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.
In 1999, seeking to expand healthcare coverage for virtually all of the state’s residents, Wisconsin implemented BadgerCare, a companion healthcare coverage program to Medicaid. In 2008, the program was greatly expanded and BadgerCare Plus was created. At the time it was implemented, the goal was to ensure that 98% of Wisconsin residents had access to quality and affordable health care.
BadgerCare Plus specifically targets benefits for all uninsured children, pregnant women, parents and caretaker relatives, young adults leaving foster care, parents with children in foster care who want to reunite their families and certain farmers and other self-employed parents and caretaker relatives
Because some people get confused about government healthcare programs, it is important to understand that Wisconsin Medicaid, BadgerCare Plus and Medicare are separate and distinct programs.
Medicaid and Medicare were both created in 1965, and their goal remains to ease the financial burdens of illnesses on Americans. Medicare is administered by the federal government and provides healthcare coverage if you are 65 or older or have certain qualifying disabilities or conditions, no matter what your level of income is.
To be eligible for Wisconsin Medicaid, you must meet certain requirements before submitting your application. In general, the following eligibility standards apply:
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 Plus Eligibility
BadgerCare Plus provides healthcare coverage programs for low income Wisconsin residents who are not elderly, blind or disabled but still need healthcare coverage. BadgerCare Plus does not have an open enrollment period and people can apply at any time.
Eligible groups include:
Before you start the application process, you should have the following information available:
Applicants can apply online, by phone, by mail or in person at their local Wisconsin Department of Health Services agency.
To apply online, go to ACCESS.wi.gov. ACCESS is also the fastest and easiest way to apply for benefits.
To apply by mail, complete an application for each program you are applying for. Send the completed application and any proof/verification to:
If you live in Milwaukee County:
PO Box 05676
Milwaukee WI 53205
If you do not live in Milwaukee County:
PO Box 5234
Janesville, WI 53547-5234
You can also apply in person at any DHS county office or at a Consortia Office. Go here to find specific contact information for your county office or Consortia Office.
Under federal law, all states are required to provide the following mandatory Medicaid benefits:
In addition to required federal services, Wisconsin Medicaid also offers the following optional benefits:
BadgerCare Plus covers health care services such as:
Medicaid and BadgerCare Plus 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:
You must meet certain income limits to determine eligibility for various Medicaid, BadgerCare Plus 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
Eligible 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.
For 2018, if you don’t meet requirements, then you can buy Part A for $422 per month if you paid Medicare taxes for less than 30 quarters. If you paid Medicare taxes for 30-39 quarters, then the standard premium will be $232.
The standard Part B premium amount is $134 but could be higher depending on your income. Part B deductible and coinsurance is $183 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.
For more details on Medicare costs for 2018, go here.
For people who are enrolled in Wisconsin Medicaid and BadgerCare Plus, there are no premium costs as long as enrollees meet income guidelines for various medical services. When some services are actually accessed, co-pays may apply.
However, only the deductibles and a portion of the co-insurance 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.
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.
Depending on your circumstances, you have many programs you can join in Wisconsin. These include:
Children Come First
This program coordinates care for youth in Dane County with mental health challenges, so they can stay in their home. A team of people work together to develop a plan of care that meets specific needs, and can include a Children Come First coordinator, members of the youth’s family, teachers, social workers and therapists. Enrollment generally lasts less than 18 months but youth are enrolled until they are no longer at risk of being placed out of a home.
This plan helps elderly, blind or disabled people live in their own homes or in the community, instead of a state institution or a nursing home. You may be able to enroll in Community Waivers if you are a person who is elderly, blind or has a disability and you:
You may be able to enroll in a Community Waivers Plan if you are enrolled in Medicaid or receive Supplemental Security Income (SSI).
If you are married, live with your spouse and you are enrolled in a Community Waivers Plan, your spouse’s income and many of your joint assets may be protected.
Income and asset rules for minors are based on the child’s assets and income only. A minor child with a disability must also meet all rules for the Community Waivers Plans.
You may have to pay some of your medical costs depending on your income. This is called “cost-sharing”. Only your income will be used to determine how much you have to pay.
