BadgerCare Plus Gap Filling Eligibility Determinations Updates

Friday, February 16, 2018 | News Release |

This post announces changes to the notice of decision and policy clarifications regarding eligibility determinations for BadgerCare Plus under gap filling rules. 

Gap filling rules for health care apply when a person is not eligible for advance premium tax credits at the federal Health Insurance Marketplace and is also not eligible for BadgerCare Plus. Due to the difference in eligibility rules between the Marketplace, where eligibility is calculated based on expected annual income for the year, and BadgerCare Plus, where eligibility is calculated based on expected monthly income, applicants may fall into a “gap.” In these cases, eligibility for BadgerCare Plus has to be manually redetermined based on annual income. 

Under the changes to gap filling policy announced in July 2017, income maintenance agencies are assessing applicants under gap filling rules if it becomes apparent that the applicant is ineligible based on monthly income but may be eligible based on annual income. Individuals may also request that they receive a determination based on annual income regardless of whether they received a gap filling referral from the Marketplace or a denial letter from the Marketplace.

Changes to the Notice of Decision

Beginning on March 3, 2018, individuals who are found ineligible for BadgerCare Plus because their monthly income is above 100 percent of the federal poverty level (FPL) will get a new message on their notice telling them that they may request an eligibility determination based on their annual income. The dollar amount shown in the message is the annual income limit of 100% of the FPL for their household size. 

This is the message:

Your monthly income is over the program limit. See the part of this letter that shows how we counted your income. You could still get health care if your household’s annual income is under $XX,XXX. Call your agency to see if you are eligible based on annual income.

View an example notice with the message.

Anyone can still contact their agency to request a gap filling determination, even if they have not received this message on their notice. 

Backdated Eligibility

Under existing policy, individuals may request up to three months of BadgerCare Plus eligibility prior to their month of application; these are referred to as backdated months. As of February 16, 2018, we have clarified that individuals may qualify under gap filling rules for eligibility during backdated months. 


We have also clarified two issues related to BadgerCare Plus overpayments, that can occur when members fail to report changes in household circumstances and, as a result, must pay back benefits that they were not actually eligible for. 

In Operations Memo 17-35, we clarified that agencies must review potential eligibility under gap filling rules before establishing an overpayment based on a member having too much monthly income to qualify for BadgerCare Plus. 

We have clarified that this policy applies to overpayments for the month of February 2014 and later. A member who has an overpayment already established may request that the agency review the overpayment and see if they would have been eligible under gap filling rules. If the individual would have been eligible, the overpayment may be reversed and refunded as appropriate.

We have also clarified that going forward, agencies should not establish BadgerCare Plus overpayments based on income until they can confirm that both the monthly and annual income amounts for the member are over the respective 100% FPL thresholds.

If you have questions about gap filling, email DHS ForwardHealth Partners.  


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