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Frequently asked Questions from the BadgerCare Plus Core Plan Provider Training sessions (June 2009)

Frequently asked Questions from the BadgerCare Plus Core Plan Provider Training sessions (June 2009)


Question:Once a person applies online how does he or she pay the $60 application fee?
Answer:The application fee can be paid online by credit card, debit card or electronic check. If a member is going to mail the payment he or she should mail the payment slip and the payment directly to the Enrollment Support Center (ESC).
Question:If someone is currently living in Illinois, but plans to move to Wisconsin can he or she apply for the BadgerCare Plus Core Plan?
Answer:The person must be physically present in Wisconsin in order to apply for the Core Plan.
Question:What happens if someone loses or is laid off from his or her job due to no fault of his or her own? Does he or she need to wait 12 months before applying for Core Plan?
Answer:No, this scenario falls into one of the exceptions to the 12-month health insurance requirement. A list of health insurance and exceptions can be found at the following Web site: http://badgercareplus.org/core/publications.htm.
Question:If someone has only a major medical plan, is this 'insurance'?
Answer:Yes.
Question:What if a member has other insurance through the Consolidated Omnibus Reconciliation Act (COBRA)? Does this make him or her ineligible for the Core Plan?
Answer:Yes, because this is an insurance plan.
Question:Why does the Core Plan have the rule that states members can't have other insurance for 12 months?
Answer:This is a federal requirement and is part of the waiver.
Question:What if the member does not have access to a personal computer?
Answer:The member can contact the ESC directly by telephone or work with a community partner who can assist them with enrolling online.
Question:How long does it take to complete application online?
Answer:The application process takes approximately 30 minutes.
Question:Will applications/enrollment be back dated?
Answer:No we won't be backdating enrollment for Core Plan members.
Question:Do members enrolling in the Core Plan have to provide proof of employment (e.g. taxes, paystub)?
Answer:Yes.
Question:Are routine mammograms covered?
Answer:Yes, this is covered under the physician services area.
Question:What Current Procedural Terminology (CPT) codes meet the physical exam requirement?
Answer:99385, 99386, 99395, 99396, 99203, 99204, 99205, 99214, 99215, 99243, 99244, 99245, 99253, 99254, 99255, 99221, 99222, 99223, 99234, 99235, 99236, 99284, 99285, 99326, 99327, 99328, 99336, 99337, 99343, 99344, 99345, 99349 and 99350.
Question:Is substance abuse detoxification covered?
Answer:Yes, if provided by a physician, but no post treatment is covered.
Question:Is there coverage for psychiatric testing?
Answer:No; however, all services normally provided by a psychiatrist under the physician services benefit are covered.
Question:If an HMO covers transportation is that OK?
Answer:Yes; however, it is not billable to Wisconsin Medicaid or BadgerCare Plus.
Question:Will the new BadgerCare Plus Core Plan card show Core 1 or 2?
Answer:No. You will need to verify enrollment in order to determine if the member is enrolled in the BadgerCare Plus Core 1 or 2 Plan.
Question:Can you deny a Core Plan member service if he or she doesn't pay his or her copay?
Answer: Yes.
Question:How is the member notified he or she has met their maximum service limitation under the Core Plan (e.g., therapy services)?
Answer:Members need to keep track of the number of services they have used. Also, the provider will be responsible for tracking this in order to assure the claim is not denied.
Question:How can a provider tell if a member has met his or her service limitations under the Core Plan?
Answer: The provider can contact Provider Services.
Question:What happens if a member is enrolled in an HMO and meets the covered service limitation and then moves to fee-for-service? Is the HMO required to notify the Department of Health Services (DHS) that the member has reached his or her covered service limitation?
Answer:No, the HMO is not required to notify the DHS that the member has reached the service limitation. In this situation the service limitation would start over when they moved to fee-for-service.
Question:If the DHS determines that a member is no longer eligible for the Core Plan will we retroactively disenroll a member and recoup services from a provider that may have already been performed?
Answer:No. We won't retroactively disenroll a member from the Core Plan. A member's enrollment will always end the last day of the month. Providers should always verify enrollment to validate if the member is eligible for benefits.
Question:If there a payment plan for the $60 enrollment fee?
Answer:No.
Question:Is the Core Plan benefit primary over the Health Insurance Risk Sharing Plan (HIRSP) and the Wisconsin Well Woman Program (WWWP)?
Answer:Yes.
Question:What happens if member doesn't get an exam within 12 months?
Answer:They will be disenrolled from the Core Plan for six months unless they have a "Good Cause" reason for not completing a physical exam.
Question:Are there agencies that have funds to pay the Core Plan enrollment fee?
Answer:A Medicaid-certified provider is not allowed to pay the fee. Community support agencies can pay the enrollment fee. A list is being developed that you can give to members that includes agencies that will provide this support.
Question:Are we going to inform HMOs about physicals performed prior to a member being enrolled in an HMO?
Answer:Yes. We will review fee-for-service claims and encounter data to get this information.
Question:When will this notification occur?
Answer:This will be done through a report that is exchanged with the HMOs on a monthly basis.
Question:Are ostomy supplies now covered under the Core Plan?