Emergency Services Plan
This is a program for people who have an emergency medical condition but who cannot get Medicaid or BadgerCare Plus because of their immigration or citizenship status. This is for emergency medical conditions only and does not include chronic or ongoing conditions.
Social Security numbers are not required and information about families will not be shared with United States Citizenship and Immigration Services.
This plan only pays for medical emergencies and there is no guarantee the care received will result in payment. If it is determined that the care you receive is not an emergency, you will have to pay for the cost of your healthcare.
Emergency Services begins the first day a person gets medical care and ends when a condition is no longer considered an emergency.
Pregnant women can apply for Emergency Services one month before their due date, but this plan will not pay for prenatal or postpartum care. It will pay for emergencies up to 60 days after your delivery date. NOTE: If you are pregnant, you may be able to enroll in BadgerCare Plus Prenatal Services.
This is a long-term program that helps frail elderly people and adults with physical, developmental or intellectual disabilities. The goal is to assist people with long-term care so that they can live in their own home when possible.
Care includes providing service and support a person may need help with because they are getting older or have a chronic illness that limits their ability to perform daily tasks such as bathing, grooming, getting dressed, making meals, and so forth.
Family Care provides a full range of services through a single flexible benefit program. Managed care organizations oversee implementation of the program and are responsible for overseeing quality care and services for members. Some of the benefits of the Family Care Plan include:
Medicaid/BadgerCare Plus Deductible Plans
This plan assists people who meet all program rules except the income limit rule, and who have high medical bills. Eligible groups include pregnant women, children under 19 years old, and elderly or disabled adults
Your agency will figure out how much your monthly income is above the Medicaid or BadgerCare Plus limit and will assign a deductible. You can use the cost of unpaid and recently paid bills for medical or remedial expenses to meet your deductible. You will need to provide proof of the expenses to your agency. Once your deductible has been met, Medicaid/BadgerCare Plus will pay for covered services until the end of a six-month period.
Medical expenses may include health insurance premiums, portions of medical bills you must pay for yourself, your spouse or your minor children after Medicare or private insurance has paid.
Remedial expenses are costs for services and/or goods that you get to relieve, remedy or reduce a medical or health condition. These may include case management, day care, housing modifications for accessibility, respite care, supportive home care, and transportation.
Medicaid Purchase Plan (MAPP)
This plan offers people with disabilities who work or who are interested in working the opportunity to buy health insurance through BadgerCare Plus. Depending on a person’s income level, a premium payment may be required for this program. The Medicaid Purchase Plan offers the same benefits through the Wisconsin Medicaid Program and participants may earn more income than other groups of Medicaid members without the risk of losing healthcare coverage.
Medicare Savings Programs
Medicare offers several cost sharing programs to help offset costs for Medicaid beneficiaries who meet certain requirements.
The cost sharing programs are:
Qualified Medicare Beneficiary (QMB)
The first day of the month after your application is approved, Medicaid pays Medicare Part A and B premiums, deductibles, and coinsurance if all of the following apply:
Specified Low-Income Medicare Beneficiary (SLMB)
Up to three months before your application date, Medicaid pays Medicare Part B premiums if all of the following apply:
Specified Low-Income Medicare Beneficiary Plus (SLMB+)
Up to three months before your application date, Medicaid pays Medicare Part B premiums if all of the following apply:
Qualified Disabled and Working Individual (QDWI)
Up to three months before your application date, Medicaid pays Part A premiums if all of the following apply:
Tuberculosis-Related Only Services
This plan is for people who have been diagnosed with tuberculosis but who do not meet the rules to apply for BadgerCare Plus. The Tuberculosis-Related Only Services plan helps pay some medical costs for the care of tuberculosis infection or TB disease.
Tuberculosis-Related Only Services only covers services directly related to the care of TB. These include:
This plan does not pay for hospital stays or room and board.
A person must meet income and asset rules and have been infected with tuberculosis to enroll in this plan. For one person, the monthly gross income limit is $1,555 and the asset limit is $2,000 or less.
