Wisconsin Medicaid does not pay for services provided to members enrolled in other state Medicaid programs. Providers are advised to contact other state Medicaid programs to determine whether the service sought is a covered service under that state's Medicaid program.
When a member travels out of state but is within the United States (including its territories), Canada, or Mexico, BadgerCare Plus and Wisconsin Medicaid cover medical services in any of the following circumstances:
Note: Some providers located in a state that borders Wisconsin may be Wisconsin Medicaid enrolled as a border-status provider if the provider notifies ForwardHealth in writing that it is common practice for members in a particular area of Wisconsin to seek his or her medical services. Border-status providers follow the same policies as Wisconsin providers.
Certain non-U.S. citizens who are not qualified aliens are eligible for services only in cases of acute emergency medical conditions. Providers should use the appropriate diagnosis code to document the nature of the emergency.
An emergency medical condition is a medical condition manifesting itself by acute symptoms of such severity that one could reasonably expect the absence of immediate medical attention to result in the following:
Due to federal regulations, BadgerCare Plus and Wisconsin Medicaid do not cover services for non-U.S. citizens who are not qualified aliens related to routine prenatal or postpartum care, major organ transplants (e.g., heart, liver), or ongoing treatment for chronic conditions where there is no evidence of an acute emergent state. For the purposes of this policy, all labor and delivery is considered an emergency service.
Note: Babies born to certain non-qualifying immigrants are eligible for Medicaid enrollment under the CEN option. However, babies born to women with incomes over 300 percent of the FPL are not eligible for CEN status. The baby may still qualify for BadgerCare Plus. These mothers should report the birth to the local agencies within ten calendar days.
A provider who gives emergency care to a non-U.S. citizen should refer him or her to the local county or tribal agency or ForwardHealth outstation site for a determination of BadgerCare Plus enrollment. Providers may complete the Certification of Emergency for Non-U.S. Citizens form for clients to take to the local county or tribal agency in their county of residence where the BadgerCare Plus enrollment decision is made.
Providers should be aware that a client's enrollment does not guarantee that the services provided will be reimbursed by BadgerCare Plus.
Most individuals detained by legal process are not eligible for BadgerCare Plus or Wisconsin Medicaid benefits.
Note: "Detained by legal process" means a person who is incarcerated (including some Huber Law prisoners) because of law violation or alleged law violation, which includes misdemeanors, felonies, delinquent acts, and day-release prisoners.
Pregnant women detained by legal process who qualify for the BadgerCare Plus Prenatal Program and state prison inmates who qualify for Wisconsin Medicaid or BadgerCare Plus during inpatient hospital stays may receive certain benefits. Additionally, inmates of county jails admitted to a hospital for inpatient services who are expected to remain in the hospital for 24 hours or more will be eligible for PE determinations for BadgerCare Plus by qualified hospitals. Refer to the Presumptive Eligibility chapter of either the Inpatient or Outpatient Hospital service area for more information on the PE determination process.
The DOC oversees health care-related needs for individuals detained by legal process who do not qualify for the BadgerCare Plus Prenatal Program or for state prison inmates who do not qualify for Wisconsin Medicaid or BadgerCare Plus during an inpatient hospital stay.
As a result of 2013 Wisconsin Act 20, the 2013-15 biennial budget, state prison inmates may qualify for Wisconsin Medicaid or BadgerCare Plus during inpatient hospital stays.
Only inmates of a state prison, not a county jail, are eligible to receive benefits. To qualify for Wisconsin Medicaid or BadgerCare Plus, state prison inmates must meet all applicable eligibility criteria. The DOC coordinates and reimburses inpatient hospital services for inmates who do not qualify for Wisconsin Medicaid or BadgerCare Plus.
Inmates are eligible for Wisconsin Medicaid or the BadgerCare Plus Standard Plan for the duration of their hospital stay. Eligibility begins on their date of admission and ends on their date of discharge.
Inmates are not eligible for outpatient hospital services, including observations, under Wisconsin Medicaid and BadgerCare Plus. Inmates may only be eligible for ER services if they are admitted to the hospital directly from the ER and are counted in the midnight census; otherwise, ER services are considered outpatient services. Outpatient hospital services approved by the DOC are reimbursed by the DOC.
