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Medicaid What is it? Medicaid is a joint federal/state program established in 1965 to pay for medical services for people with disabilities, people 65 years and older, children and their caretakers, and pregnant women who meet the program's financial requirements. Wisconsin Medicaid is also known as the Medical Assistance Program, Title XIX, or T19. Wisconsin Medicaid is administered by the Department of Health and Family Services (DHFS), Division of Health Care Financing (DHCF). BadgerCare Plus BadgerCare Plus is a program for children under 19 years of age and families in Wisconsin who need and want health insurance. BadgerCare Plus is for all kids, regardless of income. It also offers access to comprehensive, affordable health care to many families and pregnant women in Wisconsin. FoodShare Wisconsin FoodShare Wisconsin helps single people, couples and families who have little money buy the food they need for good health. FoodShare benefits come on a plastic card, called the Wisconsin QUEST card that you use just like a bank card. If your household has little or no money and needs help right away, contact your local agency. You may be able to get FoodShare benefits within seven (7) days after the day that the local agency gets your signed application. To find out more about FoodShare, call 1-800-362-3002, go to dhfs.wisconsin.gov/em/customerhelp or contact your local agency. Women, Infants, and Children (WIC) If you are able to get Medicaid, you may also be able to get the special supplemental food program for women, infants and children (WIC). Pregnant women and young children may get nutritious food and health/nutrition counseling through this program. To find out more about WIC and other programs you may be able to get, contact 1-800-722-2295. Caretaker Supplement (CTS) Wisconsin’s Caretaker Supplement (CTS) is a cash benefit for parents who get SSI payments. Caretaker Supplement is not a Medicaid benefit. It pays cash to eligible parents. For more information on CTS or to apply for CTS, contact your local agency. Why does it exist? The purpose of Wisconsin Medicaid is to provide reimbursement for and assure the availability of appropriate medical care to persons who meet the criteria for Medicaid. What is my cost? Providers can collect copayments when the service is provided or they can bill you for it later. You may be asked for more than one copayment, if you get more than one service at an appointment. Who pays for it? Some people enrolled in Medicaid will have certain out of pocket costs. These include: Copayments You may be required to pay a part of the cost of a service. This payment is called a “copayment” or “copay”. If you cannot pay your copayment right away, the provider cannot refuse to provide the service. Premiums If you are enrolled in the Medicaid Purchase Plan (MAPP) program, you may have a premium. The amount you pay depends on your income and the Federal Poverty Levels (FPL). For more information, see the Medicaid Purchase Plan Section. Deductibles If you are enrolled in Medicaid with a deductible, the amount of your deductible is the difference in your family’s monthly income and the program income limit for a six-month period. For more information see Medicaid Deductibles. Patient Liability / Cost Share If you are enrolled in a Long Term Care Medicaid plan, you may have a patient liability or a cost share. The amount is based on your monthly income after certain credits are given. Your patient liability must be paid to the nursing home or care facility in which you live. Who is eligible? Medicaid provides health care for the elderly, blind or disabled. The Medicaid plan you are enrolled in depends on your income, assets, and type of care you need. If you are not elderly, blind or disabled, and you are in need of health care coverage, you may be able to enroll in BadgerCare Plus. You will need to provide proof of certain information at application/review and when changes occur including: Assets You will be required to provide proof of all your assets. Examples of proof can be a copy of your bank statement showing the value of your bank account on the date the application is completed, or a statement that shows the current face value and cash value of your life insurance policy. Divestment If you are enrolled in Long Term Care you will be required to verify assets you divested. For more information on divestment refer to the Medicaid program you are enrolled in. Other Health Insurance If you or anyone in your family has any other health insurance coverage, you must tell the local agency and your medical providers. If you have other health insurance coverage, your health insurance will be billed before Medicaid. Medicaid may pay for services that your health insurance does not pay. If you have questions about your other insurance coverage, ask your insurance company. If you have questions or complaints regarding that insurance company contact: Office of the Commissioner of Insurance Bureau of Market Regulation, PO Box 787, Madison WI 53707-7873, 1-800-236-8517. Accident and Injury Claims If you are in an accident or injured and you get a cash award or settlement due to the accident or injury and Medicaid pays for part or all of your care, you must report this to your local agency. If you have hired an attorney or are working with an insurance agency to settle your claim, you must report this information. Telephone: (608) 221-4746 ext. 80062 Fax: (608) 221-4567 Other Below are some examples of other information you may need to prove. Your worker may ask for proof of: Income (pension, annuity, IRA, etc.) Medical expenses Citizenship/Immigration status Identity Doctor’s verbal or written statement that a person in an institution who is maintaining a home or property is likely to return to that home or apartment within six months Documentation of Power of Attorney or Guardianship You can send a copy of