• 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 Responsibilities

Loss of Medicaid Eligibility — Financial Liability

Some Medicaid-covered services consist of a series of sequential treatment steps, meaning more than one office visit is required to complete treatment.

In most cases, if a recipient loses eligibility for Wisconsin Medicaid midway through treatment, Wisconsin Medicaid will not reimburse services (including prior authorized services) provided after eligibility has lapsed.

Recipients are financially responsible for any services received after their Wisconsin Medicaid eligibility has been terminated. If the recipient wishes to continue treatment, it is a decision between the provider and the recipient whether the service should be given and how the services will be paid. The provider may collect payment from the recipient if the recipient accepts responsibility for payment of a service and certain conditions are met. Refer to the Covered and Noncovered Services section of this handbook for more information.

To avoid misunderstandings, it is recommended that providers remind recipients that they are financially responsible for any continued care after eligibility ends.

Note:

Exceptions to the loss of eligibility in mid-treatment include dental prosthodontia or orthodontic treatment. Providers of these services should refer to their service-specific publications for more information on these exceptions. Other types of providers should not assume Wisconsin Medicaid covers completion of services after the recipient’s eligibility has been terminated.

To avoid potential reimbursement problems that can arise when a recipient loses eligibility midway through treatment, the provider is encouraged to verify the recipient’s eligibility using the Medicaid Eligibility Verification System (EVS) prior to providing each service, even if an approved prior authorization request is obtained for the service. Refer to the Eligibility Verification Methods chapter of this section for more information about the EVS.

Next — Eligibility Responsibilities, Reporting Changes to Caseworkers
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