Inmates are not presumptively eligible. Retroactive eligibility will only apply to dates of admission on and after April 1, 2014.
The DOC coordinates the submission of enrollment applications on behalf of inmates.
The only services allowable by Wisconsin Medicaid or BadgerCare Plus for inmates are inpatient hospital services and professional services provided during the inpatient hospital stay that are covered under Wisconsin Medicaid and BadgerCare Plus. Providers with questions regarding services covered by Wisconsin Medicaid and BadgerCare Plus may refer to the applicable service area or contact Provider Services.
Inmates receive services on a fee-for-service basis; they are not enrolled in HMOs.
The DOC will assist inpatient hospital providers with their submission of PA requests for any services requiring PA. If PA is denied, the DOC is responsible for reimbursement of the services.
Inmates are only enrolled for the duration of their hospital stay. Providers should always verify an inmate's enrollment in Wisconsin Medicaid or BadgerCare Plus before submitting a claim.
When submitting a claim for an inmate's inpatient hospital stay, providers should follow the current claim submission procedures for each applicable service area.
Acute care hospitals that provide services to inmates are reimbursed at a percentage of their usual and customary charge.
Critical access hospitals that provide services to inmates are reimbursed according to their existing Wisconsin Medicaid reimbursement methodology.
Wisconsin Medicaid reimburses professional services related to an inmate's inpatient hospital stay (e.g., laboratory services, physician services, radiology services, or DME) at the current maximum allowable fee.
Providers may contact the DOC at (608) 240-5139 or (608) 240-5190 with questions regarding enrollment or PA for inmate inpatient hospital stays.
Retroactive enrollment occurs when an individual has applied for BadgerCare Plus or Medicaid and enrollment is granted with an effective date prior to the date the enrollment determination was made. A member's enrollment may be backdated to allow retroactive coverage for medical bills incurred prior to the date of application.
The retroactive enrollment period may be backdated up to three months prior to the month of application if all enrollment requirements were met during the period. Enrollment may be backdated more than three months if there were delays in determining enrollment or if court orders, fair hearings, or appeals were involved.
When a member receives retroactive enrollment, he or she has the right to request the return of payments made to a Medicaid-enrolled provider for a covered service during the period of retroactive enrollment, according to DHS 104.01(11), Wis. Admin. Code. A Medicaid-enrolled provider is required to submit claims to ForwardHealth for covered services provided to a member during periods of retroactive enrollment. Medicaid cannot directly refund the member.
If a service(s) that requires PA was performed during the member's period of retroactive enrollment, the provider is required to submit a PA request and receive approval from ForwardHealth before submitting a claim.
If a provider receives reimbursement from Medicaid for services provided to a retroactively enrolled member and the member has paid for the service, the provider is required to reimburse the member or authorized person acting on behalf of the member (e.g., local General Relief agency) the full amount that the member paid for the service.
If a claim cannot be filed within 365 days of the DOS due to a delay in the determination of a member's retroactive enrollment, the provider is required to submit the claim to Timely Filing within 180 days of the date the retroactive enrollment is entered into Wisconsin's EVS (if the services provided during the period of retroactive enrollment were covered).
Occasionally, an individual with significant medical bills meets all enrollment requirements except those pertaining to income. These individuals are required to "spenddown" their income to meet financial enrollment requirements.
The certifying agency calculates the individual's spenddown (or deductible) amount, tracks all medical costs the individual incurs, and determines when the medical costs have satisfied the spenddown amount. (A payment for a medical service does not have to be made by the individual to be counted toward satisfying the spenddown amount.)
When the individual meets the spenddown amount, the certifying agency notifies ForwardHealth and the provider of the last service that the individual is eligible beginning on the date that the spenddown amount was satisfied.
If the individual's last medical bill is greater than the amount needed to satisfy the spenddown amount, the certifying agency notifies the affected provider by indicating the following:
The certifying agency also informs ForwardHealth of the individual's enrollment and identifies the following:
When the provider submits the claim, the spenddown amount will automatically be deducted from the provider's reimbursement for the claim. The spenddown amount is indicated in the Member's Share element on the Medicaid Remaining Deductible Update form sent to providers by the member's certifying agency. The provider's reimbursement is then reduced by the amount of the member's obligation.