BadgerCare Plus Changes for Childless Adults: Stakeholder FAQs

These frequently asked questions (FAQs) provide information about the BadgerCare Plus changes for providers, partners, stakeholders, and the public. Anyone with questions about the upcoming changes that are not addressed below can email the Department of Health Services (DHS). While emails will not be responded to individually, DHS will be monitoring the questions and updating the FAQs below, as applicable.

Background and Timeline

Why is the Wisconsin Department of Health Services making these changes?

The Wisconsin Department of Health Services is required by law to implement these policy changes.

Who do the BadgerCare Plus changes for childless adults affect?

These changes will affect childless adults ages 19-64 who are not pregnant, who do not have dependent children living in the home, and who have incomes below 100 percent of the federal poverty level (FPL). To find out where a member's household income falls, refer to the BadgerCare Plus Federal Poverty Levels page for more information.

What are the BadgerCare Plus changes?

The BadgerCare Plus changes include:

  • An $8 copay for non-emergency use of an emergency room (ER), so known as the hospital emergency department or (ED).
  • Monthly premiums for members with income over 50 percent of the federal poverty level (FPL), which may be reduced by completing a health survey, and for which non-payment may result in a period of ineligibility.
  • A health risk assessment in the form of a treatment needs question as a condition of eligibility for BadgerCare Plus as a childless adult.
  • An optional health survey that may lead to a reduction in the monthly premium amount based on completion of a health survey.
  • [Pending]Coverage of residential substance use disorder (SUD) treatment for all full-benefit Badger Plus and Medicaid members. Implementation of this policy is pending, and is not yet in effect.
  • [Pending] Community engagement requirements, including limiting benefit eligibility to 48 months for non-compliance. Implementation of this policy is pending, and is not yet in effect.

How do these changes affect health care benefits?

BadgerCare Plus members who are childless adults will receive the same full coverage health care benefits as they do today. Members will also receive coverage for residential treatment of substance use disorder (SUD).

When will these changes go into effect?

New applicants, beginning February 1, 2020, will:

  • Be required to answer a treatment needs question as part of their application.
  • Accrue premiums monthly, which can be paid at any point after the premium is billed. All owed premiums must be paid by the end of the enrollment period.
  • Have the option to complete an optional health survey that could reduce their premium amount.

Current members, at their next renewal after February 1, 2020, and those who become a childless adult during their enrollment period after February 1, 2020, will:

  • Be required to answer a treatment needs question as part of their renewal.
  • Accrue premiums monthly beginning at their renewal date.
  • Have the option to complete an optional health survey that could reduce their premium amounts.
Policy New Enrollees Current Members
Mandatory treatment needs question February 1, 2020 At renewal
Optional health survey February 1, 2020 At renewal
Premiums February 1, 2020 At renewal
Emergency room copays February 1, 2020  February 1, 2020
Residential SUD treatment coverage Pending Pending 
Community engagement Pending Pending

What if a member's circumstances change?

As with all benefits, if a member's circumstances change, they should notify their income maintenance agency based on their reporting requirements to determine if their eligibility will change.

How will these changes impact tribal members?

Tribal members, children or grandchildren of a tribal member, and those qualifying for Indian Health Services will be exempted from premiums and emergency room copays.

Who should I contact if I do not like these changes?

Emergency Room (ER) Copay

What will the copay be for use of ER services?

Members will be charged a copay of $8 if they visit the ER for care in a situation that is not an emergency. The $8 copay will not apply if the provider determines the visit to be an emergency. This determination is based on the patient's symptoms, rather than the final diagnosis.

How will hospitals determine if a visit is an emergency?

This determination should be based on the patient's symptoms, rather than the final diagnosis. Hospitals will determine that a visit is an emergency if a person with average medical knowledge could reasonably expect the health of the individual to be in serious jeopardy, or that any bodily functions, organs, or parts may be seriously impaired if they do not get immediate medical attention.

What if a member cannot pay their ER copay?

Federal law requires hospital emergency departments to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay. Additionally, Medicaid providers may not deny services to Medicaid members who are unable to pay a copay. However, providers must attempt to collect copays owed to them unless the provider determines that the cost of collecting the copay exceeds the amount to be collected.

Does the ER copay apply to all BadgerCare Plus members or just childless adults?

ER copays only apply to BadgerCare Plus childless adults.

Will DHS share the 5% cost share information with providers, pharmacies, and MCOs so they will know if member's cost share has exceeded 5% of their income so that they know not to charge them?

Providers can check whether a member is subject to the $8 copay on the ForwardHealth Portal. They can also check if the member is exempt from paying the ER copay due to the 5% cost sharing limit.

How is the 5% cost share tracked for members?

