State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

32.1 Introduction

 

Presumptive eligibility is a streamlined eligibility determination for temporary enrollment in BadgerCare Plus or Family Planning Only Services. It is based on preliminary household and financial information provided by the applicant. It allows eligible applicants immediate health care coverage for a short period until an application for ongoing coverage is completed and processed.

 

Note: See the Medicaid Eligibility Handbook Section 36.2.2.1 Temporary Enrollment/Presumptive Eligibility Available Only To Women Enrolling Through WWWP for information on temporary enrollment under the Wisconsin Well Women  Medicaid program for women under age 65 with breast or cervical cancer.

32.1.1 Definitions

• Express Enrollment: The process of making a presumptive eligibility determination to temporarily enroll an individual in BadgerCare Plus or Family Planning Only Services. Qualified entities (see Section 32.1.2 Qualified Entities) make these determinations using ACCESS for Partners and Providers (see ACCESS Handbook Chapter 12 ACCESS for Partners and Providers).
• Presumptive eligibility: The determination of whether or not an applicant is eligible to temporarily enroll in BadgerCare Plus or Family Planning Only Services.
• Temporary enrollment: Short-term eligibility for BadgerCare Plus or Family Planning Only Services.

32.1.2 Qualified Entities

Qualified entities that can make presumptive eligibility determinations include hospitals, providers, and partners that are approved by ForwardHealth and have received Express Enrollment training. The table below explains which qualified entities can make presumptive eligibility determinations for a population and program:

 

Qualified Entities:	Can make presumptive eligibility determinations for:
	Children	Pregnant Women	Family Planning Only Services	Adults, Parents, and Caretakers
Qualified Hospitals	X	X	X	X
Providers	X	X	X
Partners	X

 

Examples of qualified partners include:

• Head Start programs.
• Authorized child care providers.  
• Women Infant and Children (WIC) agencies.
• Faith-based organizations such as the YMCA.
• Certain community-based organizations, such as the Boys and Girls Club.
• Authorized agencies offering emergency food and shelter.
• Elementary and secondary schools.
• Any other entity the state so deems as approved by the Secretary.

32.1.2.1 Process for a Qualified Entity to Temporary Enroll a Person

A qualified entity follows the process below for a person to get temporary enrollment in BadgerCare Plus or Family Planning Only Services:

1. Complete a presumptive eligibility application through one of the following methods:
   1. Online using ACCESS for Partners and Providers. This is also known as an Express Enrollment application.
   2. Fill out and submit a paper application.
      1. BadgerCare Plus Express Enrollment for Pregnant Women application (F-10081).
      2. Temporary Enrollment for Family Planning Only Services application (F-10119).
2. If the applicant is found eligible:
   1. Provide a temporary ForwardHealth ID card.
   2. Advise the applicant that a permanent ForwardHealth ID card will be mailed within 3-5 business days, if the member has not already been issued a ForwardHealth card. If the member has been issued a ForwardHealth card in the past, a new one will not be mailed. The member can use his or her previously issued ForwardHealth card or contact Member Services at 1-800-362-3002 to request a new one.
3. Provide a denial notice if the applicant is found not eligible.
4. Stress the importance of applying through the local agency for ongoing health care coverage. The qualified entity is encouraged to assist the applicant with applying. Advise that the application can be submitted online, by telephone, by mail, or in person.

32.1.3 Coverage Period

32.1.3.1 Begin Date

Temporary enrollment in BadgerCare Plus or Family Planning Only Services begins on the date a person is found presumptively eligible by a qualified entity.

32.1.3.2 End Date

Temporary enrollment in BadgerCare Plus or Family Planning Only Services ends the month following the month in which the person was determined presumptively eligible or the date ongoing health care or Family Planning Only Services eligibility is determined (see Section 32.1.3.3 Early Termination and Section 32.1.3.4 Automatic Extension).

32.1.3.3 Early Termination

If a person applies for ongoing health care or Family Planning Only Services coverage and the IMincome maintenance agency makes an eligibility determination prior to the end date of the temporary enrollment period, the temporary enrollment period must end on the date the agency completes processing the application for ongoing coverage, regardless of the result of the eligibility determination. The early termination of temporary enrollment will be applied systematically. Tables 1 and 2 further explain when eligibility for ongoing health care or Family Planning Only Services coverage will end temporary enrollment.