Answer:Yes, this has been added as a covered service under the Core Plan. See the June 2009 ForwardHealth Update (2009-33), titled "Expansion of the BadgerCare Plus Core Plan for Adults with No Dependent Children," for a specific list of codes that are covered.
Question:What is the definition of emergency dental services?
Answer:Emergency dental services are those related to relief of pain. A copy of the procedure codes that are considered emergency dental services can be found in Update 2009-33.
Question:Will providers have access to a list of dentists who are taking Core Plan members?
Answer:The Member area of the ForwardHealth Portal area has a listing of certified dentists by county. This does not mean that they are taking members. Non-certified providers can take members as "in-state emergency only."
Question:If a Core Plan member goes into the physician's office and has dental pain, are the physician services covered?
Answer:Yes.
Question:If you find a psychiatrist to perform psychotherapy will this be covered?
Answer:Yes.
Question:Does the Core Plan cover obstetrics/gynecology (OB/GYN) exams?
Answer: Yes; however, if a woman becomes pregnant she is no longer eligible for the BadgerCare Plus Core Plan. The member would need to contact the ESC to find out about other programs for which she may qualify.
Question:If a member wants services beyond the covered service limitations can providers request prior authorization?
Answer: No.
Question:How is a member's income determined if the member's income fluctuates?
Answer:Income is based on an average of 12 months.
Question:What if the member's income increases after he or she is enrolled in the Core Plan, will he or she lose eligibility?
Answer:No, the member will remain enrolled for the full 12 months unless one of the reasons for exemptions occurs (e.g., out of state move, pregnancy, access to other health insurance, member turns 65 years of age, member is incarcerated or institutionalized).
Question:What is the average turn around time for the application?
Answer:The DHS will process the application within 30 days.
Question:Once the one year enrollment expires, does the member need to reapply?
Answer:Yes, the person needs to reapply and pay the $60 application fee.
Question:Does the member need to have another physical exam if he or she is enrolled for two consecutive years?
Answer:No. The physical exam requirement only needs to be performed once during the first year.
Question:If a person is in his or her waiting time for Supplemental Security Income (SSI) can they apply for Core Plan?
Answer:Yes.
Question:Will the enrollment materials that are sent to members be in multiple languages?
Answer:Yes, it will be in Spanish as well as English.
Question:Until the Core Plan is phased in for HMO enrollment can members go anywhere for services?
Answer:Yes, the member will be enrolled fee-for-service and can see any Medicaid-certified provider.
Question:Can a member who is enrolled in the Core Plan switch HMOs?
Answer:Members can change within the first 90 days.
Question:Do people go on and off of the Core Plan?
Answer:No, unless they meet one the reasons for termination (e.g. out of state move, access to other health insurance coverage).
Question:If a woman is enrolled in the Core Plan and becomes pregnant what should a provider do?
Answer:The provider should have the member call ESC so the member can be enrolled in BadgerCare Plus for pregnant women.
Question:Are podiatry services covered under the Core Plan?
Answer:If provided by a physician. Podiatrists are not covered.
Question:Can a member be enrolled in both the Family Planning Waiver (FPW) and the Core Plan?
Answer:Yes.
Question:Will reimbursement for outpatient hospital services be per diem? Will the copays be multiple per service provided?
Answer:Per diem. One copayment per day for services provided for outpatient hospital services.
Question:Are providers required to have members sign a waiver for services that are not covered under the Core Plan?
Answer: No; however, it is suggested that providers have the member sign a waiver stating they will pay for non covered services.
Question:Under the Core Plan, a member has a maximum of 20 visits per therapy discipline. If a medical doctor orders more than 20 visits, is that billable?
Answer:No, the service is not covered and the member is responsible.
Question:If the member says they don't have money can the provider take the member to collections?
Answer:Yes.
Question:Does the member get an explanation of what the services are that are covered?
Answer:Yes, the member receives an Enrollment and Benefits brochure. If a member has questions about what services are covered under the Core Plan, he or she can contact the ESC at (800) 291-2002 between the hours of 7:00 a.m. — 6:00 p.m. Monday through Friday. Providers can also refer members to the following Web site: http://dhs.wisconsin.gov/badgercareplus/core/index.htm.
Question:Does the member identification number stay the same if a member moves from the BadgerCare Plus Standard Plan or the BadgerCare Plus Benchmark Plan to the Core Plan?
Answer:Yes.
Question:How will current Core Plan members (members with medical status codes GT) be identified?
Answer: BadgerCare Plus Core Plan 1.
Question:Is this considered a Medicaid program?
Answer:The BadgerCare Plus Core Plan is a Medicaid waiver program, but not an entitlement.
Question:When a member applies for the Core Plan, what information does he or she have to send to ESC?
Answer:Core Plan applicants will receive a verification request that explains the proof we need. They will be given a minimum of 10 days to provide it. They will need to provide proof of income (taxes, paystub) and if claiming good cause for losing health insurance coverage they would need to provide proof of this. Also, if they weren't born in Wisconsin, they will need to send a copy of their birth certificate or passport.
Question: The member is enrolled in the FPW and the Core plan and sees a physician for a health-related issue and also receives an intrauterine device (IUD) during the visit. Does the provider bill a single claim for both Core Plan and FPW?
Answer:Yes, the provider can bill one claim. The office visit would be paid under the Core Plan and the IUD would be paid under the FPW.
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