17.4 Meeting The Deductible

17.4.1 When Expenses Can Be Counted Toward a Deductible
17.4.2 Countable Expenses
17.4.3 Expenses That Cannot Be Counted Toward a Deductible

The BadgerCare Plus member or group meets the deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. by incurring medical or remedial costs that equal the dollar amount of the deductible. The countable costs are added together. When they are equal to or greater than the amount of the deductible, the pregnant woman or child under 19 can be certified for BadgerCare Plus through the end of the deductible period.

Note: Under MAGIModified Adjusted Gross Income. MAGI rules are used to determine BadgerCare Plus eligibility for new applicants beginning in 2014 and for existing members as of March 31, 2014, or their next regularly scheduled renewal, whichever is later. MAGI rules are based on tax relationships and family relationships, and they consider taxable income and whether children and tax dependents are required to file. rules, the deductible is built on an individual basis. To meet the deductible, the member and his or her parents in the BadgerCare Plus group must incur medical bills equal to the deductible amount. The parent’s medical expenses may be used for meeting the deductible of more than one child at a time, but deductible-based eligibility is not extended to other children or members of the original assistance group.

If an expense was applied to a prior deductible but did not result in BadgerCare Plus certification, it can be applied to a later deductible, as long as it still meets the criteria listed in (17.4.1).

17.4.1 When Expenses Can Be Counted Toward a Deductible

To be counted toward the deductible, a medical or remedial expense must meet all of the following conditions.

Be incurred by a member of the child’s or pregnant woman’s BadgerCare Plus group.

Expenses may also be counted if incurred for someone the pregnant woman is legally responsible for if that individual could be counted in the member's BadgerCare Plus group. The medical bill may be used even if the family member is no longer living or no longer in the current BadgerCare Plus group.

Example 1: Sally's minor child Ida died of leukemia in April. In September, Sally requests that a medical bill incurred for Ida be used towards her deductible. Sally is still legally responsible for the bill. The bill can be used to meet the deductible as long as it did not result in a BadgerCare Plus certification in an earlier period.

Meet the Definition of Medical or Remedial expense described in 17.4.2.
Meet one of the following four conditions:
1. Still be owed to the medical service provider sometime during the current deductible period.

Expenses which have been "deferred” by the provider are considered a countable cost still owed to the provider and can be used to meet a BadgerCare Plus deductible.

1. - The deferred charge should be viewed as an incurred expense that remains an unpaid obligation for the member.
  - If only a portion of the deferred charge was used to meet a prior deductible, any remaining balance can be used to meet future deductibles.

1. - Because many deferred charge situations involve very high costs for the services provided, it is extremely important to document in Case Comments which portion of the deferred charges are used to meet previous deductibles, and any remaining balance that can be used to meet current or future deductibles.

Example 2: In May, Helen resided in an Institute for Mental Disease ( IMD ) and incurred a $14,000 bill. In October, Helen becomes pregnant and applies for BadgerCare Plus.

Helen turned in the bill for the stay in the IMD which shows the amount as 'deferred charges’ which means the member would never be billed for the charges, but if he or she happens to come into a windfall of money (lottery or inheritance), they will change the status of those charges to current and try to collect the debt.

Helen can use this "deferred" charge toward her deductible.

Example 3: Lestat’s parent applies for BadgerCare Plus in July 2008. A BadgerCare Plus deductible of $700 is calculated for him. In January 2003, he had a blood transfusion. The bill for the transfusion was $800. The bill was never paid. Lestat can use the unpaid bill to meet his BadgerCare Plus deductible, but must provide documentation to show that the charges are currently owed. The remaining $100 can be applied to the next deductible period, as long as it is still owed.

1. Paid or written off sometime during the current deductible period. Medical bills written off through bankruptcy proceedings are not allowed as a medical expense to meet a deductible.

Example 4: Estelle applies for BadgerCare Plus in March. A deductible period is set up for March through August. In April, she had a two-year-old medical bill of $300 written off. She can apply the $300 toward the March - August deductible because it was written off during the deductible period.

1. Paid or written off sometime during the deductible period that immediately precedes and borders on the current deductible period. These bills can be used even if they were paid after the person met the deductible in the prior period.

Example 5: Jeffrey is in his second deductible period. He did not meet his deductible in the prior period, which borders on the current period. He has a bill that was written off in the prior period. He can apply this bill to his current deductible.

Example 6: Malcolm is in his second deductible period which began March 1, 2007. He did not meet his deductible in the prior deductible period, which immediately preceded the current deductible period. He has a medical bill that he paid in February 2006. He may not apply this toward his current deductible.

Example 7: Norah is in her second deductible period which began in September. In June, Norah met her deductible and was certified for BadgerCare Plus. After certification, and before the prior deductible period ended in August , Norah paid for medical services that were not BadgerCare Plus covered services. Norah can apply these paid bills to the deductible period that began in September.

1. Paid or written off some time during the three months prior to the date of applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. . This expense can only be used for the first deductible period. Balances cannot be carried forward to future deductible periods.

Example 8: Julie applies for BadgerCare Plus in August. Her deductible for the period from August through January is $1500. On May 10th she paid off a $2000 outstanding medical bill. She can use that expense to meet her deductible because it was paid in the three months prior to the date of her application. The remaining $500 cannot be applied to future deductible periods.