DHS is currently updating systems to ensure that 5% cost share is tracked appropriately across all Medicaid programs. The ER copay policy is going live February 1, 2020. However, members will be exempt from copays until July 1, 2020, to allow DHS to implement system changes to be in compliance with the federal 5% cost share cap requirement. 

Who is exempt from ER copays?

The following individuals are exempt:

  • Tribal members
  • Children and grandchildren of tribal members
  • People who qualify for Indian Health Services

Can hospitals or HMOs pay the copay?

Hospitals and HMOs may cover the $8 ER copay.

Monthly Premium

Who has to pay premiums?

Most childless adults ages 19-64 with household income above 50 percent of the federal poverty level (FPL) will have to pay a monthly premium.

To find out where a member's household income falls, refer to the BadgerCare Plus Federal Poverty Levels page.

Members who do not have to pay premiums include:

  • A tribal member, or a child or grandchild of a tribal member.
  • An individual who qualifies for Indian Health Services.
  • Those determined to be disabled by the Disability Determination Bureau or Social Security Administration.
  • Those currently residing in a medical institution for at least 30 days.
  • Those who are homeless or have been homeless in the last 12 months.

How much are premiums?

Monthly premiums are $8 and may be reduced based on answers on the optional health survey. If monthly household income is 50 percent or less of the federal poverty level (FPL), there is no premium.

Monthly Household Income Monthly Premium Amount
0 to 50 percent of the FPL No premium
Above 50 percent of the FPL Between $4 to $8 per household

How can the optional health survey reduce premium amounts?

Member who report health habits or report that they are managing a health risk on their health survey may see their monthly premium lowered. The premium reduction will take account the size of household and number of individuals in the household who indicate healthy habits.

How does a member pay their premium?

Premiums may be paid by:

  • Credit or debit card.
  • Banking account through the ACCESS website.
  • Banking account through the MyACCESS mobile app.
  • Check.
  • Money order.

Premiums will be charged monthly, due on the 10th of every month. However, members may pay the premium balance at that time or at any time up to the end of their certification period. Premiums cannot be pre-paid and partial payments will not be accepted. In addition, in-person payments are not permitted.

Can a member pay their premium in cash?

No, cash will not be accepted.

When are premium payments due?

Premiums will be charged monthly, due on the 10th of every month. However, members may pay the premium balance at any time up to the end of their enrollment period.

What happens if a member does not make a premium payment?

If a member does not pay all owed premiums by the end of their certification period, they will enter a six-month ineligibility period.

Once a member enters a six-month ineligibility period, they may:

  • Pay owed premiums from their past certification period at any time during the six-month ineligibility period and then re-enroll in BadgerCare Plus. Once owed premiums are paid, they may re-enroll at any time, if all other eligibility criteria are met. They are also eligible to receive up to three months of backdated eligibility.
  • Wait until the six-month ineligibility period ends, and then re-apply for BadgerCare Plus as a childless adult.
  • Members may also regain eligibility if their circumstances change; for example:
    • They qualify for a premium exemption or their income has dropped to 50 percent or less of the federal poverty level.
    • They become eligible for benefits under a different category of Medicaid (e.g. member becomes pregnant).

Note that Wisconsin Department of Health Services policy allows members to backdate their coverage for three months when enrolling for BadgerCare Plus.

If the member enters a six-month ineligibility period, also called a restrictive re-enrollment period, but becomes eligible for another program, does the member still have to pay back all owed premiums?

If the member or applicant qualifies for other Medicaid programs during the six-month ineligibility period, they may enroll in those programs without paying owed premiums.

If their eligibility changes back to their previous status as a childless adult, then they would be subject to the six-month ineligibility period until it's completed, or they pay all owed premiums.

What is an restrictive re-enrollment period (RRP)?

The RRP is a 6-month period of disenrollment following non-payment of a required BadgerCare Plus premium at the end of the certification period. Members enter the RRP if they fail to pay their premiums at the end of the certification period.

How will members know about RRP?

Members will be notified on their monthly premium statement if they have not paid premiums and are at risk of entering an RRP. Members will also receive a notification about the RRP for premium non-payment when they receive their Notice of Decision, which will include information about the length of their RRP.

What happens if a member tries to enroll during an RRP?

Members are allowed to re-apply for benefits anytime during the RRP; however, their application will be denied unless they pay their outstanding premiums, report an exemption to the premium requirement, or have an income at 50% of the FPL or below. Members’ applications will also be denied if they are eligible for a different full benefit Medicaid program. They will receive a verification checklist informing them of the date they must pay the premiums by.

Will premiums for the following year be based on past or expected income?  

Premiums will be based on expected income for a member’s certification period. If the member’s income drops to 50% of the FPL or below and they become exempt from premium payments, they are expected to report the change by the 10th of the month following the change.

