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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
5.7.8.1.1 Processing Timeframe
5.7.8.1.2 Previous MA/BC Eligibility
5.7.8.1.3 Initial Premium Payment
5.7.8.2.1 Reduced Premiums for Native Americans/Alaskan Natives
As a condition of their BC eligibility, families who are eligible with total family income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. that exceeds 150% FPL (8.1.6) for their group size must pay a premium in order to receive BC. The premium is calculated based on the total family income and will be no more than 5% of that income amount.
Compare the total family income (5.7.6.2) to the table in 8.1.11 to determine the premium. Payment or non-payment of the premium does not affect the eligibility of any person in the household who qualifies under a different MA sub-program (Healthy Start, AFDC-Related MA, etc.). The premium is due in the benefit month, except for initial eligibility with a free month (5.7.8.1).
The first month is free if no one in the FTG (5.7.5) was on MA or BC in the previous month, and the BC AG has not received a free month in the previous 12 months. Consider someone with an unmet deductible as not being on MA.
In certain circumstances, a client may need to pay his/her premium for the first and/or second month following the free month before eligibility can begin depending on when his/her application is processed. The following indicates the eligibility and timeframe for premium payments:
Eligibility and Processing Occur in the Month of Application.
When an application is processed in the same month it was received, and there is a free month, the premium for the second month must be paid in advance before BC eligibility can begin.
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Example 1: Lisa and her family apply for MA and BC in January. They are determined eligible beginning January 1st. January is the free month. Lisa must pay the premium for her family for February before the family’s BC eligibility can begin. |
Eligibility Begins in the Month of Application – Processing Occurs in a Future Month.
When an application is not processed within 30 days, and there is a free month, the family must pay both the second and third months’ premium. CARES Client Assistance for Re-employment & Economic Support requires that the second and third months’ premiums be paid before opening when eligibility is processed any time in the third month.
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Example 2: Cheryl and her family apply for MA on March 25th. No one in her FTG was on MA in the previous month. Her worker extends the 30-day processing time period. Her family is approved for BC on May 2nd with eligibility beginning March 1st. March is Cheryl’s free month. Cheryl must pay the premium amount for April and May before BC eligibility can begin. |
Eligibility Begins in a Future Month – Processed in the Month of Application.
When an application is processed within 30 days and eligibility does not begin until a future month, the free month is the first future month of eligibility. The client will receive a coupon for the premium amount. S/he must pay the second month’s premium by the tenth of the benefit month to remain eligible for BC. The client is responsible for paying the premium as described in 5.7.8.2.
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Example 3: Arnie and his family apply for BC on April 12th. He and his family are first eligible for BC beginning May 1st. May is the free month. A coupon for Arnie’s June premium is mailed out May 20th. Arnie must pay his premium by June 10th. |
If someone in the FTG was on MA the previous month or current month, s/he must pay the first month’s premium. If the first month of BC eligibility is this month or a prior month, the premium must be paid in advance before eligibility can begin. If the first month of eligibility is a future month, no advance premium is due.
The Income Maintenance agency collects advance Payment payments and the worker records the payment in CARES. Payment must be either a check (personal, cashiers, travelers, etc.) or a money order. Do not accept cash. The check must be made out to BadgerCare’. Complete a BC premium coupon. Write in the client’s Medicaid ID number on the BC premium coupon and on the check. Mail the client’s initial BC premium payment (check or money order) and completed BC premium coupon directly to the BadgerCare lockbox at:
BadgerCare
c/o Wisconsin Department of Health and Family Services
Box 93187
Milwaukee, WI 53293-0187
Do not co-mingle the money with other county or tribal funds. Do not combine all premiums into a county/tribal agency check.
Each agency should have a supply of blank BC premium coupons, BadgerCare Premium Employer Wage Withholding forms ( HCF-13025 ), BadgerCare Premium Recipient/ Employer Electronic Funds Transfer forms ( HCF-13026 ) and pre-addressed envelopes.
Premiums can be paid by anyone. Ask the client to identify a payor when a premium is owed, and enter that information into CARES. Regardless of who pays the premium, the premium payor identified in CARES must be a household member, and is responsible for the payment of the premium. EDS uses that information when sending the first coupon. The premium month is the benefit month.
Some Native Americans or Alaskan Natives paying BC for Native Americans/ premiums may be eligible for a reduced premium amount. The premium amount is reduced by 35.7%, which is the amount designated for the children in the household. This amount does not change regardless of the number of children in the household eligible for BC. There is no premium obligation if the only BC eligible household members are Native American or Alaskan Native children.
