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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
The fiscal test group or family fiscal unit ( FFU ) meets the deductible by incurring medical costs that equal the dollar amount of the deductible.
A fiscal test group can apply to the deductible any countable (4.9.8.1) cost of anyone in his/her fiscal test group. An individual member of an FFU can apply to the deductible any countable (4.9.8.1) cost of anyone in his/her FFU.
The countable costs are added together. When they are equal to or greater than the amount of the deductible, the group can be certified for Medicaid.
Note: The medical cost that is stated on the bill from the service provider is the amount that should be applied to the deductible, even when you know from other sources that the usual and customary cost of the service is different from what is stated on the bill.
If the group does not meet the deductible within the deductible period, it can choose to begin a new deductible period.
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Example. Johnny Moss had a deductible period of July through December. He had some paid and unpaid medical bills that totaled $370. His deductible was $380. Since he did not meet his deductible, he cannot be certified for Medicaid. But, he can begin a new deductible period January 1 if he chooses. |
To be counted toward the deductible, a medical bill must be for a medical service provided to a member of a fiscal test group or FFU.
A bill can be counted even if it is for medical services to a member of the group who has died.
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Example 1: When Roy died, he owed $372 for Medicaid covered services he had received. He and his wife and child were in the same fiscal test group. They had a deductible of $472. The $372 can be applied to that deductible, leaving $100 still to be met. |
The medical bill must meet one or more of the following conditions: (See 4.9.8.2 for non-countable costs.)
Still owed sometime during the current deductible period.
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Example 2: Lestat applies for MA in July, 1998. An MA deductible of $700 is calculated for him. In 1993 he had a blood transfusion. The bill for the transfusion was $300. He never paid it. He can use the unpaid bill to meet his MA deductible. |
Note: Applicants must submit documentary proof of liability for medical costs incurred more than six months prior to the date of application.
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.
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Example 3: Mr. and Mrs. Avenue apply for MA on April 1, 1998, requesting that their deductible period begin January 1, 1998. Their deductible for the period January 1 - June 30 is $340. One month earlier, on March 1, they had paid a ten-year-old medical bill of $300. They can count it because it was paid in the current deductible period. |
Paid or written off sometime during the deductible period that immediately precedes and borders on the current deductible period.
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Example 4: 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. |
These bills can be used even if they were paid after the person met the deductible in the prior period.
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Example 5: You are in your second deductible period. You met the deductible and were certified for MA in your prior deductible period, which borders on the current period. After certification, and before the prior deductible period ended, you paid for some medical services that were not MA covered services. You can use these paid bills to apply to your current deductible. |
Paid or written off some time during the three
months prior to the date of application.
Past medical bills incurred for someone the client is legally responsible for if that individual could be counted in client’s FTG or FFU. The medical bill can be used even if the family member is no longer living or no longer in the current FTG or FFU.
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Example 6: A parent of a disabled child requests that a medical bill incurred for his minor daughter in the past be used towards his deductible. The parent is still legally responsible for the bill. The daughter has since died. The bill should be allowed as long as it did not result in a Medicaid certification in an earlier period. |
A bill cannot be counted if it has been used to meet a prior deductible.
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Example 7: An applicant incurs a $300 medical bill. She applies the $300 toward her deductible even though s/he has not made any payments on the bill. She meets her deductible and is certified for Medicaid. Three years later she applies for Medicaid again and a deductible is calculated for her. She now pays the $300 bill. But she cannot use it to meet her current deductible because she already used it to meet the prior deductible. |
Note:If the medical bills were applied to a prior deductible but did not result in MA certification, they can be applied to a later deductible.
The following are costs that can be counted against the deductible if they meet the above conditions:
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 MA.
Some examples of medical expenses are deductibles and co-payments for MA, for Medicare, for private health insurance; and bills for medical services which are not covered by the Wisconsin Medicaid program.
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:
Case management
Day care.
Housing modifications for
accessibility.
Respite care.
Supportive home care.
Transportation.
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.
CBRF, AFH, RCAC, and all other community substitute care setting program costs, not including room and board expenses, can be counted as a remedial expense only as they are incurred. CBRF, AFH, RCAC and all other community substitute care setting program costs will be considered incurred as of the date that the client is billed for these expenses by the CBRF, AFH, RCAC or other community substitute care setting. The billing procedure used by the CBRF, AFH, RCAC or other community substitute care setting (one month in advance, bimonthly, etc.) for MA residents should be the same as that which is used for its non-MA residents.
