• 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

Special Eligibility Circumstances

Spenddown to Meet Medicaid Financial Eligibility Requirements

Occasionally, an individual with significant medical bills meets all Medicaid eligibility requirements except those pertaining to income. These individuals are required to “spenddown” their income to meet Medicaid’s financial eligibility requirements.

The certifying agency calculates the individual’s Medicaid spenddown (or deductible) amount, tracks all medical costs the individual incurs, and determines when the medical costs have satisfied the spenddown amount. (A payment for a medical service does not have to be made by the individual to be counted toward satisfying the spenddown amount.)

When the individual meets the spenddown amount, the certifying agency notifies Wisconsin Medicaid and the provider of the last service that the individual is Medicaid eligible beginning on the date that the spenddown amount was satisfied.

If the individual’s last medical bill is greater than the amount needed to satisfy the spenddown amount, the certifying agency notifies the affected provider by indicating the following:

• The individual is eligible for Wisconsin Medicaid as of the DOS on the last bill.
• A claim for the service(s) on the last bill should be submitted to Wisconsin Medicaid. (The claim should indicate the full cost of the service.)
• The portion of the last bill that the individual must pay to the provider.

The certifying agency also informs Wisconsin Medicaid of the individual’s eligibility and identifies the following:

• The DOS of the final charges counted toward satisfying the spenddown amount.
• The Medicaid provider number of the provider of the last service.
• The spenddown amount remaining to be satisfied.

When the provider submits the claim to Wisconsin Medicaid, the spenddown amount will automatically be deducted from the provider’s reimbursement for the claim. The spenddown amount is indicated in the Recipient’s Share element on the Medicaid Remaining Deductible Update form, HCF 10109, sent to providers by the recipient’s certifying agency. The provider’s reimbursement is then reduced by the amount of the recipient’s obligation.

Next — Special Eligibility Circumstances, Persons Detained by Legal Process
Previous — Special Eligibility Circumstances, Retroactive Eligibility, Reimbursing Recipients in Cases of Retroactive Eligibility