EDS sends corrected coupons for future benefit months for Native Americans/ tribal members that have been identified as having a reduced premium amount. Tribal outreach workers will submit the necessary information to EDS to establish the client as eligible for a refund (5.7.8.2.4), which will establish the client at EDS as eligible for a reduced premium amount. Refer any clients that are potentially eligible for a reduced premium to their local tribal agency. Refer clients that have questions about the reduced premium coupons to the BadgerCare Unit at 1-888-907-4455.
A reduced premium amount will not be reflected in the CARES premium records. View adjusted premium amounts on the BD screen on MMIS.
When requested, EDS will provide clients with instructions for choosing the payment method they want. Clients can contact the BadgerCare Unit, 1-888-907-4455.
The payment methods are:
Direct payment by check or money order.
Electronic Funds Transfer ( EFT ).
Wage withholding from each paycheck received.
(Unlike Child Support, there is no statutory requirement that the employer participate in BC premium wage withholding. If the employer decides not to participate, the client will have to choose direct pay or EFT.)
Provide clients with the Wage Withholding ( HCF-13025 ) and EFT ( HCF-13026 ) forms to allow the client to choose a payment method other than direct payment. Instruct the client to mail the completed forms to the address listed on the forms once s/he has chosen a payment method. Since it takes some time to set up EFT and wage withholding, the client pays directly until EDS informs them otherwise.
Payments can be made in advance (further than the next month), but the payment cannot exceed the current certification period.
If paying in advance, the payments must be the full amount of subsequent month’s premiums (no partial monthly payments). If the income amount changes, recalculate the premium. The client will be notified through CARES that his/her premium amount has changed. If the premium amount has decreased, EDS will refund any excess premium that was paid. If the premium amount has increased and the premium coupon has not been sent for that month, the client will receive a coupon with the new premium amount. If the premium coupons have already been sent, the client will need to pay the additional amount owed. The client will not receive a coupon for the difference that is owed.
Contact the BadgerCare Unit to issue a refund if the premium was paid in advance if the premium is for one of the following:
A month that the AG was ineligible for BC.
A month that the AG’s budgetable income drops to or below 150% of the FPL (8.1.6) and the income change was reported within ten days of the date the change occurred.
A month which requires a lower premium amount due to a change in circumstances which was in effect for the entire month so long as the change was reported within ten days of the date it occurred. The lower premium amount due is the first day of the month in which the change was reported. A refund for the difference will be issued.
Native American/Alaskan Native Premium Refunds
Native Americans or Alaskan Natives paying BC premiums can receive a refund of the portion of the BC premium that is designated for children in the household. The refund is 35.7% of the premium amount, regardless of the number of children in the household eligible for BC. If a premium has been paid for a case in which the only eligible household members are Native American or Alaskan Native children, a full refund of the premium amount will be made. EDS will send corrected coupons for future benefit months for those tribal members that have been identified as having a reduced premium amount.
Those who are eligible to receive a refund of part, or all, of their BC premium must meet all of the following criteria:
Have a child in the household who is:
A Native American or Alaskan Native tribal member, or
A natural or adoptive child of a Native American, or
Alaskan Native tribal member, or
Possesses a letter identifying the child as a descendant of a Native American or Alaskan Native tribal member, or
A natural or adoptive child of a household member that possesses a letter identifying the child as a descendent of a Native American or Alaskan Native tribal member, and
Have a child in the household who is eligible for BC, and
Have paid a premium for BC sometime after July 1, 1999. Tribal outreach workers will submit the necessary information to EDS to establish the client as eligible for the refund. Refer any clients who are potentially eligible for this refund to their local tribal agency.
A reduced premium amount will not be reflected in the CARES premium records. View adjusted premium amounts on the BD screen on MMIS. Do not issue notices regarding the refunds or reduced premium amounts. Refer clients that have questions about the status of a refund and/or a reduced premium amount to the BadgerCare Unit at 1-888-907-4455.
On-going premium payments are sent directly to the BadgerCare lockbox at:
BadgerCare
c/o Wisconsin Department of Health and Family Services
Box 93187
Milwaukee, WI 53293-0187
Checks are made out to ‘BadgerCare’. BC premiums are due on the tenth of the benefit month, no matter which payment method is chosen. For families who have chosen ‘direct pay’ as their payment method, EDS sends out the BC premium coupons on the 20th of the month before the benefit month. EFT occurs on the third business day of the benefit month.
Cases are treated differently depending on when the late payment is received. The following explains the policy based on those time differences. Clients must pay the overdue payment(s) that closed the case, but do not have to pay the following month right away to open, unless the late pay is made after the benefit month.
