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Wisconsin Department of Health and Family Services |
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Wisconsin Department of Health and Family Services |
5.16.7.1. Level 1 : Co-Payment
5.16.7.2.1 Level 2b: Deductible
5.16.7.3.1 Level 3: FTG of One
5.16.7.3.2 Level 3: FTG of Two
For applicants determined eligible, SC pays for a portion of covered prescription drugs (5.16.16), depending on the person’s participation level.
Effective with benefit periods starting September 1, 2003 there are four participation levels. The level of benefits an applicant receives depends on his/her annual income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. and, for some, on the amount they spend on covered prescription drugs during their 12-month benefit period.
The participation levels are:
Level 1: Co-Payment
(Annual income is at or below 160% of the FPL.)
Level 2a: Deductible $500
(Annual income is greater than 160% of the FPL and less than or equal to 200% of the FPL.)
Level 2b: Deductible $850
(Annual income is greater than 200% of the FPL and less than or equal to 240% of the FPL.)
Level 3: Spenddown
(Annual income is above 240% of the FPL.)
Note: The FPL is set annually by the Department of Health and Human Services see 8.1.14
If the FPL changes during the eligibility determination process or before a redetermination can be completed, the new levels will be used.
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SeniorCare Levels of Participation |
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Income Limits* |
Annual Out-of-Pocket Expense Requirements and Benefits |
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Level 1
Income at or below 160% of FPL
At or below $15,680 per individual or $21,120 per couple annually.*
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Level 2a
Income above 160% and at or below 200% FPL
$15,681 to $19,600 per individual and $21,121 to $26,400 per couple annually.* |
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Level 2b
Income above 200% - and at or below 240% of FPL
$19,601 to $23,520 per individual and $26,401 to $31,680 per couple annually.
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Level 3
Annual income is above 240% of the FPL
$23,521 or higher per individual and $31,681 or higher per couple annually.* |
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* These income amounts are based on the 2005 federal poverty guidelines, which increase by a small amount each year.
SC will pay for covered prescription drugs purchased from participating pharmacies except for participant co-payments.
Level 1 participants are required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.
When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.
If a participant has private insurance with a higher co-payment per prescription than SC, the SC co-payment rules will apply and benefits will be coordinated with the private insurance company. Providers who have questions regarding billing/benefit coordination should contact Provider Services Hotline at 1-800-947-9627.
Residents of nursing homes and community based residential facilities will have to pay the usual SC co-payment even when they are required to purchase drugs on less than a monthly basis.
Participant has an annual deductible of $500. Participant will get a discount off the retail price for most covered prescription drugs during the deductible period. The discount amount depends on the particular drug prescribed.
After this deductible is met, a level 2a participant is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.
When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.
Participant has an annual deductible of $850. Participant will get a discount off the retail price for most covered prescription drugs during the deductible period. The discount amount depends on the particular drug prescribed.
After this deductible is met, a level 2b participant is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.
When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.
Note: If married persons in the same FTG with annual income above 160% of FPL are determined non-financially eligible at different times, the deductible amount is prorated for the spouse who applies later. (5.16.9.2.1)
Level 3 participants must meet a spenddown. The amount of spenddown is the difference between the FTG annual income and 240% of the FPL corresponding the size of the FTG. The SC program tracks the amount spent on covered prescriptions drugs that can be applied to an applicant’s spenddown.
A SC participant considered as a FTG of one with gross annual income above 240% FPL pays retail prices for covered prescription drugs until those payments equal the spenddown amount.
After the spenddown has been met by purchasing drugs at regular prices the participant has an annual deductible of $850. During the deductible period the participant will get a discount off the retail price for most covered prescription drugs during the deductible period.
After this deductible is met, s/he is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.
When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.
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Example: Dorothy’s annual income is $24,520. This is $1,000 more than 240% of the FPL for a FTG of one (8.1.14). Her spenddown amount for the 12-month benefit period is $1,000. Dorothy pays the retail price for her covered prescription drugs until those payments equal the spenddown amount.
If Dorothy meets the spenddown during her benefit period, she can begin purchasing covered prescription drugs at the discounted rate. These costs are applied toward the $850 deductible.
After this deductible is met, Dorothy purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period |
Married persons considered as a FTG of two with annual income greater than 240% FPL and in which both spouses are determined non-financially eligible at the same time pay retail price for covered prescription drugs until the spenddown requirement is met. In this case, the spenddown amount is shared, and covered prescription drugs purchased for either person in the married couple will count toward meeting the spenddown requirement, when both are eligible.
After the spenddown has been met, each spouse must meet a separate $850 deductible requirement. Participants will get a discount off the retail price for most covered prescription drugs during the deductible period. Only the covered prescription drugs purchased for an individual spouse may count toward that spouse’s deductible.
After a spouse has met his/her deductible, s/he is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.
When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.
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Example 1: Bob and Alice’s annual income is $33,680, which is $2,000 more than 240% of the FPL for a FTG of two (5.16.7). Both spouses are eligible and, for the 12-month benefit period, their joint spenddown amount is $2,000.
Bob and Alice pay for their covered prescription drugs at retail price until the $2,000 spenddown is met. Covered prescription drugs purchased for either Bob or Alice will count toward the spenddown requirement.
After Bob and Alice meet the spenddown, each person has a $850 deductible. Only covered prescription drugs purchased for Bob count toward his deductible, and only covered prescription drugs purchased for Alice count toward her deductible.
Bob meets his deductible in two months. He then purchases covered prescription drugs at the co-payment amounts for the remainder of his benefit period. Alice meets her deductible in three months. She then purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period. |
If only one spouse in a married couple is determined eligible, only his/her costs count toward the spenddown. S/he pays retail price for covered prescription drugs until the spenddown requirement is met.
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Example 2: Tracy and Dave’s annual income is $33,680, which is $2,000 more than 240% of the FPL for a FTG of two (5.16.7). Because Tracy is 63 years old, only Dave is eligible for SC. For the 12-month benefit period Dave’s spenddown amount is $2,000.
Tracy and Dave pay for their covered prescription drugs at retail price. Only covered prescription drugs purchased for Dave count toward the spenddown requirement.
After Dave has met the $2,000 spenddown, he has a $850 deductible. Only covered prescription drugs purchased for Dave count toward his deductible. After Dave meets his deductible, he purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period. |
This page last updated in Release Number: 06-01
Release Date: 03/13/06
Effective Date: 02/01/06
