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State of Wisconsin |
Release 24-03 |
Financial eligibility for home and community-based waivers cases is determined in CARES.
Although Katie Beckett cases are Group A, these cases are processed manually outside of CARES by Katie Beckett staff.
Group A members are waiver functionally eligible and Medicaid eligible via any full-benefit Medicaid subprogram other than HCBW Medicaid.
Group A members do not have a cost share.
Members who have met a deductible are eligible for community waivers as a Group A. The member remains eligible as a Group A until the end of the deductible period. At the next review the member will be able to make a choice between meeting the deductible to receive Medicaid (remaining a Group A) or becoming eligible for community waivers as a Group B or B Plus with a potential cost share.
Group A members are financially eligible with no cost share. They are only subject to the asset limit and any premiums associated with the full-benefit Medicaid source, if applicable. For example, if the member’s Medicaid source is MAPP, s/he would be subject to the MAPP asset limit and premium calculated. If the member’s Medicaid source is BadgerCare Plus, the member would not have an asset limit, but may still have a premium calculated.
| Note: |
Group A members do not have an asset limit if they are Group A eligible via BadgerCare Plus, Adoption Assistance Medicaid, Foster Care Medicaid, Katie Beckett Medicaid, or Wisconsin Well Woman Medicaid since these programs do not have an asset test. All Group A members, including those who are eligible for Group A through BadgerCare Plus eligibility, are subject to the divestment policy described in Chapter 17 Divestment. |
Group B members are defined as those not in Group A, but who have gross income at or below the nursing home institutions categorically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).
Group B Plus members are defined as those not in Group A, who have gross income above the nursing home institutions categorically needy income limit, but whose income does not exceed the cost of the appropriate institutional care by more than the medically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).
The cost share amount is the monthly amount Group B and B Plus members must pay toward the cost of their waiver services. The cost share amount is calculated in CARES by applying the cost share deductions to Group B and B Plus members’ gross income. For former SSI members who are not eligible for Special Status Medicaid (Section 25.0 Special Status Medicaid Introduction) special status disregards are not used in the Cost Share calculation. Members who owe a cost share must pay one in the month that they enroll in a community waiver program, even if they only receive services for part of a month. If the member changes from one MCO to another MCO in the same month after paying a cost share to the original MCO, they do not owe a cost share to the new MCO that month.
Family Care, Family Care Partnership, or PACE members institutionalized in a medical institution pay a patient liability calculated according to Chapter 27 Institutional Long-Term Care rather than cost share under this section.
Cost Share or Patient Liability Effective Dates
Income changes which are reported timely and result in an increased patient liability or cost share have the following effective dates:
Decreases in patient liability or cost share are always effective the first of the month in which the decrease in income occurs or the decrease is reported, whichever is later.
A personal maintenance allowance for room, board, and personal expenses must be deducted from income when calculating cost share.
The personal maintenance allowance is calculated as the total of the following, but must not exceed the Community Waivers Personal Maintenance Allowance Maximum (see Section 39.4.3 LTC Post-Eligibility Allowances):
Waiver participants under age 18 do not qualify for the special housing amount deduction.
If two spouses who are both waiver participants live together (or they have separate rooms in a substitute care facility, but there is only one room and board contract) the special housing amount deduction is allocated between them in the way that results in the lowest total cost share for the couple.
| Example 1 | Jennifer and Markus are married and live together. Both are waiver participants. Their total housing costs are $1,600. The special housing amount is calculated as $1600 − $350 = $1250. Before deducting the special housing amount, Jennifer has a cost share of $800 and Markus has a cost share of $500. To get the lowest total cost share for the couple, $500 of the special housing amount is allocated to Markus, reducing his cost share to $0. The remaining $750 of the special housing amount is allocated to Jennifer, reducing her cost share to $50. |
| Example 2 | Dan and Allison are married and live together. Both are waiver participants. Their total housing costs are $1,075. The special housing amount is calculated as $1,075 − $350 = $725. Before deducting the special housing amount, Dan has a cost share of $1,200. Allison is eligible for Group A waivers with no cost share. To get the lowest total cost share for the couple, the full $725 special housing amount is allocated to Dan, reducing his cost share to $475. |
If two spouses who are both waiver participants have separate living arrangements (e.g., they reside in two different substitute care facilities, or they reside in the same substitute care facility but each has a private room and a separate room and board contract) a separate special housing amount is calculated for each based on their individual housing costs.
If the total of 1, 2, and 3 above is greater than the Community Waivers Personal Maintenance Allowance Maximum, the maximum amount is used. See SECTION 39.4.3 LTC POST-ELIGIBILITY ALLOWANCES for the current Community Waivers Personal Maintenance Allowance Maximum.
A family maintenance allowance, an amount to be used for the support of the applicant’s family members, should only be deducted from income when calculating cost share in certain cases. The family maintenance allowance may not be used for a deduction when spousal impoverishment policies apply or if the member is a disabled child. For spousal cases, the institutionalized person can allocate income to the community spouse and children in the home, see Section 18.6 Spousal Impoverishment Income Allocation.
When the waiver participant has one or more children under the age of 18 who do not live with a community spouse, an allowance for those children is calculated as follows:
If there are no minor children in the home, and spousal impoverishment policies do not apply, calculate the following:
If (7) is greater than (8), there is no family maintenance allowance. If (7) is less than (8), the family maintenance allowance is the difference between (7) and (8).
Special exempt income (see Section 15.7.2 Special Exempt Income) must be deducted from income when calculating cost share.
All health and dental insurance premiums covering the waiver person and for which he or she is responsible and pays a premium must be deducted from income when calculating cost share. This includes any Medicare Premium obligation including Medicare Part D. See Section 9.6.2 Policies Not To Report for a list of insurance types for which premium deductions are not allowed.
If the waiver participant is part of a covered group but not responsible for the premium, find his or her proportionate share by dividing the premium by the number of people covered. If both members of a couple apply, but only one pays the premium, divide the premium equally. Prorate premiums over the months payment covers.
| Example 8: | Sally pays a $600 premium quarterly for her Medicare supplement policy. Six hundred dollars divided by three equals $200. Enter $200 as her monthly health insurance premium payment on the Medical Coverage page. |
The dollar amount of the applicant’s medical and remedial expenses, as reported by the MCO care manager, ICA, or ADRC, must be deducted from income when calculating cost share. See Section 15.7.3 Medical/Remedial Expenses and Section 20.3.6 Medical or Remedial Expenses.
| Note: |
Care managers should refer to the limitations associated with allowable medical or remedial expenses that are described in Section 27.7.7 Medical or Remedial Expenses and Payments for Non-Covered Services. |
For Family Care, Family Care Partnership, and PACE, see Section 39.4.4 for maximum cost share amount.
Family Care, Family Care Partnership, or PACE members may request a waiver or reduction of their cost share from the Department. Members indicating that they are having difficulty paying cost share should be informed of this right, directed to complete the Application for Reduction of Cost Share form (F-01827), and referred to the Bureau of Adult Programs and Policy (1-855-885-0287).
This page last updated in Release Number: 24-02
Release Date: 08/22/2024
Effective Date: 08/22/2024
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