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.

Covered Services

Podiatry services covered under the Standard Plan and the Benchmark Plan are the same as those covered under the current Wisconsin Medicaid program. Refer to the appropriate publications for covered services, policies and procedures.

Reimbursement

Providers will be reimbursed for services provided to members at the current Wisconsin Medicaid rate of reimbursement.

Copayments

Standard Plan

Copayment amounts and copayment limits for services under the BadgerCare Plus 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 and limits.

Policy regarding 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 BadgerCare Plus 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

Copayment for podiatry services under the Benchmark Plan is $15.00 per visit. Copayments for the Benchmark Plan are applied on a per-visit basis — not per procedure code as they are under the Standard Plan. There are no copayment limits.

Copayments are applied to surgery and evaluation and management (E&M) services. A visit is based on the billing of either a surgery or an E&M code. If a surgery code and an E & M code are billed on the same claim, the copay should only be applied to the E&M code.

Copayments are not applied to the following codes:

• Radiology.
• Pathology.
• Laboratory.
• Medicine.

Note: When a claim is submitted with two or more procedure codes that are subject to copayment, are provided on the same date of service, and have the same performing provider, only one copayment should be collected.

The following members are exempt from copayment requirements under the Benchmark Plan:

• Pregnant women.
• Members under 18 years of age who are members of a federally recognized tribe.

No other members are exempt from the copayment requirement under the Benchmark Plan.

Under the Benchmark Plan, a provider has the right to deny services if the member fails to make his or her copayment.

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.