State Codes and Statutes
Statutes > Wisconsin > 149 > 149.12149.12
149.12 Eligibility determination.149.12(1)
(1) Except as provided in subs. (1m), (2), and (3), the authority shall certify as eligible a person who is covered by Medicare because he or she is disabled under 42 USC 423, a person who submits evidence that he or she has a positive, validated HIV test result, as defined in s. 252.01 (8); a person who is an eligible individual; and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:149.12(1)(a)
(a) A notice of rejection of coverage from one or more insurers.149.12(1)(am)
(am) A notice of cancellation of coverage from one or more insurers.149.12(1)(b)
(b) A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.149.12(1)(c)
(c) A notice of increase in premium exceeding the premium then in effect for the insured person by 50% or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.149.12(1)(d)
(d) A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50% or more for the types of coverage provided by the plan.149.12(1m)
(1m) The authority may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.149.12(2)
(2)149.12(2)(b)
(b)149.12(2)(b)1.
1. Except as provided in subd. 2., no person who is covered under the plan and who voluntarily terminates the coverage under the plan is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.149.12(2)(b)2.
2. Subdivision 1. does not apply to any person who is an eligible individual or to any person who terminates coverage under the plan because he or she is eligible to receive medical assistance benefits.149.12(2)(c)
(c) No person on whose behalf the plan has paid out the lifetime limit under s. 149.14 (2) (a) or more is eligible for coverage under the plan.149.12(2)(d)
(d)149.12(2)(d)1.
1. Except as provided in subd. 2., no person who is 65 years of age or older is eligible for coverage under the plan.149.12(2)(d)2.
2. Subdivision 1. does not apply to any of the following:149.12(2)(d)2.a.
a. A person who is an eligible individual.149.12(2)(d)2.b.
b. A person who has coverage under the plan on the date on which he or she attains the age of 65 years.149.12(2)(e)
(e)149.12(2)(e)1.
1. Subject to subd. 2., no person who is eligible for creditable coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that is provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.149.12(2)(e)2.
2. The board may specify, subject to the approval of the commissioner, other types of coverage provided by an employer that do not render a person ineligible for coverage under the plan.149.12(2)(f)
(f)149.12(2)(f)1.
1. Except as provided in subd. 2., no person who is eligible for medical assistance is eligible for coverage under the plan.149.12(2)(f)2.
2. Subdivision 1. does not apply to a person who is otherwise eligible for coverage under the plan and who is eligible for only any of the following types of medical assistance:149.12(2)(f)2.a.
a. Family planning services under s. 49.45 (24r).149.12(2)(f)2.b.
b. Care and services for the treatment of an emergency medical condition under 42 USC 1396b (v), as provided in s. 49.45 (27).149.12(2)(f)2.c.
c. Medical assistance under s. 49.46 (1) (a) 15.149.12(2)(f)2.d.
d. Ambulatory prenatal care under s. 49.465.149.12(2)(f)2.e.
e. Medicare premium, coinsurance, and deductible payments under s. 49.46 (2) (c) 2. or 3., 49.468 (1) (b) or (c), or 49.47 (6) (a) 6. b. or c.149.12(2)(f)2.f.
f. Medicare premium payments under s. 49.46 (2) (cm), 49.468 (1m) or (2), or 49.47 (6) (a) 6m.149.12(2)(f)2.g.
g. Benefits under the demonstration project for childless adults under s. 49.45 (23).149.12(2)(f)2.h.
h. Benefits under BadgerCare Plus under s. 49.471 (11).149.12(2)(g)
(g) A person is not eligible for coverage under the plan if the person is eligible for any of the following:149.12(2)(g)1.
1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.149.12(2)(g)2.
2. Medical assistance provided as part of a family care benefit, as defined in s. 46.2805 (4).149.12(2)(g)3.
3. Services provided under the disabled children's long-term support program, as defined in s. 46.011 (1g).149.12(2)(g)4.
4. Services provided under the program of all-inclusive care for the elderly under s. 49.45 (58).149.12(2)(g)5.
5. Services provided under the demonstration program under a federal waiver authorized under 42 USC 1315.149.12(2)(g)6.
6. Health care coverage under the Badger Care health care program under s. 49.665.149.12(3)
(3)149.12(3)(a)
(a) Except as provided in pars. (b) to (c), no person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.149.12(3)(b)
(b) Persons for whom deductible or coinsurance amounts are paid or reimbursed under ch. 47 for vocational rehabilitation, under s. 49.68 for renal disease, under s. 49.685 (8) for hemophilia, under s. 49.683 for cystic fibrosis, under s. 253.05 for maternal and child health services or under s. 49.686 for the cost of drugs for the treatment of HIV infection or AIDS are not ineligible for coverage under the plan by reason of such payments or reimbursements.149.12(3)(bm)
(bm) Persons for whom premium costs for health insurance coverage are subsidized under s. 252.16 are not ineligible for coverage under the plan by reason of such payments.149.12(3)(c)
(c) Persons for whom premium costs for health insurance coverage and copayments for certain prescription drugs are paid under the pilot program under s. 49.686 (6) are not ineligible for coverage under the plan by reason of such payments.149.12(4)
(4) Subject to subs. (1m), (2), and (3), the authority may establish criteria that would enable additional persons to be eligible for coverage under the plan. The authority shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.149.12(5)
(5) The authority shall establish policies for determining and verifying the continued eligibility of an eligible person.149.12 - ANNOT.
History: 1979 c. 313; 1983 a. 27, 215; 1985 a. 29, 73; 1987 a. 27, 70, 239; 1989 a. 201 s. 36; 1989 a. 332, 359; 1991 a. 39, 250; 1993 a. 27; 1995 a. 27, 407; 1997 a. 27 ss. 3025f, 4826 to 4831e; Stats. 1997 s. 149.12; 1999 a. 9; 2005 a. 74; 2007 a. 20, 39, 141; 2009 a. 28, 83, 84, 209.