Example 1: If the client owed a premium for September, and does not pay it until October, then s/he will need to pay both September and October. October eligibility will pend until the payment is received by the agency and recorded in CARES.
Between Due Date and Adverse Action of the Benefit Month
The case will stay open for the benefit month even if no payment is received by the due date. It will close at the end of the benefit month if no payment is received by adverse action in the benefit month.
Between Adverse Action of the Benefit Month and the Last Day of the Benefit Month
If the client pays between adverse action of the benefit month and the last day of the benefit month, s/he can reopen. Run SFED with dates and confirm.
Example 2: Adverse action is September 16th. Jim’s September premium was due September 10th. Jim has not paid his September premium by September 16th. He pays on September 26th. The case closed effective September 30th. Run with dates to open for October. Then run without dates for November eligibility.
Anytime in Month After the Benefit Month
If the client pays any time in the month after the benefit month, s/he can reopen. S/he must pay the premium that closed the case. If s/he owes a premium for that following month, s/he must pay that premium before CARES will open BC. The client must pay you directly (not EDS). You can check with EDS to see if a premium has already been collected for that month.
When you get the payment(s), record the payment in CARES and run SFED for the benefit month and confirm. Then run SFED for the following month, and confirm.
Example 3: Adverse action is September 16th. Jim has not paid his September premium by September 16th. He finally pays on October 26th. His case closed for October. Jim must pay both the premiums for September and October since they were in arrears before he will open. To reopen the case, run SFED for October and confirm. Finally, run SFED for November and confirm. (The November premium is not due until November 10th and does not have to be paid in advance.)
Two Months After the Benefit Month
If the client pays in the second month after the benefit month, it’s a non-payment (5.7.8.5).
If the BC AG does not pay the monthly premium by adverse action in the benefit month, apply a restrictive re-enrollment period ( RRP ), unless there is good cause (5.7.9.2). The RRP begins with the first month of closure. If a late payment is received by the end of the month after the benefit month, lift the RRP.
You will be notified with an 056 “Run SFED/SFEX” alert in CARES if a BC client pays the monthly premium through EFT or direct payment by check, and the payment is rejected for insufficient funds. Apply a restrictive re-enrollment period (RRP), unless there is good cause (anything beyond the client’s control), and close the case. The RRP begins with the first month after closure. Determine if an overpayment exists, and process the overpayment (5.7.10.1).
Lower Premium - When a change is reported that results in a lower premium amount, confirm eligibility for the entire AG. EDS will refund any excess premium that was paid. The effective month of the lower premium is the month in which the change occurred or the month in which it was reported, whichever is later.
Higher Premium - When a change is reported that results in a premium for the first time or a higher premium, you must give notice to the client. CARES will not allow you to confirm if the notice requirement cannot be met. The increase is effective the following month if BC eligibility is confirmed before adverse action. If the change is confirmed after adverse action, the increase is not effective until the month after the following month.
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Example: Jessica has BC with a premium for her and her family. She reports a change in income to her worker on April 23rd that results in a higher premium amount. Jessica’s premium will not increase until June 1st. She will receive the coupon for the new premium amount at the end of May. |
Lower Premium - When adding a person to the group results in a lower premium, add the person to the group on CARES and confirm eligibility for the whole AG. EDS will refund any excess premium that was paid.
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Example 1 : A child with no income is added to the group. The group's income is now below 150% FPL (8.1.6) so it no longer owes a premium. EDS will refund the premium. |
Higher Premium - You must give a notice to the client when adding a person to the group causes the group to pay a premium for the first time or to pay a higher premium. CARES will not allow you to confirm if the notice requirement cannot be met. Certify the new person by completing and returning the HCF 10110 (formerly DES 3070) for the period you cannot confirm eligibility in CARES.
Mail:
EDS
P.O. Box 7636
Madison, WI 53707
E-mail: veds@wisconsin.gov
Fax: (608) 221-8815
The increase is effective the following month if the person add was before adverse action.
Example 2: Mike was added to Rachel’s case on June 6th (before adverse action). His income caused a premium increase. The increase is effective July 1st. Certify Mike’s BC eligibility effective June 6th by sending in a HCF 10110 for the dates between June 6th and June 30th.
If the person add was after adverse action, the increase is not effective until the second month.
Example 3: Ann was added to the case on December 22nd (after adverse action). Her income caused a premium increase. The increase is not effective until February 1st. December and January premiums are correct. Certify Ann’s BC eligibility effective December 22nd by sending in a HCF 10110 for the dates between December 22nd and January 31st.
This page last updated in Release Number : 04-01
Release Date: 01/01/04
Effective Date: 01/01/04