Wisconsin Medicaid and BadgerCare Plus Deductible
The Wisconsin Medicaid /BadgerCare Plus Deductible plan is for those people who meet all the program rules, except the income limit rule and who have high medical bills.
You may be able to enroll in a Deductible plan, if you are a:
- Pregnant woman,
- Child under 19 years of age, or
- Elderly or disabled adult.
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 the six-month period.
Medical expenses are cost for services or goods that have been prescribed or provided by a professional medical practitioner. The expense is for diagnosis, cure, treatment, or prevention of disease or for treatment affecting any part of the body.
Examples of medical expenses include:
- Health insurance premiums, and
- The portion of medical bills you must pay for yourself, your spouse or your minor children after Medicare and 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 are costs that you are expected to pay and cannot be paid by any other source, such as Medicaid or BadgerCare Plus, private insurance, or an employer.
Some examples of remedial expenses are:
- Case management
- Day care
- Housing modifications for accessibility
- Respite care
- Supportive home care
- Transportation
Remedial expenses do not include housing or room and board services.
You cannot meet your deductible by using expenses that are paid by Medicare or a private insurance policy. Also, you cannot use a cost to meet more than one deductible; even if it has not been paid.
Deductible Amount
The amount of the deductible will be based on a six-month period. Your agency will figure out how much your monthly income is above the Medicaid or BadgerCare Plus limit. That amount will be multiplied by six and will be your deductible.
For example, if your income is $100 more than the monthly income limit, the deductible would be 6 x $100 = $600.
If your income is not the same for each of the six months, the amount is calculated for each month. If your income changes, before you meet your deductible, the amount will be recalculated.
Date Benefits Begin
On the date your medical costs add up to as much as, or more than the deductible amount, you can begin to get Medicaid/BadgerCare Plus for the remainder of the six-month deductible period. This is called “meeting the deductible.”
For example, your deductible is $600 when you apply in July. By August 8, your medical costs add up to $600. That means you have met your deductible. You will be able to get Medicaid or BadgerCare Plus benefits from August 8 through December 31, which is the end of your six-month deductible period.
It is important to save all your medical bills and receipts to show the amount and date of your medical expenses. Your agency will need proof of these costs.
You may also prepay the deductible amount to Medicaid/BadgerCare Plus to be able to enroll.
Please Note: You are still responsible to pay any cost you used to meet your deductible. Medicaid/BadgerCare Plus will not pay these costs.
Reporting Changes
After the deductible is met, a change in your income will not affect your Medicaid enrollment for the remainder of your six-month deductible period.
All other changes need to be reported to your agency. (For example, changes in assets could affect your enrollment.)
Covered Benefits
Once you have met your deductible, you will be able to get the same Medicaid covered services as other people on Medicaid who do not have to meet a deductible. For more information on covered services see the “ForwardHealth Enrollment and Benefits” handbook (P-00079). You will get a handbook when your application for Medicaid/BadgerCare Plus is processed or go online to dhs.wi.gov/em/customerhelp.
For more information
If you have questions, more information is available online at dhs.wi.gov/em/customerhelp, by contacting your agency or calling Member Services at 1-800-362-3002 (TTY and translation services are available). Member Services can also get your the address or phone number of your agency. This information is also online at dhs.wi.gov/em/customerhelp.
The Department of Health Services is an equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format, or need it translated to another language, contact 608-266-3356 or 1-888-701-1251 (TTY). All translation services are free of charge.
For civil rights questions call 608-267-4955, TTY: 711.
State of Wisconsin
Department of Health Services
P-10052 (04/13)