State of Wisconsin Department of Health Services

HISTORY

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

21-02 Version of 1.1 Introduction to Medicaid

1.1.1 Introduction

Wisconsin Medicaid is a state/federal program that provides health coverage for Wisconsin residents who are elderlyAnyone 65 years old or older, blind, or disabled or receive WWWMAWisconsin Well Woman Medicaid. Medicaid is also known as Medical Assistance, MA, and Title 19.

1.1.2 Subprograms of Medicaid

There are different subprograms of Medicaid:

Full-Benefit EBD Medicaid Programs

• SSI-Related Medicaid
• Medicaid Purchase Plan (MAPP)
• Katie Beckett Medicaid
• Wisconsin Well Woman Medicaid (WWWMA)
• SSI Medicaid

Full-Benefit Long-Term Care Programs

• Institutional Medicaid
• Community Waivers Programs, which include:  
  • Family Care
  • Family Care Partnership
  • Program of All-Inclusive Care for the Elderly (PACE)
  • Include, Respect, I Self-Direct (IRIS)
  • Children’s Long-term Support Waiver Program (CLTS)

Limited-Benefit EBD Medicaid Programs

• Tuberculosis-Related Medicaid (TB MA)
• Medicare Savings Program:
  • Qualified Medicare Beneficiary (QMBQualified Medicare Beneficiary)
  • Specified Low-Income Medicare Beneficiary (SLMBSpecified Low-Income Medicare Beneficiary)
  • Specified Low-Income Medicare Beneficiary Plus (SLMB+Specified Low-Income Medicare Beneficiary Plus)
  • Qualified Disabled and Working Individual (QDWIQualified Disabled and Working Individual)
• Emergency Medicaid
• SeniorCare

A person may qualify for one or more of the subprograms listed above, and will be found eligible if they meet all the requirements for a given subprogram. Individuals who do not qualify under a subprogram listed above may be eligible for BadgerCare Plus. See the BadgerCare Plus Handbook for more information.

People eligible for federal or state SSI are categorically eligible for SSI Medicaid and receive this form of Medicaid automatically. The Social Security Administration makes determinations of SSI eligibility for SSI recipients and receipt of SSI is the only eligibility criterion for SSI Medicaid.

1.1.3 Financial Introduction

See Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables for EBDElderly, Blind, or Disabled asset limits. See Section 25.7.2 Financial Tests for TB-related asset limits. See Section 1.1.3.3 Disabled Minors to determine Medicaid eligibility for disabled minors who fail BadgerCare Plus financial tests.

1.1.3.1 Assets

The EBD fiscal group’s assets must be within the appropriate categorically needy or medically needy asset limit before any member of that group can qualify for Medicaid. EBD fiscal groups that have assets in excess of the appropriate EBD asset limit are ineligible for Medicaid.

1.1.3.2 Elderly, Blind, or Disabled Fiscal Group

An EBD fiscal group includes the individual who is nonfinancially eligible for Medicaid and anyone who lives with him or her, who is legally responsible for him or her. EBD FTGfiscal test groups will always be a group of one or two. Spouses who live together are in each other’s fiscal group. This means that the income and assets of both spouses are counted when determining Medicaid eligibility for either or both spouses. The fiscal group size for this situation/living arrangement is two.

There are some exceptions to this concept. A blind or disabled minorA minor is a person less than age 18. living with his or her parents would be a one-person fiscal group. Special instructions for deeming parental income and assets to the disabled minor are described in Section 24.1 SSI Related Medicaid Introduction.

Another exception to the fiscal group policy involves SSI recipients. If one spouseA spouse is that person recognized by Wisconsin law as another person's legal husband or wife. Wisconsin does not recognize common law marriage. is applying for EBD Medicaid and the other spouse is an SSI recipient, the spouse who is an SSI recipient is not included in the other spouse’s fiscal group. For this situation you would again have a one-person fiscal group when determining the Medicaid eligibility of the non-SSI spouse.

An individual applying for LTC Medicaid, including institutional, HCBW, Family Care, PACE, Partnership, or IRIS would be a one-person fiscal group. If the individual is married, refer to Section 18.1 Spousal Impoverishment Introduction for special instructions regarding spousal impoverishment procedures.

1.1.3.3 Disabled Minors

A blind or disabled minor (or Dependent 18-year-old ) must have his or her Medicaid eligibility determined according to special procedures if eligible (see Section 15.1.2 Special Financial Tests for Disabled Minors).

Note:

EBD Medicaid testing procedures are different from those used for HCBW Medicaid for the Children’s Long-Term Support Waiver Program. (See Section 37.3 HCBW Medicaid CARES Processing for the CLTS Waiver Program.)

1.1.3.4 Income

See 39.4 Elderly, Blind, or Disabled Assets and Income Tables for EBD income limits. See Section 39.5 Federal Poverty Level Table for all other Medicaid income limits. Chapters for each type of Medicaid explain how to determine the income that you compare to the income limits.

See Section 39.4.2 Elderly, Blind, or Disabled Deductions and Allowances for TB-related income limits.

1.1.4 Health Care Choice

Once an individual has been determined eligible for EBD Medicaid, he or she must be enrolled in EBD Medicaid even if he or she is also eligible for BadgerCare Plus, unless he or she has a change in circumstances that results in ineligibility for EBD Medicaid. The only exception to this policy is pregnant women who are eligible for both EBD Medicaid and BadgerCare Plus. In these instances, the pregnant woman will be enrolled in BadgerCare Plus.

If an individual is pending for EBD Medicaid or has an unmet deductible for EBD Medicaid, the individual is not considered eligible for EBD Medicaid and can enroll in BadgerCare Plus. Pending for EBD Medicaid includes, but is not limited to, waiting for a disabilityThe law defines disability for Medicaid as "The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." determination from DDBDisability Determination Bureau or not being eligible for Medicare. If an individual enrolled in EBD Medicaid becomes ineligible for EBD Medicaid for any reason, including going over the asset limit or failure to pay a MAPP premium, he or she can enroll in BadgerCare Plus if he or she is still eligible to do so.

1.1.5 How to Apply

The following application options are available for anyone who is applying for EBD Medicaid:

• ACCESS online application at access.wisconsin.gov/.
• Face-to-face interview at the agency.
• Mail-in.
• Telephone interview.

Click here to view the directory of local IMincome maintenance agencies in Wisconsin or call Member Services at (800) 362-3002.

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030