Well Woman Medicaid Plan
This plan allows women who qualify to get Medicaid benefits if they have been diagnosed or need treatment for breast cancer or cervical cancer.
You may be able to get Wisconsin Well Woman Medicaid if you are enrolled in the Family Planning Only Services Program and you:
This program coordinates care for youth in Milwaukee County who have serious behavioral, emotional, and mental health needs to help them stay in their home and/or community. Participants have a team of people who work to develop and execute a plan of care that meets a specific person’s needs. This can include a coordinator, members of the youth’s family, teachers, social workers and therapists.
BadgerCare Plus Prenatal Services
Provides health care for pregnant women who have been denied BadgerCare Plus because of their immigration or citizenship status or who are in prison or jail. If you are not a U.S. citizen or you are an undocumented immigrant, a Social Security number is not required. Information about your family will not be shared with the United States Citizenship and Immigration Services.
Covers services such as prenatal care, doctor and clinic visits, prescription drugs, labor and delivery.
Family Planning Only Services
This program offers men and women certain family planning services and supplies to prevent unplanned pregnancies.
Services not covered include hysterectomies, mammograms, vaccinations, inpatient hospital services and other services provided during a family planning visit that are not related to family planning services.
For more information regarding any of these plans, call Wisconsin Medicaid Member Services at 1-800-362-3002.
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.
If you are eligible for both Medicare and Medicaid in Wisoncsin, 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:
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.
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.
To apply for programs online go to ACCESS.wi.gov
Member Services Phone Number
State of Wisconsin Department of Health Services - Agency Contact Information
Bay Lake Consortium: 1-888-794-5747
Brown, Door, Marinette, Oconto and Shawano Counties
Capital Consortium: 1-888-794-5556
Adams, Columbia, Dane, Dodge, Juneau, Richland and Sauk Counties
East Central IM Partnership: 1-888-256-4563
Calumet, Green Lake, Kewaunee, Manitowoc, Marquette, Outagamie, Sheboygan, Waupaca, Waushara and Winnebago Counties
Great Rivers Consortium: 1-888-283-0012
Barron, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, St. Croix and Washburn Counties
IM Central Consortium: 1-888- 445-1621
Langlade, Marathon, Oneida and Portage Counties
Milwaukee Enrollment Service (MilES): 1-888-947-6583
Morraine Lakes Consortium: 1-888-446-1239
Fond du Lac, Ozaukee, Walworth, Washington and Waukesha Counties
Northern IM Consortium: 1-888-794-5722
Ashland, Bayfield, Florence, Forest, Iron, Lincoln, Price, Rusk, Sawyer, Taylor, Vilas and Wood Counties
Southern Consortium: 1-888-794-5780
Crawford, Grant, Green, Iowa, Jefferson, Lafayette and Rock Counties
Western Region for Economic Assistance: 1-888-627-0430
Buffalo, Clark, Jackson, La Crosse, Monroe, Pepin, Trempealeau, and Vernon Counties
Kenosha and Racine Counties
Tribal Income Maintenance Agencies
Bad River Band of Lake Superior Tribe of Chippewa Indians: 715-682-7127
Forest County Potawatomi Community: 715-478-7292
Lac Courte Oreilles Band of Lake Superior Tribe of Chippewa Indians of Wisconsin: 715-634-8934
Lac du Flambeau Band of Lake Superior Tribe of Chippewa Indians: 715-588-9635
Menominee Indian Tribe of Wisconsin: 715-799-5137
Oneida Tribe of Indians of Wisconsin: 1-800-216-3216
Red Cliff Band of Lake Superior Chippewa: 715-779-3706
Sokaogon Chippewa Community: 715-478-3265
Stockbridge-Munsee Community: 715-793-4885
State of Wisconsin HMO Ombuds Program
The State of Wisconsin has created an Ombuds that can help you solve problems or complaints you may have about BadgerCare Plus or your HMO. Call (800) 760-0001 and ask to talk to an Ombud.
To file a complaint with the BadgerCare Plus Program:
BadgerCare Plus and Medicaid SSI Managed Care Ombuds
P.O. Box 6470
Madison, WI 53716-0470
Phone: (800) 760-0001
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