Eligibility Reinstatements for Some Medicaid and BadgerCare Plus Members May Require Provider Action

Due to policy clarifications recently issued by the Centers for Medicare & Medicaid Services (CMS) regarding administrative renewals, Wisconsin will be reinstating Medicaid and BadgerCare Plus coverage for some members who lost eligibility in July, August, or September 2023. Up to 4,000 members will have their coverage reinstated back to the date when it ended.

If members received care during the time that their coverage was not in effect, providers will need to resubmit claims. Payments made by a member for any such care must also be refunded as appropriate.

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Administrative renewals are a process in which members’ Medicaid or BadgerCare Plus eligibility can be automatically renewed for another 12 months based on information on file and available to the state through data exchanges.

CMS has issued recent policy clarifications requiring all states to complete administrative renewals at an individual level, rather than a household level. Previously, administrative renewals completed at the household level resulted in circumstances wherein if any one household member could not be administratively renewed, no members of the same household were administratively renewed, even if they may have been eligible individually.

Wisconsin is actively working on policy and technical changes to comply with CMS guidance, including restoring coverage to affected BadgerCare Plus or Wisconsin Medicaid members who may have been impacted by a household-level administrative renewal and lost eligibility in July, August, or September 2023. If a member states that their coverage has been restored, providers can verify this through the ForwardHealth Portal and resubmit any claims for reimbursement. If a provider has questions, they should contact their field representative for assistance.