|
|
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/ |
Calculate premiums using only client income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter.. Calculate a premium if gross monthly amount exceeds 150% of FPL (8.1.6) for the appropriate fiscal test group size.
Steps to calculate monthly premium amount:
From gross monthly unearned income, subtract the following:
Special Exempt Income (4.1.3.2).
Standard Living Allowance (8.1.5.1).
Impairment Related Work Expenses ( IRWE ). For MAPP The Medicaid Purchase Plan (MAPP) offers people with disabilities who are working or interested in working the opportunity to obtain health care coverage through the Wisconsin Medicaid Program., use only anticipated incurred expenses, past medical expenses are not allowed. (4.1.3.4).
Medical Remedial Expenses ( MRE ). For MAPP, use only anticipated incurred expenses, past medical expenses are not allowed. (4.1.3.3)
Current COLA Cost of Living Adjustment Disregard from January 1st through the date the FPL is effective in CARES Client Assistance for Re-employment & Economic Support for that year. 503, DAC Disabled Adult Child, widow/widower disregards allowed in eligibility determinations can not be allowed in premium calculations.
The balance is the Adjusted Countable Unearned Income. This number may be a negative number.
From gross monthly earned income, subtract any remaining deductions from #1. If the result from #1 is a negative amount, change it to a positive number. The balance is the Adjusted Earned Income.
Multiply the adjusted earned income by three percent (.03).
Add the results of #3 and #1 together.
Compare the result from #4 to the Premium Schedule (8.1.13) to determine monthly premium amount.
If the client puts (earned or unearned) in an amount that exceeds 50% of the actual earnings into an Independence Account, penalize the client using the following formula. At review, look back 12 months and take the:
Total verified Annual Deposits minus 50% of verified annual gross earned income divided by 12 = monthly assessment.
Add this monthly assessment to the premium for the next 12 months of eligibility. Only impose Independence Account penalties if the client is otherwise required to pay a premium.
|
Example: Brenda deposited $1,200 more than 50% of her actual annual gross earned income in her Independence Account. If Brenda’s income exceeds 150% of the FPL (8.1.6) and she is responsible for a monthly premium, add the monthly assessment of $100 to her monthly premium for the next 12 months. If Brenda’s income does not exceed 150% of the FPL (8.1.6), do not impose a penalty. |
There are no free premium months. Before eligibility confirmation, the client must pay applicable premiums for the initial benefit month and for any backdate months for which the client elects coverage. If determining eligibility in the month after application, the premium for the second month also must be paid before confirming eligibility.
|
Example 1: Eric applies for MAPP on January 29th, but his application is not processed until February 11th. You determine that he owes a $50 premium per month. Before confirming eligibility, Eric must pay a $50 premium for January and a $50 premium for February. |
|
Example 2: If Eric applies for MAPP on January 29th. Eric is requesting MAPP for February but not January. CARES will not pend the case for February’s premium because you are processing it in January. Confirm the case. The Medicaid fiscal agent will pursue collection of the premium for February. |
Complete the premium coupon and the Medicaid Purchase Plan ( MAPP ) Recipient/Premium Information ( HCF 10122 ) for benefit months prior to January 2002. For benefit months beginning January 2002, CARES will send premium information to MMIS, but the IM continues to be responsible for collecting the premium due for initial month(s) and any backdated months for which the client elects coverage. Complete the premium coupon and record receipt of the premium payment in CARES.
Send MAPP premium payments separate from BadgerCare premium payments and other agency funds. Send premium payments to the following address:
Medicaid Purchase Plan
P.O. Box 6738
Madison, WI 53716-0738
When requested, EDS will provide clients with instructions for choosing the payment method they want. Clients can contact Recipient Services at 1-800-362-3002.
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 premium wage withholding. If the employer decides not to participate, the participant will have to choose direct pay or EFT.)
Provide clients with the MAPP Premium Recipient/Employer Electronic Funds Transfer ( HCF 13023 ) and MAPP Premium Employer Wage Withholding ( HCF 13024 ) forms to allow the client to choose a payment method other than direct payment. Since it takes some time to set up EFT and wage withholding, the client pays directly until EDS informs them otherwise.
Clients can make advance payments, but the payment cannot exceed the certification period. If paying in advance, the payments must be the full amount of subsequent month’s premiums (no partial month payments). If the income amount changes, recalculate the premium. The client will be notified through CARES that their 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.
EDS issues refunds if the client:
Lost MAPP eligibility and already paid the premium. Refunds will only be given if adverse action notice requirements were met.
Overpaid. The client overpaid and the excess cannot be applied to the next month’s premium.
Retroactive Adjustment. The premium was recalculated and reduced for prior month(s).
Requested to close MAPP and already paid the premium.
The client’s estate can receive a refund if s/he dies between adverse action and the beginning of the benefit month.
Ongoing premium payments are sent to the MAPP Premium Unit. Checks are made out to “Medicaid Purchase Plan.” MAPP premiums are due on the tenth of the benefit month, no matter which payment method is chosen. For clients who have chosen ‘direct pay’ as their payment method, EDS sends out the premium coupon on the 20th of the month before the benefit month. The payment must be received at EDS by the tenth of 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 payment that closed them, 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 ( AA ) in the benefit month.
Between Adverse Action of the Benefit Month and the Last Day of Benefit Month
If the client pays between AA 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 does pay 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 them. If they owe a premium for that following month, s/he must pay that premium before CARES will open MAPP. 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 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 it, 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 is a non-payment (5.12.5.6).
If a MAPP client does not pay the monthly premium by adverse action in the benefit month, apply a restrictive re-enrollment period ( RRP ) (5.12.6), unless there is good cause (5.12.6.1). 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 MAPP 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 which is 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.
If a MAPP client chooses to de-request MAPP coverage, or opt out, anytime prior to the beginning of the next benefit month, close the case in CARES for the next possible month. If the case cannot be closed in CARES at the end of the current benefit month, do not impose a RRP. Close the case in CARES. Submit a HCF 10110 (formerly DES 3070) by mail, e-mail or fax.
Mail:
EDS
P.O. Box 7636
Madison, WI 53707
E-mail: veds@wisconsin.gov
Fax: (608) 221-8815
Enter “MAPP OPT OUT” in red in the comment section of the 3070.
|
Example 1: Sally calls her worker on July 25th to de-request MAPP for August. Since Sally opted out prior to the benefit month Sally should not owe a premium for August. The worker will need to change the request for MAPP on ANMR and “zero” out the premium due for August.
To zero out the premium the worker has to alter the income for the process month. The altered income should be low enough that MAPP still passes with no premium, and high enough that the applicant does not qualify for another MA subprogram. At this point the worker would have to run the eligibility with appropriate dates and confirm the results. A RRP should not be imposed because Sally de-requested August MAPP coverage prior to the beginning of the benefit month.
Her worker must override the RRP on AGRR by entering an override RRP end date using the reason code “SY”, system problem. Change the request for MAPP on ANMR to “N”, and suppress the CARES notice stating that the client’s MAPP eligibility will end August 31st. Send a manual negative notice indicating that the client’s MAPP eligibility ends July 31st. |
A MAPP applicant’s decision to “opt out” does not affect other family members eligibility for MA or MA related Programs.
This page last updated in Release Number : 03-02
Release Date: 04/01/03
Effective Date: 04/01/03