• Eligibility Categories
  • Introduction
  • Medicaid Recipients
  • BadgerCare Recipients
  • Wisconsin Well Woman Medicaid
  • Limited Benefit Categories
    • Introduction
    • Family Planning Waiver Program
    • Presumptive Eligibility for Pregnant Women Benefit
    • Tuberculosis-Related Services-Only Benefit
    • Qualified Medicare Beneficiary-Only Recipients
    • Specified Low Income Medicare Beneficiaries
    • Qualifying Individual 1 Recipients
    • Qualified Disabled Working Individual Recipients
• Medicaid Identification Cards
  • Introduction
  • Forward Cards
    • Introduction
    • Forward Card Features
    • Identification Number Changes
    • Recipient Name Changes
    • Deactivated Cards
    • Defective Cards
    • Lost Cards
    • Managed Care Organization Enrollment Changes
  • Temporary Medicaid Cards
  • Presumptive Eligibility for Pregnant Women Temporary Cards
  • Presumptive Eligibility for the Family Planning Waiver Program Temporary Cards
• Eligibility Verification Methods
  • Introduction
  • 270/271 Transactions
  • Automated Voice Response System
    • Introduction
    • Dates of Services
    • Hours
  • Commercial Eligibility Verification Vendors
    • Introduction
    • Magnetic Stripe Card Readers
    • Personal Computer Software
    • Internet Access
  • Provider Services
    • Introduction
    • Hours
  • Recipient Forgets Identification Card
• Eligibility Rights
  • Introduction
  • Prompt Decisions on Eligibility
  • Requesting Retroactive Eligibility
  • Appealing Eligibility Determinations
    • Introduction
    • Claims for Appeal Reversals
  • Freedom of Choice
  • Notification of Discontinued Benefits
• Eligibility Responsibilities
  • Introduction
  • Prior Identification of Eligibility
  • Loss of Medicaid Eligibility — Financial Liability
  • Reporting Changes to Caseworkers
• Copayment Requirements
  • Introduction
  • Copayment Exemptions
  • Copayment Amounts
  • Copayment Limitations
  • Copayment Refund/Collection Requirement
• Special Eligibility Circumstances
  • Retroactive Eligibility
    • Introduction
    • Reimbursing Recipients in Cases of Retroactive Eligibility
  • Spenddown to Meet Medicaid Financial Eligibility Requirements
  • Persons Detained by Legal Process
  • Recipients Traveling Out of State
  • Non-U.S. Citizens — Emergency Services
  • Medicaid Recipients from Other States
• Misuse and Abuse of Benefits
  • Introduction
  • Examples of Misuse and Abuse
  • Requesting Additional Proof of Identity
  • Notifying Wisconsin Medicaid
  • Providers May Refuse to Provide Services
  • Recipient Lock-In Program
    • Introduction
    • Providers May Make Referrals
• Appendix
  • Appendix 1 — Limited Benefit Categories
  • Appendix 2 — Quick-Entry Guide for the Automated Voice Response System
  • Appendix 3 — Eligibility Verification Vendors
  • Appendix 4 — Certification of Emergency for Non-U.S. Citizens Form Completion Instructions
  • Appendix 5 — Certification of Emergency for Non-U.S. Citizens
• PDF

Select a section » Certification and Ongoing Responsibilities Claims Information Coordination of Benefits Covered and Noncovered Services Informational Resources Managed Care Prior Authorization Recipient Eligibility

 

 

Recipient Eligibility

Eligibility Categories

Medicaid Recipients

Medicaid is a joint federal/state program established in 1965 under Title XIX of the Social Security Act to pay for medical services for selected groups of people who meet the program’s financial requirements.

The purpose of Medicaid is to provide reimbursement for and assure the availability of appropriate medical care to persons who meet the criteria for Medicaid. Wisconsin Medicaid is also known as the Medical Assistance Program, WMAP, MA, Title XIX, or T19.

A Medicaid recipient is any individual entitled to benefits under Title XIX of the Social Security Act and under the Medical Assistance State Plan as defined in Chapter 49, Wis. Stats.

Wisconsin Medicaid eligibility is determined on the basis of financial need and other factors. A citizen of the United States or a “qualified immigrant” who meets low-income financial requirements may be eligible for Wisconsin Medicaid if he or she is in one of the following categories:

• Age 65 and older.
• Blind or disabled.
• Under age 19.
• Pregnant.
• A relative caretaker of a child under age 18 or a dependent 18-year old.

Some needy and low-income people become eligible for Wisconsin Medicaid by qualifying for programs such as:

• Healthy Start.
• Katie Beckett.
• Medicaid Purchase Plan.
• Subsidized adoption and foster care programs.
• Supplemental Security Income.
• Wisconsin Well Woman Program (WWWP).

Providers may advise these individuals or their representatives to contact their certifying agency for more information. The following agencies certify people for Wisconsin Medicaid eligibility:

• County/tribal social or human services agencies.
• Medicaid outstation sites.
• Social Security Administration offices.

In limited circumstances, some state agencies also certify individuals for Wisconsin Medicaid, including the Department of Health and Family Services’ Division of Children and Family Services.

Medicaid fee-for-service recipients receive services through the traditional health care payment system under which providers receive a payment for each unit of service provided. Some Medicaid recipients receive services through state-contracted managed care organizations.

Providers should refer to the Recipient section of the Medicaid Web site for the most current eligibility requirements and Medicaid certifying agencies.

Next — Eligibility Categories, BadgerCare Recipients
Previous — Eligibility Categories, Medicaid Recipients