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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
Members may not pay more than 5% of their household income for monthly premiums and copays for BadgerCare Plus or Medicaid card services. This limit does not apply to deductibles, patient liability for Institutional Medicaid, or cost sharing for Home and Community-Based Waiver services.
The 5% cost share limit applies to members eligible for BadgerCare Plus, SSI Medicaid, and most EBD Medicaid programs. Members enrolled in MAPP and SeniorCare do not have a cost-sharing limit.
For members subject to the cost-sharing limit, a copay limit will be set on a monthly basis. The copay limit is based on the assistance group’s income used to determine eligibility. Copays are tracked based on copays the individual has incurred, not the amount of copays actually paid.
Members who are in a copay exempt category (see Section 38.2.2 Copay Exempt Populations) will not have a copay limit while they are copay exempt since they have no copays.
Members who are enrolled in any copay exempt subprograms (see Section 38.2.3 Copay Exempt Programs) will have a copay limit of $0 as there are no copays for members enrolled in these programs.
Members enrolled in the following subprograms will continue to be charged premiums and copays with no 5% cost share limit set based on their income:
| Note |
Members who are enrolled only in Medicare Savings Programs (except for Qualified Medicare Beneficiaries (QMB)) do not receive Medicaid card services and thus do not have copays. |
For members enrolled in BadgerCare Plus or EBD Medicaid subprograms that have a copay limit, copay limits will be based on the assistance group’s income used to determine eligibility. Per-member copay limits will be set based on the income tiers (see Chapter 53 Five Percent Copay Limit Tiers).
If the member is married and both spouses are enrolled in a health care program that has a copay limit (and neither spouse is exempt from copays), the copay limit will be prorated between them. If one spouse is exempt from copays (for example, due to pregnancy), the other spouse will have the full individual copay limit for their income tier.
| Example 1 |
Jane and Benji are married with two children. The entire family is enrolled in BadgerCare Plus. The assistance group has counted income which puts their household income in the >50-100% of FPL income tier for an assistance group size of four. Since both parents are eligible and must pay copays, the $26 copay limit for the household will be prorated between Jane and Benji. They will each have a monthly copay limit of $13. |
| Example 2 |
Marianne, who is pregnant, and Joe are a married couple enrolled in BadgerCare Plus with income that falls in the >50-100% of FPL income tier for a group size of three. Marianne has a pregnancy due date of March 10. Marianne is exempt from copays beginning with the first month she is certified as a pregnant woman until May 31 (the end of the month in which her 60-day postpartum period ends). While Marianne is certified as a pregnant woman and exempt from copays, Joe’s monthly copay limit is $26. After the end of the postpartum period, eligibility and copay limits will be redetermined. Beginning June 1, the household’s copay limit will be split between Marianne and Joe, and they will each have a $13 copay limit. |
If spouses are enrolled in two different health care programs (and both programs have a copay limit), the copay limit for the household will be calculated based on the assistance group with lower income and prorated between spouses. This will prevent the spouse with lower income from paying cost sharing expenses in excess of the 5% limit.
| Example 3 | Dave, his wife Debbie, and their son Derek receive health care benefits. Dave is enrolled in SSI-Related Medicaid and Debbie and Derek are enrolled in BadgerCare Plus. Due to the different income budgeting rules for SSI-Related Medicaid and BadgerCare Plus:
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If a member who is enrolled in a health care program that has a copay limit is married to someone who is enrolled in a program that has no copay limit (MAPP or SeniorCare), the member will have the full individual copay limit for their income tier.
For members who are eligible for both QMB and a full benefit health care program that has a copay limit, the income used to determine eligibility for the full benefit program will be used to calculate the member’s copay limit.
For members who pay a monthly premium, the premium amount will be subtracted automatically when the member’s copay limit is calculated in CARES. For married couples with at least one spouse subject to CLA policy, the total household premium amount will be split evenly between the married couple even if the spouses are on different benefit programs.
| Example 4 |
Mark is a CLA with income that falls in the >50-100% of FPL income tier. He is enrolled in BadgerCare Plus and pays an $8 monthly premium. His copay limit is calculated as $26 minus the $8 premium. Mark’s monthly copay limit, after his premium has been deducted, is $18. |
| Example 5 |
Alice and Barry are married and both eligible for BadgerCare Plus as childless adults with income at 85% of the FPL. They have a household premium of $6 because Alice completed a health survey and reported healthy habits while Barry did not. Their copay limit would be prorated at the >50-100% FPL tier and the $6 premium would be split evenly and deducted from their prorated copay limit (subtract $3 from both). Alice and Barry would each have a $10 copay limit. Alice suffers injuries from a car accident. She is verified as disabled and becomes eligible for SSI-Related Medicaid. Because Alice is no longer a childless adult, her health survey response does not result in a premium reduction for the household. Barry’s household premium will increase to $8. The $8 premium would be split evenly and deducted from both Alice and Barry’s copay limits (if they continue to have income greater than 50% of the FPL). |
Once determined, the copay limit will remain the same from month to month unless changes are reported that affect the copay limit, such as a change in income or household composition. Members have the right to appeal their monthly copay limit.
Increases in copay limits may not be made without providing timely notice to the member. If a change results in an increase in the member’s copay limit and eligibility is confirmed prior to adverse action for the month, the copay limit increase will be effective the following month. If eligibility is confirmed after adverse action, the copay limit increase will be effective two months after the month in which the change occurred.
If a change results in a decrease in the monthly copay limit, the decrease should be effective during the month in which the change occurred or, if the change was reported untimely (after the 10th of the month in which the change was supposed to be reported), the month in which the change was reported, whichever is later.
Members are notified once they have incurred enough copays before the end of the month to meet their monthly copay limit. This notification is informational only and members may not appeal the date the copay limit was determined to have been met. Once the copay is met for a given month, it can never become “unmet” in the same month and the member will not be charged any more copays in that month.
| Example 1 |
Tamika is enrolled in BadgerCare Plus and has a copay limit of $13 for the month of August. On August 12, interChange notifies CARES that Tamika has met her copay limit of $13. CARES issues Tamika an automated notice stating that her $13 copay limit has been met for the month of August and that she will have no copays for the remainder of the month. On August 21, Tamika has a doctor’s appointment. She will have no copay for the doctor’s appointment since her copay limit has already been met for the month of August. Starting on September 1, Tamika will be responsible for copays incurred until her monthly limit is met. |
This page last updated in Release Number: 22-03
Release Date: 12/05/2022
Effective Date: 12/05/2022
The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.
Publication Number: P-10171