How will members know how much to and when to pay?

Monthly premium statements will be sent to childless adults. The statement will include the following information:

  • When to pay, including that all premiums for the certification period must be paid before renewal or before the certification period ends.
  • How to lower their premiums amount via the optional health survey and treatment needs question.
  • Amount due for the current month.
  • Amounts due for past months (if applicable).
  • Total amount due (appears for the certification period).
  • How to pay.
  • A mail-in section will be provided for members to include with their check or money order. 

How long do members have to report income changes that may make them not subject to monthly premiums?

If a member’s income increases, they must report the change by the by the 10th day of the next month.  If a member is affected by premiums and reports an income decrease to 50% of the FPL or below within 10 days of the income change, they will no longer be subject to monthly premiums starting in the month the income change happened. If a member is affected by premiums and does not report an income decrease to 50% of the FPL or below within 10 days, then they will no longer be subject to monthly premiums starting in the month they report their income change.

How will members know to report changes in their income?

Members are expected to report if their income goes above 50% of the FPL. We will communicate this responsibility and add the 50% of the FPL threshold amount to the reporting requirements in the Notice of Decision letter that members get. 

What if a member is determined to be exempt from paying a premium for a month which they’ve already paid?

A member would get a refund if a premium was paid for a month when any of the following apply:
• The individual or household was ineligible for BadgerCare Plus.
• The individual or household’s income dropped below 50% FPL.
• The individual or household was determined to have met any of the premium exemption requirements.

What if a member is determined to be eligible for a premium reduction after they have paid the full premium?

If the premium is paid for a month in which the household qualifies for a premium reduction, the excess premium paid will be refunded in the month that the reduction applied. For example, if the member paid $8 and later that month they qualified for a reduction to $4, the extra $4 will be refunded.

If an enrolled member with outstanding premiums drops below 50% of FPL or becomes eligible under another program, are they still required to pay the owed premiums? 

No. Premiums will not be a condition of eligibility unless their income is above 50% of the FPL. If a member whose income is above 50% of the FPL owes premiums at the end of their certification period, an RRP will be established.

If a member’s income decreases to 50% of the FPL or below, or if they become eligible under a different full-benefit Medicaid program, they will remain eligible for health care, even if they do not pay their outstanding premiums. The RRP will still be established but will only affect the member if their income increases to more than 50% of the FPL. 

 

Treatment Needs Question

What is a treatment needs question?

The treatment needs question is a screening tool that asks the member if they have used drugs during the last 12 months in ways that have caused problems for themselves or their family, and if they are open to getting help. This question must be answered in order to qualify for BadgerCare Plus as a childless adult, but the response given to this question will not impact their eligibility.

Who is required to answer the treatment needs question?

The treatment needs question is mandatory for all childless adults unless the individual is:

  • A tribal member or a child or grandchild of a tribal member.
  • An individual who qualifies for Indian Health Services.
  • Residing or expect to residing in a medical institution for at least 30 days.
  • Determined disabled by the Disability Determination Bureau or the Social Security Administration.

Eligibility for health care benefits is not impacted by the answer to this question.

When will applicants and members complete the treatment needs question?

Applicants and members must answer the treatment needs question when enrolling in or renewing their benefits. Members may change their answer to the treatment needs question at any time. Their response to this question will not impact their eligibility.

Who can complete the treatment needs question?

In addition to the applicant or member, any of the following people can complete the question on the applicant's or member's behalf:

  • Their spouse
  • An authorized representative
  • A financial power of attorney
  • A legal guardian over the estate
  • Someone else authorized by the individual

How can someone answer the treatment needs question?

Applicants and members will be able to answer the treatment needs question:

  • Online via ACCESS, the online application for benefits.
  • Via the MyACCESS mobile benefits app.
  • Over the phone with their income maintenance or tribal agency.
  • On a paper form available in the DHS Forms Library or sent to members with their verification checklist.
  • In person at their income maintenance or tribal agency.

Eligibility for health care benefits is not impacted by the answer to this question.

Which entities receive the member responses to the treatment needs question?

Member responses will be shared with their MCO or HMO. To protect sensitive information, a separate PIN-based summary will be sent to each childless adult with their treatment needs question response. 

Will a member's answer to the treatment needs question impact eligibility?

Eligibility for health care benefits is not impacted by the answer to this question.

What if the treatment needs question is not answered?

If an applicant or member does not answer the treatment needs question when required, they will not be eligible for BadgerCare Plus as a childless adult. Whether the applicant or member answers yes or no to the treatment needs question will NOT impact eligibility.

For members who are administratively renewed, how long will they have to complete the question?

This is only applicable for members who are administratively renewed on or after February 1, 2020. These members will need to answer the question within 20 days of the administrative renewal when a question response is not already on file. 

