Retroactive Enrollment

Retroactive enrollment occurs when an individual has applied for Wisconsin Medicaid or BadgerCare Plus and enrollment is granted with an effective date prior to the date the enrollment determination was made. A member’s enrollment may be backdated to allow retroactive coverage for medical bills incurred prior to the month of application.

The retroactive enrollment period may be backdated up to three months prior to the month of application if all enrollment requirements were met during the period. Enrollment may be backdated more than three months if there were delays in determining enrollment or if court orders, fair hearings, or appeals were involved.

Refer to the Recipient Eligibility and the Covered and Noncovered Services sections of the Wisconsin Medicaid All-Provider Handbook for more information about retroactive enrollment and policies regarding covered and noncovered services.

Return of Payment

When a member is retroactively enrolled, he or she has the right to request the return of payments made to a Medicaid-certified provider for a covered service during the period of retroactive enrollment, according to HFS 104.01(11), Wis. Admin. Code. A Medicaid-certified provider is required to submit claims for covered services provided to a member during periods of retroactive enrollment. Wisconsin Medicaid and BadgerCare Plus cannot directly refund the member.

Effective for dates of service (DOS) on and after October 27, 2007, if a provider receives reimbursement for services provided to a retroactively eligible member, and the member has paid for the service, the provider is required to reimburse the member or authorized person acting on behalf of the member the full amount that the member paid for the service.

If a claim cannot be filed within 365 days of the DOS due to a delay in the determination of a member’s retroactive enrollment, the provider is required to submit the claim to Timely Filing within 180 days of the date the retroactive enrollment is entered into Wisconsin’s Enrollment Verification System (if the services provided during the period of retroactive enrollment were covered). Refer to the Claims Information section of the All-Provider Handbook for more information on filing claims for services performed with DOS beyond the claims submission deadline (timely filing appeals requests).

The current wording of HFS 104.01(11), Wis. Admin. Code, and HFS 106.04(3)(b), Wis. Admin. Code, is inconsistent with the change in statutes and no longer governs to the extent of the conflict; the Department of Health and Family Services will be amending these rules to be consistent with the change in the statutes.

BadgerCare Plus

Effective with the implementation of BadgerCare Plus on February 1, 2008, this policy will affect members enrolled in the BadgerCare Plus Standard Plan and BadgerCare Plus Benchmark Plan. For more information about BadgerCare Plus, refer to the November 2007 BadgerCare Plus Update (2007-79), titled “Introduction to BadgerCare Plus — Wisconsin’s New Health Care Program.”