implement the premium methodology under this subsection and changes to the income and asset eligibility under sub. (3) and s. 49.47 (4) (c) 1., the department shall submit a state plan amendment or waiver request to the federal department of health and human services requesting those changes. If a state plan amendment or waiver is not necessary or if the federal department of health and human services does not disapprove the state plan amendment or waiver request, the department may implement subs. (3) and (4) and s. 49.47 (4) (c) 1. with any adjustments from the federal department of health and human services. If the federal department of health and human services disapproves the state plan amendment or waiver request in whole or in part, the department may implement the income and asset eligibility requirements and premium methodology under subs. (3) and (4), 2015 stats., and s. 49.47 (4) (c) 1., 2015 stats.
(6) Insured persons.
(a) Notwithstanding sub. (4), 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.
History: 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; 2017 a. 59; 2019 a. 9.