If the medical bills were applied to a prior deductible but did not result in MA certification, they can be applied to a later deductible.
In determining how much of a CBRF, AFH, RCAC or other community substitute care setting expense can be applied to meet a medical deductible, use the facility’s breakdown of the room and board versus program costs, with the program costs to be applied to the deductible.
Ambulance service and other
medical transportation (7.1.4.1)
, including attendant services (7.1.4.1.3 (12).
Medical insurance premiums
paid by a member of the fiscal test group or FFU. 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. Count the premium from the first day of the
deductible period, if they will be coming due anytime during the period.
Medical bills paid by a party who is not legally liable to pay them.
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Example 8: Medical bills paid by a person's church or fraternal organization can be counted against the deductible. Other examples include: The Children's Special Health Needs Unit of the Division of Public Health and the Veterans Administration. |
Medical services received at
a Hill-Burton facility. The Hill-Burton Act was en-acted 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.
Do not count the following toward the deductible:
Medical bills written off through bankruptcy.
Medicare Supplemental Medical Insurance ( Plan
B ) premiums if they have already been deducted from the gross social
security check.
Medical services payable or paid for by a third party who is legally liable at any time during the deductible period.
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Example 1: The Indian Health Service is a legally liable third party. When it pays the person's expenses, the expenses cannot be applied to his/her deductible. |
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Example 2: The court orders a health insurer or other third party to pay for medical services. |
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Example 3: Medical services provided to an incarcerated person. In this case, the incarcerating authority is the legally liable third party. |
Anyone can prepay a deductible for himself/herself or for someone else. It can be paid in installments or all at once. A prepaid deductible may be refunded if the client requests a refund of the prepayment prior to the begin date of the corresponding deductible period.
If the client is 55 or older, forward the payment to:
Estate Recovery/Casualty Collections
6406 Bridge Road
Madison WI 53784-0013
Prepayment checks or money orders should be made payable to: “The Department of Health and Family Services.”
With the payment, include:
Documentation that the payment is voluntary.
The client’s name and MA ID number.
If s/he is under 55, instruct the client to make the payment payable to your ESA. Report the receipt on the Community Aids Reporting System ( CARS ) on Line 909.
If the entire deductible amount is paid at any point during the deductible period, eligibility begins on the first date of the deductible period.
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Example: Laura’s deductible period is from March 1st through August 31st. The total deductible amount is $1,000. Laura submits payment of $1,000 on August 15th. Laura’s MA eligibility begins on March 1st. |
Enter the first date of the deductible period on AGTM as the date the payment was received.
If the deductible is met through a combination of payment and incurred medical expenses, count the incurred medical expenses first. Eligibility, by paying the remaining deductible amount, can begin no earlier than the last date of incurred medical expense within the deductible period.
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Example: Chad’s deductible period is from March 1st through August 31st. The total MA deductible amount is $1,800. Chad submits a medical bill with a March 8th date of service for $800. On July 15th, he submits payment of $1,000. Chad’s MA eligibility begins March 8th. Submit a Medicaid Remaining Deductible Update ( HCF 10109 ) identifying the provider of service on March 8th and the $800 client share amount. |
Enter the incurred medical expense first. Perform a PF23 sort. The remaining balance is the amount that can be paid to meet the deductible. Enter the payment date as the same date of the last incurred medical expense, which equals the balance of the deductible, on CARES Client Assistance for Re-employment & Economic Support screen AGTM. Complete and submit a Medicaid Remaining Deductible Update (HCF 10109) to EDS. Enter the deductible met date as the date of the last incurred medical expense. Enter the client share as the amount of the last incurred medical expense.
If the deductible is met through a combination of payment and outstanding medical expenses (incurred prior to the beginning of the deductible period), eligibility begins on the first date of the deductible period.
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Example: Roberta’s deductible period is from March 1st through August 31st. The total MA deductible amount is $1,500. She submits an outstanding bill from January 10th for $500. On August 15th, she submits payment of $1,000. Roberta’s MA eligibility begins March 1st |
Enter the first date of the deductible period on AGTM as the
date the payment was received.
If any portion of the deductible is paid and you find the amount was wrong due to agency error, refund the paid amount that was incorrect and report the refund on CARS.
If the deductible is paid with a check that is returned for insufficient funds, discontinue the person's eligibility.
This page last updated in Release Number: 03-02
Release Date:04-01-03
Effective Date: 04/01/03