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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/ |
6.3.7.6 BadgerCare HMO Enrollment
HIPP pays the employee’s portion of the employer subsidized health care coverage. EDS determines if it is more cost effective to buy the employer's insurance or enroll them in BC or 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..
To assess cost effectiveness, EDS checks:
If the employer pays 60-80% of the premium cost, and
For BC, that no one has been enrolled in the past six months in a HIPAA plan in which the policy owner is an AG member.
If these two criteria are met, then EDS looks at projected costs of the insurance premiums, co-insurance and deductibles. Those costs are then compared to the projected expense of paying for medical services directly through MA.
If it is cost-effective to buy the employer-subsidized insurance, the HIPP Unit will notify those clients who are required to enroll in an employer’s health plan and provide additional information related to enrollment, coverage, and cooperation.
HIPP may pay the premium for a non-MA family member if that member needs to enroll in the group health plan in order to obtain coverage for the MA client. MA will only pay for the premiums of the ineligible family member(s) and not any of their other cost sharing expenses (e.g. prescription co-pays). MA will continue to cover the employer’s health insurance premium, deductibles and co-insurance for the MA client.
Clients participating in HIPP will have MA as a backup. If the employer’s health insurance does not cover something that MA does, then MA will pick up the payment.
To remain eligible for BC or MAPP, the adult whose employer can provide insurance must:
Cooperate in providing information necessary to assess cost-effectiveness, and
Agree to enroll and actually enroll in the employer’s health care plan if the plan is determined to be cost-effective.
Failure to cooperate or enroll in the employer’s plan is non-cooperation. The adult who could get insurance coverage is not eligible for BC or MAPP. If one adult fails to cooperate, it does not affect the spouse or children’s MA eligibility.
The EDS HIPP unit worker will communicate HIPP non-cooperation directly to you. Enter the non-cooperation and the ineligible adult will close after the next adverse action.
Listed below are two exceptions to participating in HIPP:
Clients who are enrolled in a Special Managed Care Program ( SMCP ).
Some examples of SMCP’s are Independent Care Program, Elder Care Option Program, and Wraparound Milwaukee. Do not consider the client non-cooperative if s/he refuses to participate in HIPP while enrolled in a SMCP. The HIPP Unit will monitor the client’s enrollment in SMCP’s to determine the client’s responsibility for HIPP participation.
A client who is unable to enroll in an employer’s health plan on their own behalf.
An example of this situation would be when a MAPP client’s spouse is unwilling to enroll the client in their employer based health plan. Since the client’s spouse has the cost-effective employer’s health plan, but chooses not to enroll the MAPP client, the coverage under that plan is considered unavailable to the client.
If it is not cost-effective to buy the employer-subsidized insurance, the client will remain eligible for MAPP or BC.
If it is not cost-effective to buy the employer-subsidized HMO Enrollment insurance, EDS enrolls family members into a BadgerCare HMO. If only one HMO in an area accepts BC clients, s/he can choose to remain fee-for-service. If you indicate that the AG has access to insurance in CARES Client Assistance for Re-employment & Economic Support, EDS will not enroll them in a HMO until the HIPP test is completed.
This page last updated in Release Number : 02-04
Release Date: 10/01/02
Effective Date: 10/01/02
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