New Eligibility Requirements for Wisconsin Well Woman Medicaid

Effective on and after July 1, 2004, Family Planning Waiver (FPW) recipients diagnosed with cervical cancer, precancerous conditions of the cervix, or breast cancer may be eligible for Wisconsin Well Woman Medicaid. Women enrolled in Well Woman Medicaid are eligible to receive the full range of Medicaid benefits from Medicaid-certified providers, including treatment for cancer and contraceptive-related services. Previously, only women screened by the Wisconsin Well Women Program (WWWP) and diagnosed with cervical cancer, precancerous conditions of the cervix, or breast cancer were eligible for Well Woman Medicaid.

New eligibility requirements for Well Woman Medicaid may accommodate FPW recipients who are diagnosed with cervical cancer, precancerous conditions of the cervix, or breast cancer. Because treatment for cancer is not covered under the FPW program, FPW recipients who are diagnosed with cervical cancer, precancerous conditions of the cervix, or breast cancer may enroll in Well Woman Medicaid to receive treatment for these conditions. Providers should assist eligible recipients with the enrollment process for Well Woman Medicaid.

Criteria for Eligibility

Family Planning Waiver recipients are required to meet all of the following criteria to be eligible for Well Woman Medicaid:

• The recipient is enrolled, through her local county/tribal social or human services department, in the FPW program. Women receiving services through FPW Presumptive Eligibility (PE) are not eligible for Well Woman Medicaid. (If a woman receiving services through FPW PE needs diagnosis or treatment for cervical cancer or breast cancer, she should enroll in the FPW program or the WWWP immediately. Once enrolled in the permanent FPW program or the WWWP, the woman may become eligible for Well Woman Medicaid.)
   
• The recipient has received one of the following:
• Screening for cervical cancer during routine contraceptive-related services and was diagnosed, by biopsy, with cervical cancer or a precancerous condition of the cervix. (Precancerous cervical conditions include a biopsy result of CIN I Mild Dysplasia, CIN II Moderate Dysplasia, CIN III Severe Dysplasia, or endocervical adenocarcinoma in situ.)
• A clinical breast exam during routine contraceptive-related services and, after appropriate follow-up diagnostic tests (e.g., mammogram, biopsy), was diagnosed with breast cancer. (The FPW program does not cover routine screenings or diagnostic tests [e.g., mammogram, biopsy] related to breast cancer.)
   
• The recipient needs treatment for cervical cancer, a precancerous condition of the cervix, or breast cancer, as determined or confirmed by the FPW physician.
   
• The recipient does not have commercial health insurance coverage or Medicare to cover treatment of the cervical cancer, precancerous condition of the cervix, or breast cancer.

Eligibility Process for Wisconsin Well Women Medicaid

The eligibility process for Well Women Medicaid varies based on whether the recipient needs treatment for cervical conditions or breast cancer. The eligibility process varies because the FPW program covers some diagnostic tests related to cervical cancer (e.g., colposcopy, biopsy of the cervix) but does not cover diagnostic tests (e.g., mammogram, biopsy) related to breast cancer. Refer to the Attachment of this Wisconsin Medicaid and BadgerCare Update for an overview of the eligibility process.

Process for Recipients with Cervical Cancer or Precancerous Conditions of the Cervix

When an FPW recipient receives an abnormal result from a pap test during routine contraceptive-related services, some diagnostic tests — including colposcopies with biopsy — are covered under the FPW program. If, in addition to meeting the nonmedical eligibility criteria, the woman is diagnosed with cervical cancer or a precancerous condition of the cervix and needs treatment for the cancer or precancerous condition, she is eligible for Well Women Medicaid.

The FPW physician should complete a Wisconsin Well Woman Medicaid Determination Form (HCF 10075) with the recipient and refer the woman to her local county/tribal social or human services department where the woman can disenroll from the FPW program and enroll in Well Woman Medicaid. If the woman does not complete the enrollment process at the local county/tribal social or human services department, Wisconsin Medicaid will not cover her treatment.

