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State of Wisconsin |
Release 25-02 |
Members may not pay more than five percent 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 five percent 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 (21.5.2 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 (21.5.3 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 five percent 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 a health care program that has 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 Section 39.12 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 and enrolled in SSI-Related Medicaid. 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 two. Since both Jane and Benji are eligible and have to 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. |
| Note: |
If needed, use the following formula to determine the assistance group income FPL percentage and the appropriate tier: Assistance Group Income / (100% FPL for the group size) = Assistance Group Size % FPL. |
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 five percent limit.
| Example 2: |
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:
To determine the copay limit for the household, the lower BadgerCare Plus assistance group income tier of 0-50% of FPL will be used. Debbie, Dave, and Derek each have a $0 copay limit, meaning they will not be charged any copays. |
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 his or her income tier.
| Example 3: |
Sean and Sandra are a married couple. Sean is enrolled in SeniorCare and Sandra is enrolled in medically needy SSI-related MA. The countable income for Sandra’s SSI-Related Medicaid assistance group is 72% of the FPL, which puts this assistance group in the >50-100% of FPL income tier. Because Sean is enrolled in a program that has no copay limit, Sandra will pay the full individual copay limit of the 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.
| Example 4: |
Dwayne is eligible for both SSI-Related Medicaid and Medicare. He also qualifies for QMB. Under SSI-Related Medicaid, Dwayne’s income is in the >50-100% of FPL tier. His copay limit is $26 per month based on his SSI-Related Medicaid eligibility. Since QMB is a limited benefit program, no copay limit will be set for QMB. If Dwayne were only eligible for QMB, his copay limit would be set based on the income used to determine his eligibility for QMB. |
For Group B and B Plus Home and Community Based Waiver members, the copay limit will be based on the member’s cost share amount for Waiver services rather than the income used to determine the member’s eligibility.
| Example 7: |
Marge is a Group B waiver member. Her Waiver cost share amount is $15. Because this amount is less than $27, Marge’s copay limit is $0, which means that she will not be charged any copays. |
| Example 8: |
George is a Group B waiver member. His Waiver cost share amount is $120. George’s copay limit is $26 because his cost share amount is greater than $27. |
If a Group B or B Plus Waiver member is married to someone who is also a Group B or B Plus Waiver member or is enrolled in another Medicaid subprogram that has a copay limit (and who is not exempt from copays), the copay limit calculated for the spouse in the lower copay limit tier will be prorated between the two spouses.
| Example 9: |
If Marge and George in examples 6 and 7 above were a married couple, the copay limit for the household would be based on the spouse in the lower copay limit tier (in this case, Marge). Marge and George would therefore each have a copay limit of $0. |
| Example 10: |
Trevor and Kate are married and enrolled in different health care benefits. Trevor is eligible for SSI-Related Medicaid and his income falls in the >0-50% FPL tier. Kate is eligible for Community Waivers Group B. Her Waiver cost share amount is $65. Since Trevor’s income would be in a lower FPL tier than Kate’s Waiver cost share amount, Trevor and Kate would each have a copay limit of $0. |
If a Group B or B Plus Waiver member is married to someone who is enrolled in a program that has no copay limit (MAPP or SeniorCare), the Waiver member will have the full individual copay limit for his or her copay limit tier.
| Example 11: |
Steve and Angela are a married couple. Steve is a Group B Plus Waiver member and Angela is enrolled in MAPP. Steve’s Waiver cost share amount is $30, so his copay limit is based on the >50-100% of FPL income tier. Angela has no copay limit. |
If an SSI Medicaid member is married to someone who is enrolled in BadgerCare Plus or an EBD Medicaid subprogram that has a copay limit, each spouse’s copay limit will be calculated individually and the copay limit will not be prorated between spouses.
| Example 12: |
Chantal and Peter are married and both are receiving health care benefits. Chantal is eligible for SSI Medicaid and Peter is eligible for SSI-Related Medicaid with income at 84% of the FPL. Chantal and Peter will each have individual copay limits as listed in Appendix 39.12 Five Percent Copay Limit Tiers. |
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 (more than ten days after the change occurred), 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 13: |
Tamika is enrolled in HCBW and has a copay limit of $26 for the month of August. On August 12, interChange notifies CARES that Tamika has met her copay limit of $26. CARES issues Tamika an automated notice stating that her $26 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. On September 1, Tamika will be responsible for copays incurred until her monthly limit is met. |
This page last updated in Release Number: 24-02
Release Date: 08/22/2024
Effective Date: 01/01/2024
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030