your proof with your Medicaid Change Report or mail a copy to your local agency. If you are having trouble getting what you need to provide proof, contact your local agency for help. What is covered? Covered Services include, but are not limited to: Ambulance (Emergencies only) Alcohol and Other Drug Abuse (AODA) services Case management services Chiropractic services Dental services Family planning services and supplies HealthCheck (Early and Periodic Screening, Diagnosis and Treatment) for people under 21 years of age Home and community-based services if you are enrolled in Home and Community Based Waivers (HCBW) or Family Care Hospice care Inpatient hospital, skilled nursing facility, and intermediate care facility services for patients in institutions for mental disease who are: Under 21 years of age Under 22 years of age who received services immediately before reaching age 21 65 years of age or older Laboratory and X-ray services Legend drugs and over-the-counter drugs listed in Wisconsin’s Medicaid drug index. dhfs.wisconsin.gov/MEDICAID/pharmacy/pdl/index Medical supplies and equipment Mental health and medical day treatment Mental health and psychosocial rehabilitative services including case management services provided by staff of a certified community support program Nurse midwife services Nursing services, including services performed by a nurse practitioner Optometric or optical services, including eye glasses Outpatient hospital services Personal care services Physical and occupational therapy Physician services Podiatry services Prenatal care coordination for women with high-risk pregnancies Respiratory care services for ventilator-dependent individuals Skilled nursing home services other than in an institution for mental disease Speech, hearing and language disorder services Substance abuse (alcohol and other drug abuse) services Transportation to obtain medical care Tuberculosis services Where can you receive services? U.S. and Wisconsin laws guarantee rights, which include the right to: Be treated with respect by state and county employees Have all the information you give to the local agency kept private. This does not prohibit the use of such records for program administration. Have access to agency records and files relating to your case, except information given to the local agency under a promise of privacy Remain enrolled in Medicaid even if you are temporarily out of Wisconsin but you are still a Wisconsin resident Have your enrollment in Medicaid determined within 30 days from the day the local agency receives your application for Medicaid Be notified in advance of changes in your benefits or enrollment status Get emergency medical care Ask for reasonable accommodation to take part in Medicaid for a disability-related reason Ask for interpreters or translators in order to take part in Medicaid What do I need to be cautious about? Reporting Changes You must report within ten days of the change: Changes in your household’s income, assets or expenses A change in where you live, where you are staying or if someone moves in or out of your home If someone gets married or divorced You will be required to verify (give proof) of some of these changes (See Verification/Proof). If you do not report a change, you may be required to pay for services you received after your cost share or Enrollment status should have changed.You can report changes online. Go to access.wi.gov and click on “Report My Changes”. You may also use the Medicaid Change Report form or call your local agency. If you receive SSI benefits, your changes should be reported to the Social Security Office. Overpayments An “overpayment” occurs when Medicaid benefits are paid for someone who was not eligible for them, or when Medicaid calculations are incorrect. You may be required to pay for services you received incorrectly if you: Conceal or fail to report income. Fail to report a change in income. Provide misinformation, at the time of application, regarding any information that would affect your enrollment. Fraud Fraud means to enroll in Medicaid and receive services you should not get. Fraud also means to help another person get coverage or payment for services you know they should not get. Anyone who commits fraud can be prosecuted. If a court decides that someone received health care benefits by fraud, the court may require repayment for those services in addition to other penalties. You may be fined up to $10,000 and jailed for not more than one year in a county jail, if you: Give false or incomplete information on your application for Medicaid Intentionally do not report a change that causes you to get more benefits than you should Apply for Medicaid for someone else and use part of that benefit for yourself Let someone else use your ForwardHealth card or use someone else’s card to get medical services or prescription drugs Local Resources Marathon County Department of Social Services 400 E. Thomas Street Wausau, WI, 54403 Telephone: (715) 261-7500 Fax: (715) 261-7510 Web Resources Access: https://access.wisconsin.gov/ Member Services: 1-800-362-3002 (General information, including questions about your Forward card, or bills for services and contact information for your local county or tribal agency.) Premium Information: 1-888-907-4455 (For questions about MAPP premiums and the Health Insurance Premium Payment (HIPP). HMO – Enrollment: 1-800-291-2002 (For questions about HMO enrollment) HMO – Complaints: 1-800-760-0001 Reporting Changes: Contact your local county or tribal agency or go to access.wi.gov. Supplemental Security Income (SSI) Medicaid: 1-800-362-3002 SSI program: 1-800-675-0249 Social Security Administration and Medicare: 1-800-772-1213 (voice) or 1-800-325-0778 (TTY) For more information: www.dhfs.wisconsin.gov/em/customer help. All the telephone numbers listed have TTY and translation services available, at no cost to you.
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