BCS 216832 (04/07/2025)
Termination for no renewal was proper, even though notice of renewal never sent

Preliminary Recitals

Pursuant to a petition filed on January 22, 2025, under Wis. Stat. § 49.45(5)(a), to review a decision by the La Crosse County Department of Human Services regarding Medical Assistance (MA), a hearing was held on February 19, 2025, by telephone.

The issue for determination is whether the agency correctly terminated the petitioner’s BadgerCare Plus as of December 31, 2024.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Kristi Matz
La Crosse County Department of Human Services
300 N. 4th Street
PO Box 4002
La Crosse, WI 54601

ADMINISTRATIVE LAW JUDGE:
Kate J. Schilling
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Trempealeau County. She is married and had four minor children at the time of the hearing.
2. On August 13, 2024, the petitioner called the agency to report that she was pregnant. Her due date was the first week of November.
3. On October 29, 2024, the petitioner had her baby. She reported this to the agency on November 4, 2024.
4. The petitioner’s BCP renewal was due in December 2024; however, no renewal paperwork was sent out to the petitioner 45 days prior to the renewal, as is the common practice of the agency.
5. On December 19, 2024, the agency sent a notice to the petitioner that her BadgerCare Plus benefits would end on January 1, 2025, due to lack of renewal.
6. On January 15, 2025, the petitioner completed her BCP renewal with the agency over the phone.
7. On January 16, 2025, the agency sent a request for verification of income to the petitioner. This verification was due by February 4, 2025.
8. On February 5, 2025, the agency sent out a notice that the petitioner was not eligible for BCP as she did not provide verification of income.

Discussion

Medical Assistance/BadgerCare Plus is a means-tested public assistance program. To be eligible for BadgerCare Plus (BCP), individuals must have income that is less than the applicable program income limit. Parents and caretakers of minor children as well as childless adults are subject to an income limit of 100% of the federal poverty level (FPL). BadgerCare Plus Eligibility Handbook (BCP Handbook) §16.1.1. Generally, the test group size of a tax filer who is not being claimed as a tax dependent by another individual includes himself, his spouse (if any), and all of his tax dependents. BCP Handbook §2.3 and 42 C.F.R. §435.603(f)(1).

There are several categories in which a person could qualify for BCP, one being a pregnant person.

2.1 BadgerCare Plus Nonfinancial Requirements

Wisconsin residents in the following coverage groups may be non-financially eligible for BadgerCare Plus:

• Children younger than 19 years old
• Pregnant persons
• Parents and caretakers of children younger than 18 years old and dependent 18-year-olds
• Parents and caretaker relatives whose children have been removed from the home and placed in out-of-home care
• Former Foster Care Youth younger than 26 years old who were in out-of-home care when they turned 18
• Adults ages 19-64 who are not receiving Medicare, except Medicare Part B Immunosuppressive Drug Benefit (Part B-ID), and who do not have dependent children who reside with them at least 40% of the time.

(Emphasis added.) BCP Handbook §§ 2.1. Each category of eligibility has a different income limit. For example, childless adults are subject to a 100% federal poverty level (FPL) income limit, children are subject to a 306% FPL income limit, and pregnant people are subject to a 306% FPL income limit. BCP Handbook § 51.1.

The petitioner notified the agency that she was pregnant on August 13, 2024. This made her eligible for BCP as a pregnant person, with a higher income limit, and the agency updated her coverage accordingly. According to the BCP Handbook, a pregnant person is eligible for BCP through the end of the pregnancy and for an additional 60 days after the end of the pregnancy.

8.1 Pregnant Members

A pregnant member who is enrolled in BadgerCare Plus stays eligible for both:

• Through the end of the pregnancy.
• An additional 60 days after the last day of pregnancy through the end of the month in which the 60th day occurs.

(Emphasis added.) BCP Handbook § 8.1. On November 4, 2024, the petitioner notified the agency that she had had her baby on October 29, 2024. Her baby was added to the BCP household and case. This also started the 60 day period of coverage after a member has a baby, which in this case would end on December 31, 2024.

The agency admitted that it did not send out the renewal notice that is typically sent out approximately 45 days before the renewal is due. The petitioner testified that when she called the agency she was told over the phone that her BCP coverage was not due for renewal until February 2025. There is no record of this being told to the petitioner in the case notes; however, in reviewing the case exhibits it appears that the renewal for her children’s BCP was possibly due in February 2025 as their coverage year started on March 1, 2024.

The agency sent out a notice to the petitioner on December 19, 2024, that her BCP coverage would be ending on January 1, 2025. The petitioner stated that she did not receive the notice that her coverage was ending until January 7, 2025, when she went to a medical appointment and was informed that she no longer had coverage. She received the written notice of termination in the mail at some point after that date.

The BCP rules require that the agency mail a notice of adverse action or termination at least 10 days prior to the effective date of the change.

29.1 Notices

A notice must be either mailed or sent electronically at least 10 days prior to the effective date of an adverse action, such as a termination of benefits or an increase in premium.

BCP Handbook § 29.1. In this case, the agency notice was dated December 19, 2024, which was 12 days prior to the termination of the health care coverage. Hence, the agency met its obligation to notify the petitioner. While I am aware that it is customary for the agency to send out a 45 day advance notice of renewal, it is not required that this 45 day notice be sent out according to the BCP Handbook.

While I understand the petitioner’s position that she may have been told incorrect information over the phone regarding her renewal month by the agency, I do not have equitable powers and cannot deviate from the administrative code and the statutes. “An agency or board created by the legislature has only those powers which are expressly or impliedly conferred on it by statute. Such statutes are generally strictly construed to preclude the exercise of power which is not expressly granted.” Browne v. Milwaukee Board of School Directors, 83 Wis. 2d 316, 333, 265 N.W.2d 559 (1978) (citation omitted). Thus, as an administrative law judge, I do not have authority to render a decision on the basis of fairness or equity.

As was mentioned during the hearing, the petitioner can reapply for BCP and request up to a three month backdate of coverage, if she is eligible. She would need to work with the income maintenance consortium to determine her eligibility.

Conclusions of Law

The agency correctly terminated the petitioner’s coverage as of December 31, 2024.

THEREFORE, it is

Ordered

That the petitioner is hereby dismissed.

[Request for a rehearing and appeal to court instructions omitted.]