 

Table 1: Systematic Early Termination of Temporary Enrollment—Applicant Applied for One Program
Applicant is confirmed in CARESThis system supports the Income Maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs. as:	Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:	Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:
Eligible for BadgerCare Plus or other ongoing Medicaid coverage	End temporary enrollment	End temporary enrollment
Eligible for Family Planning Only Services	No change to temporary enrollment	End temporary enrollment
Not eligible for BadgerCare Plus or other ongoing Medicaid coverage	End temporary enrollment	No change to temporary enrollment
Not eligible for Family Planning Only Services	No change to temporary enrollment	End temporary enrollment

 

Table 2: Systematic Early Termination of Temporary Enrollment—Applicant Applied for Multiple Programs
Applicant is confirmed in CARES as:	Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:	Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:
Eligible for BadgerCare Plus or other ongoing Medicaid coverage but not for Family Planning Only Services	End temporary enrollment	End temporary enrollment
Eligible for Family Planning Only Services but not for BadgerCare Plus or other ongoing Medicaid coverage	End temporary enrollment	End temporary enrollment
Not eligible for Family Planning Only Services, BadgerCare Plus, or other ongoing Medicaid coverage	End temporary enrollment	End temporary enrollment

 

Example 1: Joe Green applied for presumptive eligibility for BadgerCare Plus for his son Jim on February 4 at the Center Street Boys Club. Jim was found presumptively eligible for BadgerCare Plus from February 4 through March 31. Joe submits a BadgerCare Plus ACCESS application to the local IM agency on February 10. The agency determines Jim’s eligibility for ongoing BadgerCare Plus coverage on March 1. Jim is found ineligible for BadgerCare Plus for February and March and the application is denied. A notice is sent to Joe informing him Jim is not eligible for BadgerCare Plus and his BadgerCare Plus temporary enrollment is terminated effective March 1.

 

Example 2: Sandra was determined presumptively eligible for BadgerCare Plus for pregnant women on January 10. Her temporary enrollment period lasts from January 10 through February 28. She applied for ongoing BadgerCare Plus through her local income maintenance agency on January 15 and was found eligible on January 28 with an effective date of January 1. Her temporary enrollment will end on January 28.

32.1.3.4 Automatic Extension

If the income maintenance agency is unable to finish processing the application for ongoing coverage by the end of the temporary enrollment period, the system will automatically extend the temporary enrollment period for an additional calendar month. Tables 3 and 4 further explain when temporary enrollment will be extended.

 

Table 3: Systematic Extension of Temporary Enrollment—Applicant Applied for One Program
Applicant has applied for one program and eligibility has not been confirmed:	Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:	Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:
BadgerCare Plus or other ongoing Medicaid coverage	Extend temporary enrollment for BadgerCare Plus	Do not extend temporary enrollment for Family Planning Only Services
Family Planning Only Services	Do not extend temporary enrollment for BadgerCare Plus	Extend temporary enrollment for Family Planning Only Services

 

Table 4: Systematic Extension of Temporary Enrollment—Applicant Applied for Multiple Programs
Applicant has applied for multiple programs but eligibility has not been confirmed for all programs:	Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:	Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:
Eligibility has been confirmed for BadgerCare Plus or other ongoing full-benefit Medicaid coverage but not for Family Planning Only Services	Do not extend temporary enrollment for BadgerCare Plus	Do not extend temporary enrollment for Family Planning Only Services if the applicant is eligible for BadgerCare Plus or other ongoing full-benefit Medicaid coverage Extend temporary enrollment for Family Planning Only Services if the applicant is not eligible for BadgerCare Plus or other ongoing full-benefit Medicaid coverage
Eligibility has been confirmed for Family Planning Only Services but not for BadgerCare Plus or other ongoing full-benefit Medicaid coverage	Extend temporary enrollment for BadgerCare Plus	Do not extend temporary enrollment for Family Planning Only Services

 

 

 

This page last updated in Release Number: 17-01

Release Date: 04/11/2017

Effective Date: 09/24/2016

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The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Publication Number: P-10171