What is BadgerCare Plus and Wisconsin Medicaid?

Wisconsin Medicaid is a joint state and federal program that provides healthcare coverage for the state’s citizens who have a very low income and people with qualifying disabilities. Although it is funded by both the federal and state government, it is primarily administered at the state level.  The Wisconsin Department of Health Services is the state agency that is responsible for this oversight. A part of DHS, ForwardHealth is the umbrella program that brings together many state agencies and programs to provide an improved and more efficient healthcare experience.

In addition to Medicaid, Wisconsin also administers BadgerCare Plus, a similar program for groups of people who need healthcare coverage but who may not qualify for Medicaid or who need different kinds of services. BadgerCare Plus is also sometimes informally referred to as just BadgerCare.

What You Should Know about Wisconsin Medicaid Includes:

Is BadgerCare Medicaid?

No. BadgerCare Plus is a separate program from Medicaid. It offers similar benefits and also targets low income and disabled residents but has different parameters and eligibility.

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Medicaid and BadgerCare Eligibility in Wisconsin

To be eligible for Wisconsin Medicaid, you must meet certain requirements before submitting your application.  In general, the following eligibility standards apply:

  • You must be a resident of Wisconsin
  • Be a U.S. citizen or legal immigrant
  • Meet financial income and resources limitations standards

Wisconsin Medicaid offers several programs that will have more specific eligibility requirements and will depend on the type of care you need.  You will need to review specific program details to determine if you are eligible or call Wisconsin Medicaid to discuss your particular situation.

BadgerCare provides healthcare coverage programs for low-income Wisconsin residents who are not elderly, blind or disabled but still need healthcare coverage. It does not have an open enrollment period, and people can apply at any time.

Eligible groups include:

  • All children under age 19, regardless of income.
  • Pregnant women with incomes up to 300% of the Federal Poverty Level (FPL).
  • Parents and relatives caring for a child up to 200% of the FPL.
  • Young adults in foster care who turn 18 on or after January 1, 2008, will automatically be able to get BadgerCare until they turn 21, regardless of income.
  • Farm families and other families who are self-employed may be eligible under BadgerCare if their income is under 200% of the FPL.
  • Parents whose child/children are in foster care and who have a reunification plan in place may be eligible for BadgerCare if their income is below 200% of the federal poverty level.
6 Groups Eligible for BadgerCare Plus

How to Apply for Medicaid and BadgerCare Plus in Wisconsin

Before you start the application process, you should have the following information available: 

  • You and your spouse’s taxable income.
  • Social Security numbers and birthdates of people in your home. 
  • Current or recent health insurance information.
  • Identity and citizenship information, or alien registration information.
  • Income information including employer name, address and phone number, of all household members who are employed.
  • Amount of money received from other types of income. 
  • Expected date of delivery and number of babies of any pregnant household member.
  • Current health insurance information for all household members with health insurance including company name, policy or group number, type of coverage, effective date, policy holder’s name, and ID.

Applicants can apply online, by phone, by mail or in person at their local Wisconsin Department of Health Services agency.

How to Apply for BadgerCare

Medicaid and BadgerCare Coverage

Under federal law, all states are required to provide the following mandatory Medicaid benefits:

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic and Treatment Services
  • Nursing Facility Services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse midwife services
  • Certified pediatric and nurse practitioner services
  • Freestanding birth center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women

In addition to required federal services, Wisconsin Medicaid also offers the following optional benefits:

  • Freestanding ambulatory surgery centers
  • Certified registered nurse anesthetists
  • Chiropractic care
  • Dental care
  • Dental surgery
  • Optometrists
  • Podiatrists
  • Psychologists
  • Occupational therapy
  • Physical therapy
  • Speech/hearing/language therapy
  • Dentures
  • Eyeglasses
  • Hearing aids
  • Home medical equipment
  • Prosthetics
  • Case management
  • Home or community-based long-term care
  • Hospice care
  • Personal care
  • Private duty nurse
  • Program of All-Inclusive Care for the Elderly (PACE)
  • Inpatient psychiatric care for individuals under age 21
  • Inpatient care for mental diseases for individuals age 65+
  • Intermediate care for intellectual disabilities
  • Religious non-medical care

 Health care services covered include:

  • Check-ups
  • Shots and immunizations
  • Prenatal care
  • Preventative and wellness doctor visits
  • Emergency department visits
  • Hospital care
  • Maternity and newborn care
  • Mental health and behavior health services
  • Substance abuse treatment
  • Prescription Drugs
  • Rehabilitation services and devices
  • Lab visits
  • X-ray services
  • Vision care

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Income Requirements for Wisconsin Medicaid

Medicaid and BadgerCare are subject to federal income standards.  This includes certain population groups and the maximum income amount that enrollees can make.  By federal law, all states, including Wisconsin, are required to cover the following groups and income levels:

  • Pregnant women up to at least 138% of the federal poverty level ($16,643 for an individual, $33,948 for a family of four in 2017)
  • Preschool-age children up to at least 138% of the federal poverty level ($16,643 for an individual, $33,948 for a family of four in 2017)
  • School-age children up to at least 100% of the federal poverty level ($12,060 for an individual, $24,600 for a family of four in 2017)
  • Elderly and disabled individuals up to at least 75% of the federal poverty level ($9,045 for an individual, $18,450 for a family of four in 2017)
  • Working parents up to at least 28% of the federal poverty level ($3,376 for an individual, $6,888 for a family of four in 2017)

You must meet certain income limits to determine eligibility for various Medicaid, BadgerCare, and Medicare supplement payment programs in Wisconsin.  Programs will have varying levels of income maximums, and some will also have asset limitations as well.

Determining eligibility based on income can be complicated.  To get a sense of what income levels are used for enrollment in various programs, go here.  You can also see if you are able to enroll in various programs by submitting an application at  ACCESS.wi.gov.

Wisconsin Medicaid Eligibility | Medicare Plan Finder

Cost of Medicaid in Wisconsin

For people who are enrolled in Wisconsin Medicaid and BadgerCare, there are no premium costs as long as enrollees meet income guidelines for various medical services. When some services are actually accessed, copays may apply. 

However, only the deductibles and a portion of the coinsurance are paid when services are covered by Medicare.

Under the Medicaid Purchase Plan (MAPP), people who are working or who are interested in working can buy healthcare insurance through Wisconsin Medicaid.  Depending on the person’s income, there may be a premium associated with this coverage. Family coverage is not available through MAPP.

Prescription Drugs with Medicaid in Wisconsin

Wisconsin Medicaid has a List of Covered Drugs (Formulary) which is also known as the Drug List.  This is the comprehensive listing of prescription and over-the-counter drugs covered by Medicaid. The list also lets people know if there are any restrictions for coverage. Use this search tool to find out if a drug you need is on the list.

In addition, sometimes Medicaid covers additional drugs not on the Drug List. If a drug you need is not on the list, contact Wisconsin Medicaid’s customer service line to inquire about possible coverage.

Once a prescription is written, you can take it to almost any pharmacy in Wisconsin to have it filled. Over 95% of Wisconsin pharmacies participate in Wisconsin Medicaid.

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Is BadgerCare Medicare?

No. BadgerCare and Wisconsin Medicare are two different programs. Eligible Medicare beneficiaries in Wisconsin receive coverage through Medicare Part A at no cost if they have met eligibility requirements and enroll in a timely manner.  In general, eligibility requirements are that you have turned 65 years old, have paid Medicare taxes for at least 40 quarters in your working life, or you have qualifying disabilities or conditions if you are under 65 years old.

The standard Part B premium amount is $135.50 but could be higher depending on your income.  The Part B deductible is $185 per year. After a deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment.

Medicare Part C, also known as Medicare Advantage, offers a different way to receive Medicare Part A and Part B benefits.  Private Medicare providers cover required services and will offer enhanced coverage in exchange for a beneficiary paying a premium for the added coverage.  Different plans will offer different benefits, and you will need to shop around to find the most suitable plan that combines the services you want and the price you can afford.

Part D coverage pays for prescription drugs and is also offered by Medicare-approved insurance providers at an additional premium.

Part C and Part D coverage will vary by location and provider.  Higher-income consumers may pay more in premiums as well.

Dual-Eligible Medicare and Medicaid Plans in Wisconsin

The term dual-eligible means that people are covered by both Medicare and Medicaid at the same time.  In addition to qualifying for Medicaid, people usually qualify for Medicare Part A, Medicare Part B and a Medicare Savings Program that may pay for Medicare deductibles, coinsurance, and copayments when certain conditions are met.  Dual-eligible people are typically elderly and low income.

The four kinds of Medicare Savings Programs are the Qualified Medicare Beneficiary Program, the Specified Low-Income Medicare Beneficiary Program, the Qualifying Individual Program and the Qualified Disabled and Working Individuals Program. To see if you qualify for any of these programs, contact Wisconsin Medicaid’s customer service phone number for details and to apply

Which Medicare Plan is Best in Wisconsin?

If you are eligible for both Medicare and Medicaid in Wisconsin, you’ll need to select the best dual-eligible plan for you. There is no single best answer regarding which Medicare plan is best for you in Wisconsin. Just like any other major decision, you need to shop around, compare prices and benefits and then decide what is best for your personal situation.

Below are some considerations for finding which Medicare plan is best in Wisconsin:

  • Make a list of the types of treatments that you need to be covered
  • Compare the networks of primary doctors and specialists to ensure your doctor is in-network
  • Understand the additional benefits you may qualify for such as dental, vision, hearing, and wellness

Once you have gone through that exercise in full, you’ll be better suited to determine which Medicare plan is best suited for you.Hint: If you are dual-eligible, you’ll probably want a dual-eligible special needs Medicare Advantage plan.

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