Process for Recipients Who Need Follow-Up Related to Breast Cancer

Routine screenings and diagnostic tests related to breast cancer are not covered under the FPW program. When an FPW recipient receives a suspicious result from a clinical breast exam during routine contraceptive-related services, the woman can seek diagnostic tests through the WWWP, through commercial health insurance or Medicare, or at her own expense. If, after receiving the necessary diagnostic tests, the woman is diagnosed with breast cancer and needs treatment for the cancer, she may be eligible for Well Women Medicaid.

An FPW recipient who has received a clinical breast exam and needs follow-up diagnostic tests related to breast cancer has the following options:

• Prior to receiving diagnostic tests, the recipient — if she is at least 35 years of age — can disenroll from the FPW program and seek enrollment in the WWWP. Once enrolled in the WWWP, the woman can receive the necessary diagnostic tests through the WWWP. If, in addition to meeting the nonmedical eligibility criteria, she is diagnosed with breast cancer and needs treatment for the cancer, she is eligible for Well Woman Medicaid through the WWWP. (A woman cannot enroll in the WWWP while she is enrolled in either the FPW program or full-benefit Wisconsin Medicaid or BadgerCare. If a woman disenrolls from the FPW program, enrolls in the WWWP, and is not diagnosed with cancer, she may re-enroll in the FPW program.)
  
  The FPW provider should refer the recipient to her local county/tribal social or human services department, where she can disenroll from the FPW program. The local WWWP coordinating agency can help the woman enroll in the WWWP. Providers may call (608) 266-8311 or go to the WWWP Web site at dhs.wisconsin.gov/dph_bcdhp/wwwp/ for WWWP coordinating agencies.
   
• The FPW recipient can either:
  • Seek coverage for diagnostic tests through commercial health insurance or Medicare.
  • Receive diagnostic tests at her own expense or check with the local Public Health Department for other funding options.
     
  If, in addition to meeting the nonmedical eligibility criteria, the recipient is diagnosed with breast cancer while enrolled in the FPW program and needs treatment for the cancer, she is eligible for Well Woman Medicaid.
  
  A recipient diagnosed with breast cancer should notify her FPW provider immediately. After confirming the recipient’s diagnosis and need for treatment, the FPW physician should complete a Wisconsin Well Woman Medicaid Determination Form (HCF 10075) with the recipient. The physician should refer the woman to her local county/tribal social or human services department where the woman can disenroll from the FPW program and enroll in Well Woman Medicaid. If the woman does not complete the enrollment process at the local county/tribal social or human services department, Wisconsin Medicaid will not cover her treatment.

Wisconsin Well Woman Medicaid Determination Form

To request paper copies of the Wisconsin Well Woman Medicaid Determination Form (HCF 10075), call the Division of Health Care Financing at (608) 267-9049 or send a fax to (608) 261-6861. Faxed requests should include a return address, the name of the form, and the HCF number of the form.

The completed Wisconsin Well Woman Medicaid Determination Form must be typed or printed clearly and signed by the FPW physician. The provider should fax the completed form to (608) 261-6861 or send the pink copy of the form (labeled "LOCAL COORDINATING AGENCY COPY") to:

Division of Health Care Financing
Wisconsin Well Woman Medicaid
Bureau of Health Care Eligibility Rm 365
PO Box 309
Madison WI 53701-0309

The FPW provider should keep the yellow copy of the form (labeled "PROVIDER COPY") as part of the recipient’s record. The woman should keep the blue copy (labeled "APPLICANT COPY") for her records and present the white copy (labeled "ES COPY") to her local county/tribal social or human services department.

For More Information

For questions about this Update, providers may contact Provider Services at (800) 947-9627 or (608) 221-9883.

Information Regarding Medicaid HMOs

This Update contains Medicaid fee-for-service policy and applies to providers of services to recipients on fee-for-service Medicaid only. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment: Overview of Eligibility Process for Wisconsin Well Women Medicaid from the Family Planning Waiver Program