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Reimbursement and Capitation

Reimbursement and Capitation

The reimbursement and capitation rates webpage contain information to assist Managed Care Organization (MCO) in receiving reimbursement for services rendered under the Department of Health Services (DHS) contract.
Questions regarding the information presented should be directed to DHSDMSBFM@dhs.wisconsin.gov

MCO Reimbursement Grid

This grid provides summary information on the Department’s reimbursement policy of the Medicaid contract. Information on this grid includes the source of the reimbursement file, the frequency, the method and type of reimbursement, and where reports showing payments or recoupments are located.

Electronic Funds Transfer User Guide

This guide is designed to assist MCOs in understanding the HPE Electronic Funds Transfer (EFT) system and being able to track any EFT related activity.

Health Insurance Fee Reimbursement Guide

This guide is designed for MCOs to report the Wisconsin specific costs associated with Section 9010 of the Affordable Care Act (ACA) Health Insurance Fee (HIF).

Maternity Kick Payment Guide

This guide is designed to support the Managed Care Organizations (MCOs) in reporting of the maternity deliveries for reimbursement in the Badgercare Plus program. Each pregnant member is covered for all care related to the pregnancy, delivery and any complications that may occur during pregnancy and up to 60 days postpartum. The Maternity Kick Payment is made to the MCO outside of the monthly Capitation payment

MMIS System Capitation Payments Rate Cell Description

This guide is designed to be used with the Capitation Load Tables below.

Resources for Enhanced Dental Services

Below are resources for the Dental Pilot program for enhanced reimbursement to Brown, Marathon, Polk, and Racine County.

The matrix below contain the maximum fee rates for orthodontic and manually priced dental services. Rates for Non-Dental Pilot and Dental Pilot counties are listed as a resource for MCOs.

Accounting Reason Codes

The Accounting Reason Codes contain the HPE assigned four digit code and description for any financial transaction between the MCO and the State.

Capitation Report Documents for BadgerCare Plus and SSI

The reports below show the capitation rates for the BadgerCare Plus (BCP) and Wisconsin's Supplemental Security Income (SSI) populations. The Childless Adult population (CLA) can be found in the BCP Capitation Report.
Year Population Rate Report Rate Exhibit
January 2016 BCP and CLA January 2016 WI BCP and CLA Rate Report January 2016 BCP and CLA Rate Exhibits
January 2016 SSI January 2016 SSI WI SSI Rate Report January 2016 SSI Rate Exhibits
2016 BCP and CLA CY16 BCP and CLA Rate Report 2016 BCP and CLA Rate Exhibits
2016 SSI CY16 SSI Rate Report 2016 SSI Rate Exhibits
2017 BCP and CLA CY17 BCP and CLA Rate Report 2017 BCP and CLA Rate Exhibits
2017 SSI CY17 SSI Rate Report 2017 SSI Rate Exhibits
2017 CCF and WAM CY17 CCF and WAM Rate Report
2018 CCF and WAM CY18 CCF and WAM Rate Report
2018 BCP and CLA CY18 BCP and CLA Rate Report 2018 BCP and CLA Rate Exhibits
2018 SSI CY18 SSI Rate Report 2018 SSI Rate Exhibits
2019 BCP and CLA CY19 BCP and CLA Rate Report 2019 BCP and CLA Rate Exhibits
2019 SSI CY19 SSI Rate Report 2019 SSI Rate Exhibits
2020 BCP and CLA CY20 BCP and CLA Rate Report 2020 BCP and CLA Rate Exhibits
2020 SSI CY20 SSI Rate Report 2020 SSI Rate Exhibits

Capitation Load Tables for BadgerCare Plus and SSI

The load tables contain the regional and programs rates which are entered into Medicaid Management Information Systems (MMIS) for the BadgerCare Plus, Childless Adult, and Supplemental Security Income populations.
Year Report
January 2016 January 2016 HMO All Program Load Tables
2016 CY16 HMO All Program Rate Load Tables
2017 CY17 HMO All Program Rate Load Tables
2018 CY18 HMO All Program Rate Load Tables
2019 CY19 HMO All Program Rate Load Tables
2020 CY20 HMO All Program Rate Load Tables

Managed Care Rate Regions

The file contains Wisconsin rate region for the BadgerCare Plus and SSI Managed Care Programs.

Encounter Based Payment Guide

SSI Care Management Billing Guide

 
 
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