BadgerCare Plus Overview

In January 2007, Governor Jim Doyle included in his 2007-09 Biennial Budget proposal an innovative state-sponsored health care program to expand coverage to Wisconsin residents and ensure that all children in Wisconsin have access to affordable health care. This new program is called BadgerCare Plus, and it will start on February 1, 2008.

BadgerCare Plus merges family Medicaid, BadgerCare, and Healthy Start into a single program. BadgerCare Plus will expand enrollment to:

• All uninsured children.
• More pregnant women.
• More parents and caretaker relatives.
• Parents with children in foster care who are working to reunify their families.
• Young adults exiting out-of-home care, such as foster care, because they have turned 18 years of age.
• Certain farmers and other self-employed parents and caretaker relatives.

All individuals enrolled in BadgerCare Plus and Wisconsin Medicaid will be referred to as “members.”

BadgerCare Plus is comprised of two benefit plans, the Standard Plan and the Benchmark Plan. The services covered under the BadgerCare Plus Standard Plan are the same as the current Wisconsin Medicaid program; therefore, the term “Standard Plan” will be used in all future Updates to describe the shared policy and billing information. The BadgerCare Plus Benchmark Plan is a more limited plan, modeled after commercial insurance.

New services covered under BadgerCare Plus and Wisconsin Medicaid include over-the-counter tobacco cessation products for all members and mental health and substance abuse screening, preventive mental health counseling, and substance abuse intervention services for pregnant women at risk of mental health or substance abuse problems. Future Updates will describe these new benefits in detail.

Refer to the November 2007 Update (2007-79), titled “Introduction to BadgerCare Plus — Wisconsin’s New Health Care Program,” for general information on covered and noncovered services, copayments, and enrollment.

Enteral Nutrition Under BadgerCare Plus

Standard Plan

Policy and procedures pertaining to enteral nutrition products are the same under the Standard Plan as they are under the current Wisconsin Medicaid program except for copayments.

Copayment amounts under the Standard Plan are the same as they are under the current Wisconsin Medicaid program. Refer to previously published service-specific publications for more information on copayment amounts.

Policy regarding Standard Plan members who are subject to copayments and members who are exempt from copayments is different than that of the current Wisconsin Medicaid program.

Providers should note that the following Standard Plan members are subject to copayment for services where copayment applies:

• Members enrolled in BadgerCare Plus Standard Plan HMOs (previously referred to as Medicaid HMOs).
• Members under 18 years of age with incomes above 100 percent of the Federal Poverty Level (FPL).

Providers are prohibited from collecting copayments from the following Standard Plan members:

• Nursing home residents.
• Pregnant women.
• Members under 18 years of age who are members of a federally recognized tribe.
• Members under 18 years of age with incomes at or below 100 percent of the FPL.

Under the Standard Plan, providers cannot deny services if a member fails to make his or her copayment.

Benchmark Plan

Enteral nutrition products are not covered under the Benchmark Plan.

Benchmark Plan members may request noncovered services and products from the provider. Providers may collect reimbursement for noncovered services or products from the member if the member accepts responsibility for payment and makes payment arrangements with the provider. Providers are strongly encouraged to obtain a written statement in advance documenting that the member has accepted responsibility for payment of the service or product.

A future Update will address policies and procedures for billing BadgerCare Plus members for noncovered services.

Information Regarding BadgerCare Plus HMOs

BadgerCare Plus HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements. For managed care policy, contact the appropriate managed care organization.