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

Index

Document	Last Update
MCO Reimbursement Grid	02/28/2019
Electronic Funds Transfer User Guide	07/10/2015
Health Insurance Fee Reimbursement Guide	02/28/2019
Maternity Kick Payment Guide	01/31/2018
MMIS System Capitation Payments Rate Cell Description	02/01/2019
Resources for Enhanced Dental Services	01/01/2018
Accounting Reason Codes	02/28/2019
Capitation Report for BadgerCare Plus and SSI	01/22/2024
Capitation Load Tables for BadgerCare Plus and SSI	01/22/2024
Managed Care Rate Regions	10/28/2020
Encounter Based Payment Guide	12/27/2023
Vent Payment Guide	02/07/2024
SSI Care Management Billing Guide	02/07/2024

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.

• MCO Reimbursement Grid

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.

• Electronic Funds Transfer User Guide
• Electronic Funds Transfer Fact Page

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).

• Health Insurance Fee Reimbursement Guide
• HIF MA Calculation Template

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

• Maternity Kick Payment Guide

MMIS System Capitation Payments Rate Cell Description

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

• MMIS System Capitation Payment Rate Cell Description

Resources for Enhanced Dental Services

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

• Resources for Dental Services Providers in Brown, Marathon, Polk, and Racine Counties
• Dental Pilot MCO Frequently Asked Questions
• Dental Pilot Timeline and Expectations

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.

• Orthodontic and Manually Priced Dental Rates.

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.

• Accounting Reason Codes and Descriptions

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
2021	BCP and CLA	CY21 BCP and CLA Rate Report	2021 BCP and CLA Rate Exhibits
2021	SSI	CY21 SSI Rate Report	2021 SSI Rate Exhibits
2022	BCP and CLA	CY22 BCP and CLA Rate Report	2022 BCP and CLA Rate Exhibits
2022	SSI	CY22 SSI Rate Report	2022 SSI Rate Exhibits
2023	BCP and CLA	CY23 BCP and CLA Rate Report	2023 BCP and CLA Rate Exhibits
2023	SSI	CY23 SSI Rate Report	2023 SSI Rate Exhibits
2024	BCP and CLA	CY24 BCP and CLA Rate Report	2024 BCP and CLA Rate Exhibits
2024	SSI	CY24 SSI Rate Report	2024 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
2021	CY21 HMO All Program Rate Load Tables
2022	CY22 HMO All Program Rate Load Tables
2023	CY23 HMO All Program Rate Load Tables
2024	CY24 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.

• Managed Care Rate Regions

Encounter Based Payment Guide

• Encounter Based Payment Guide

Vent Payment Guide

• Vent Payment Guide

SSI Care Management Billing Guide

• SSI Care Management Billing Guide