• Covered Services
  • Introduction
  • Definition
    • Introduction
    • Program Requirements
  • Emergency Services
  • Services Not Separately Reimbursable
  • Recipient Payment for Covered Services
• Noncovered Services
  • Introduction
  • Definition
  • Recipient Payment for Noncovered Services
    • Introduction
    • Missed Appointments
    • Translation Services
• Collecting Payment from Recipients
  • Introduction
  • Conditions That Must Be Met
• HealthCheck "Other Services"
  • Introduction
  • Prior Authorization
• Appendix
  • Appendix 1 — Services Not Covered by Wisconsin Medicaid
• PDF

Covered and Noncovered Services

Collecting Payment from Recipients

Medicaid providers may not collect payment from a recipient, or authorized person acting on behalf of the recipient, except for the following:

• Required recipient copayments for certain services. (Refer to the Recipient Eligibility section of this handbook for more information.)
• Commercial insurance payments made to the recipient. (Refer to the Coordination of Benefits section of this handbook for more information.)
• Spenddown. (Refer to the Recipient Eligibility section of this handbook for more information.)
• Charges for a private room in a nursing home or hospital. (Refer to service-specific publications for more information.)
• Noncovered services if certain conditions are met.
• Covered services for which prior authorization (PA) was denied (or an originally requested service for which a PA request was modified) if certain conditions are met. These services are treated by Wisconsin Medicaid as noncovered services.
• Services provided to a recipient in a limited benefit category when the services are not covered under the limited benefit and if certain conditions are met.

If a provider inappropriately collects payment from a recipient, or authorized person acting on behalf of the recipient, that provider may be subject to program sanctions including termination of Medicaid certification. Refer to the Certification and Ongoing Responsibilities section of this handbook for more information about provider sanctions.

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