28.4 Overpayment Calculation

28.4.1 Overpayment Period
28.4.2 Overpayment Amount
28.4.3 Overpayments for Individuals Eligible for Family Planning Only Services
28.4 4 Determining Liable Individual

28.4.1 Overpayment Period

Misstatement or Omission of Fact

If the overpayment is a result of a misstatement or omission of fact during an initial BadgerCare Plus applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. or review, determine the period for which the benefits were determined incorrectly and determine the appropriate overpayment amount (28.4.2).

Failure to Report

For ineligible cases, if the overpayment is a result of failure to report a required change, calculate the date the change should have been reported and which month the case would have closed or been adversely affected if the change had been reported timely.

Fraud/IPV

For ineligible cases, if the overpayment was the result of fraud, determine the date the fraudulent act occurred. The period of ineligibility should begin the date the case would have closed or been adversely affected allowing for proper notice. If an overpayment exists, but the case is still being investigated for fraud, establish the claim so collection can begin promptly. Prosecution should not delay recovery of a claim.

The ineligible period should begin with the application month.

28.4.2 Overpayment Amount

Use the actual income that was reported or required to be reported in determining if an overpayment has occurred. The amount of recovery may not exceed the amount of the BadgerCare Plus benefits incorrectly provided.

If the case was ineligible for BadgerCare Plus, recover the amount of medical claims paid by the state and/or the capitation rate. Use the ForwardHealth interChange data from the Total Benefits Paid by Medicaid Report(s). Deduct any amount paid in premiums (for each month in which an overpayment occurred) from the overpayment amount.

If the case is still eligible for BadgerCare Plus for the time frame in question, but there was an increase in the premium, recover the difference between the premiums paid and the amount owed for each month in question. To determine the difference, determine the premium amount owed and view the premium amount paid on CARESThis system supports the Income Maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs. screen AGPT.

The overpayment amount is the difference between the premium paid and premium owed even if the premium that was paid was $0.

Example: Tom and his family became eligible for BadgerCare Plus in June, without a premium. In his application Tom failed to disclose income from a second job which would have resulted in $100 per month group premium. All individuals in the group remained eligible for BadgerCare Plus. This new information was discovered in July of that year.

Overpayment Calculation

$100 premium owed for June

+ $100 premium owed for July

$200 Total premium owed

- $ 0 premium paid

$200 Overpayment

If the unreported information would have placed the individual in the Benchmark plan instead of the Standard plan, the overpayment amount would be the difference in the co-pays and deductibles for the services provided.

If a member error increases a deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. amount before the deductible is met, there is no overpayment. Recalculate eligibility and notify the member of the new deductible amount.

If the member met the incorrect deductible and BadgerCare Plus paid for services after the deductible had been met, there is an overpayment. Recover the difference between the correct deductible amount and the previous deductible amount or the amount of claims over the six month period (whichever is less).

If the member was ineligible for the deductible, determine the overpayment amount. If the member prepaid his or her deductible, deduct any amount he or she paid toward the deductible from the overpayment amount.

28.4.3 Overpayments for Individuals Eligible for Family Planning Only Services

If an individual or case was ineligible for Medicaid or BadgerCare Plus but would have been eligible for FPOSFamily Planning Only Services - This plan provides certain services and supplies to people who are of childbearing or reproductive age to prevent unplanned pregnancies. , the calculation of the BC +overpayment amount is as follows:

If the incorrect/overpaid FPOS costs were “fee for service” medical claims paid by the state, recover the amount of benefits that were actually paid by the state minus any BadgerCare Plus premiums which the member may have paid and the amount of any actual FPOS services that were provided.

If the incorrect /overpaid BadgerCare Plus benefits were paid by an HMO, recover the HMO capitation rate paid by the state minus any premiums which the member may have paid and the “average” monthly cost of the FPOS.

28.4 4 Determining Liable Individual

Except for minors, collect overpayments from the BadgerCare Plus member, even if the member has authorized a representative to complete the application or review for him or her.

If a minor received BadgerCare Plus in error, make the claim against the minor’s parent(s) or legally responsible relative, if the parent or legally responsible relative was living with the minor at the time of the overpayment.

This page last updated in Release Number: 16-02

Release Date: 08/08/2016

Effective Date: 08/08/2016