BadgerCare Plus Changes for Childless Adults: Frequently Asked Questions

These frequently asked questions (FAQs) provide information about the BadgerCare Plus changes for members, 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.
  • Coverage of residential substance use disorder (SUD) treatment for all full-benefit Badger Plus and Medicaid members.
  • [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.

For both new applicants and current members, a copay for any non-emergency visits to the emergency room will be required starting February 1, 2020.

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 February 1, 2020 February 1, 2020
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.

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 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.

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.

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.

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.

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.

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.

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

Has the coverage policy changed for residential facility SUD treatment?

Previously, federal policy restricted coverage of residential facility SUD treatment in BadgerCare Plus.

Now, residential facility (inpatient) SUD treatment coverage will be available to all full-benefit BadgerCare Plus and Medicaid members.

What is the timeline for implementation of SUD benefit coverage?

While the timeline is still being finalized ,DHS anticipates the following implementation timeline:

  • November 1, 2019: Begin provider enrollment
  • February 1, 2020: Begin coverage of residential facility SUD treatment. 

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: December 2, 2019