17.4.2 Countable Expenses

Medical expenses. Medical expenses are costs for services or goods that have been prescribed or provided by a professional medical practitioner (licensed in Wisconsin or another state) regardless of whether the services or goods are covered by BadgerCare Plus. Medical expenses for services or prescriptions acquired outside of the U.S. may be counted toward a deductible if a licensed medical practitioner or pharmacy provided the service or drug.

Some examples of medical expenses are deductibles, co-payments and premiums for BadgerCare Plus, Medicare, private health insurance; and bills for medical services which are not covered by the Wisconsin BadgerCare Plus program.

Note: MMIS data may be used to calculate BadgerCare Plus co-payments from the previous deductible period.

Remedial expenses. Remedial expenses are costs for services or goods that are provided for the purpose of relieving, remedying or reducing a medical or health condition. Some examples of remedial expenses are:

1. Case management.
2. Day care.
3. Housing modifications for accessibility.

1. Respite care.

1. Supportive home care.

Supportive Home Care is necessary assistance to help people meet their daily living needs, ensure adequate functioning in their home, and safely access their community. Services may include:

1. - Assistance with activities of daily living
  - Attendant care
  - Supervision
  - Reporting changes in the member’s condition,
  - Assistance with medication and medical procedures which are normally self-administered, or
  - The extension of therapy services, ambulation and exercise.
  - Tasks associated with routine household upkeep, including general housekeeping chores, lawn mowing, snow removal, changing storm or screen windows and other household services that are essential to the member’s safety, well being and care at home.

1. Transportation.
2. Community Based Residential Facility (CBRF), Adult Family/Foster Home (AFH), Residential Care Apartment Complex ( RCAC ), and all other community substitute care setting program costs not including room and board expenses.

Remedial expenses do not include housing or room and board expenses.

Ambulance service and other medical transportation including attendant services

Medical insurance premiums paid by a member of the BadgerCare Plus Group. These insurance premiums include disease specific and per diem hospital and nursing home insurance payments. Do not allow accidental insurance policy premiums as a countable cost.

Note: Unlike other expenses listed in this section that may not be applied toward a deductible until they are incurred, count medical insurance premiums from the first day of the deductible period, if the premium will be coming due anytime during the current deductible period.

Medical bills paid by a party who is not legally liable to pay them can be counted against a deductible...

Examples of parties that pay medical bills when not legally liable include, but are not limited to: Churches, fraternal organizations, Children's Special Health Needs Unit of the Division of Public Health, Veterans Administration and the AIDS Drug Assistance Program (ADAP).

The cost of medical services received at a Hill-Burton facility. The Hill-Burton Act was enacted by Congress to provide federal assistance for the construction and modernization of health care facilities. Medical facilities which receive Hill-Burton assistance must provide without charge a reasonable volume of services to persons unable to pay for those services.

In-kind payments. These are services or goods supplied to the provider in lieu of cash. Self declaration of the bill being satisfied is adequate verification.

Medical or remedial expenses that are paid or will be paid by a state, county, city or township administered program that meets the conditions detailed in # 1 through 7 above.

Examples include:

- General Assistance
- Community Options Program
- AIDS Drug Assistance Program (ADAP)

Example 1: Jenna receives a medical service which will be paid by ADAP. When Jenna becomes pregnant and applies for BadgerCare Plus she has a deductible to meet. This medical bill that has not been paid can be used immediately because it will be paid by the state administered ADAP program.

Example 2: Sally received a medical service in January which was paid by the state administered; state funded Community Options Program in the same month. In February Sally applies for BadgerCare Plus for herself and her son, James. Sally has access to health insurance so James must meet a deductible. Since the medical bill was paid by COP within three months of Sally's BadgerCare Plus application it can be used to meet James’ BadgerCare Plus deductible.

Medical or remedial expenses that have been paid or will be paid by Indian Health Services that meet the conditions detailed in (17.4.2).

Example 3: On January 1, Michael received a medical service which will be paid by Indian Health Services. When Michael applies for BadgerCare Plus on January 10 he has to meet a deductible. The bill for the January 1 medical services may be used immediately because it will be paid by the Indian Health Services program.

Example 4: Charlie received a medical service in January which was paid by Indian Health Services in the same month. In February Charlie’s mother applies for BadgerCare Plus. Charlie has to meet a deductible. Since the bill was paid by Indian Health Services within three months of Charlie's BadgerCare Plus application, it can be used to meet Charlie's BadgerCare Plus deductible.

17.4.3 Expenses That Cannot Be Counted Toward a Deductible

Do not count the following toward the deductible:

Medical bills written off through bankruptcy.
Medical services payable or paid for by a third party who is legally liable for the bill. This includes bills that will be paid or have been paid by BadgerCare Plus, Medicare or other Insurance.

Example 1: The costs of medical services provided to an incarcerated person are not allowed as expenses to meet a deductible. The incarcerating authority is the legally liable third party.

A bill cannot be used if it has been used to meet a prior deductible. If only a portion of an unpaid bill was used to meet a prior deductible, any remaining balance that was not applied to the prior deductible, may be applied to a subsequent deductible period as long as it is still owed or meets criteria in (17.4.1).

This page last updated in Release Number: 14-02

Release Date: 05/14/14

Effective Date: 04/01/14