Will the member be given notice that the treatment needs question is outstanding before benefits are denied or terminated?

DHS will mark the case as pending completion of the treatment needs question and send a verification checklist with information about how to answer it. The verification checklist will provide a paper form for the member to complete and mail in. The verification checklist will also indicate other ways the response could be provided. If the member does not answer the question by the given due date, the Notice of Decision will indicate a denial/termination for failure to answer the question. 

If a member indicates they are interested in receiving treatment, will resources be provided?

If the member is enrolled in an HMO or MCO, the HMO or MCO will be notified of the their response and will help the member access treatment resources. If a member is not enrolled in an HMO or MCO, they will get a letter with information on how to access treatment. 

Will members have to take a drug test?

No. There is no drug test requirement for BadgerCare Plus.

Optional Health Survey

What is the optional health survey?

The optional health survey is a short healthy habit questionnaire. This survey is not a condition of eligibility for BadgerCare Plus, but gives members an opportunity to reduce their premiums by attesting to healthy habits or managing health risk behaviors.

What happens if a member completes the optional health survey?

A premium reduction is granted when any one of the following is true:

  • The childless adult reports at least one healthy habit.
  • The childless adult reports managing their health risks.
  • The childless adult reports having a health condition that prevents their ability to engage in a healthy habit.

See the Premium FAQ section below for further information about premium reductions based on the optional health survey.

When can a member take the optional health survey?

Members can complete the optional health survey at any time:

  • Online via ACCESS, the online application for benefits.
  • Via the MyACCESS mobile benefits app.
  • Over the phone.
  • On a paper form available in the DHS Forms Library.

Who can complete the health survey?

In addition to the member or applicant, the following people can complete the survey on the behalf of the childless adult:

  • An authorized representative
  • A financial power of attorney
  • A legal guardian over the estate
  • Someone authorized by the individual

How many healthy habits does someone have to report in order to get a premium reduction?

The premium reduction is granted when any of the following is true:

  • The childless adult reports at least one healthy habit.
  • The childless adult reports managing their health risks.
  • The childless adult reports having a health condition that prevents their ability to engage in a healthy habit.

How long will the premium reduction apply?

The premium reduction will only be valid for the certification period for which it has been completed. When completing a new application or renewal, childless adults must complete a treatment needs question and can also complete a new health survey. Their responses to the treatment needs question and health survey may qualify them for a reduction. The answers to the previous period’s survey will not carry over into the new certification period.

Can members complete the health survey more than once in a certification period?

Members can complete the health survey at any time during their certification period. Only the results of the most recent survey will be used to calculate premiums and the reporting of new healthy behaviors will not result in a greater premium reduction. 

Can premium reductions based on the health survey be applied retroactively?

No. Generally, premium reductions granted based on answering the optional health survey will not be applied retroactively. Premium reductions will be applied in the month that it was received by the member's agency.

Residential Facility Substance Use Disorder (SUD) Treatment Coverage

What is the policy for residential facility substance use disorder treatment?

DHS has been working to launch a new benefit to improve access to and quality of residential services for substance use disorders. The state applied for and received federal approval to cover these services in an effort to expand access to these services statewide, which until now have been only available in very limited circumstances and for a limited number of people.

In accordance with the BadgerCare Reform demonstration waiver, DHS plans to implement a benefit for residential substance use disorder treatment (including opioid use disorders) for all Badger Care Plus members. 

Why is DHS delaying the implementation of the residential facility substance use disorder treatment benefit?

As a result of extensive feedback from stakeholders, DHS is delaying the implementation of the substance use disorder treatment benefit to reexamine our policy, rates and implementation plan. We recognize that the proposal we initially put forth, including our proposed rates, needs to be modified to adequately meet the needs of our members. We are working to launch the new benefit as soon as we can. We will work with stakeholders to continue to get input on the benefit and will provide updates as soon as we have them. 

Where can I learn more about the status of the residential facility substance use disorder benefit?

DHS will be updating the BadgerCare Plus: Residential Facility Substance Use Disorder Treatment webpage as new information about the benefit is available. 

Community Engagement (Employment and Training)

What is community engagement?

Community engagement refers to a requirement for childless adults ages 19 through 49 to complete at least 80 hours per month of qualifying community engagement activities and limits benefit eligibility to 48 months for non-compliance. Qualifying activities include having a job, volunteering, or participating in certain job training programs. The timeline for implementing community engagement is yet to be determined.

When will the community engagement be implemented?

The Wisconsin Department of Health Services is not implementing community engagement on February 1, 2020. The timeline for implementing community engagement is yet to be determined.

To learn more about the changes for childless adults see: BadgerCare Changes for Childless Adults.

Last Revised: February 20, 2020