Wisconsin BadgerCare Application Information

BadgerCare Plus (BC+) is a state-sponsored health insurance program launched on February 1, 2008. It is aimed at low-income, vulnerable population groups such as children under 19 years old (regardless of income), pregnant women living up to 300% of the Federal Poverty Level, and adults with certain household arrangements. Approved beneficiaries can receive benefits through one of the accredited health maintenance organizations (HMOs), a list of which can be found here: http://www.dhs.wisconsin.gov/publications/p1/p12020a.pdf

The BC+ program offers several types of plans that suit your income, age group, household status, and most importantly, your health needs:

Standard Plan

If your family income is at or below 200% of the Federal Poverty Limit even without deducting depreciations, you will be enrolled in this plan. Services covered by the BC+ Standard Plan are:

  • Case management services

  • Chiropractic services

  • Dental services

  • Family planning services and supplies

  • Early and periodic screening, diagnosis and treatment for people under 21 years old

  • Home- and community-based services

  • Home-based health services or nursing services if a home health agency is unavailable

  • Hospice care

  • Inpatient hospital services other than mental health service institutions

  • 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 and was getting services when you turned 21 years of age

    • 65 years of age or older

  • Intermediate care facility services other than mental health service institutions

  • Laboratory and x-ray services

  • Medical supplies and equipment

  • Mental health and psychosocial rehabilitative services

  • Nurse and nurse midwife services, including services performed by a nurse practitioner

  • Optometric/optical services, including eye glasses

  • Outpatient hospital services

  • Personal care services

  • Physical and occupational therapy

  • Physician services

  • Podiatry services

  • Prenatal care for women with high-risk pregnancies

  • Prescription and over-the-counter drugs

  • Respiratory care services for ventilator-dependent individuals

  • Rural health clinic services

  • Skilled nursing home services other than mental health service institutions

  • Smoking cessation programs

  • Speech, hearing, and language disorder services

  • Substance abuse (including alcohol) services

  • Transportation to obtain medical care in health facilities

  • Tuberculosis treatment services

This list may be updated from time to time, or your HMO may have its own list of services. Please contact Member Services at 1-800-362-3602 to confirm the coverage of your needed service. You may also call your HMO directly to inquire about the availability of BC+ covered services.

Benchmark Plan

If your family income falls at or below 200% of the Federal Poverty Limit after depreciations have been deducted, you will be enrolled in this plan. Services covered by the BC+ Benchmark Plan (including extent of coverage) include:

  • Coverage of certain surgical procedures and related lab services in ambulatory surgical centers

  • Chiropractic Services

  • Dental services: preventive, diagnostic, simple restorative, periodontics, and surgical procedures for pregnant women and children. Coverage is limited to $750 per enrollment year.

  • Diabetic supplies, ostomy supplies, and other disposable medical supplies

  • Prescription drugs (members will be automatically enrolled in the BadgerRX Gold Plan which is a separate program by Navitus Health Solutions)

  • Durable medical equipment: coverage up to $2,500 per enrollment year (excluding cochlear implants, hearing aids, and hearing aid equipment

  • End-Stage Renal Disease treatment)

  • Health Screenings for children

  • Hearing Services

  • Home Care Services (e.g. home health, private duty nursing, personal care): coverage limited to 60 visits per enrollment year (except for private duty nursing and personal care services)

  • Hospice Care: coverage limited to 360 days lifetime

  • Inpatient hospital services

  • Mental health and substance abuse treatment (excluding crisis intervention, community support programs, comprehensive community services, outpatient mental health services in the home and community for adults, and substance abuse residential treatment)

  • Nursing home services: coverage limited to 30 days per enrollment year

  • Emergency room services

  • Physician visits, including laboratory and radiology services

  • Podiatry Services

  • Prenatal and maternity care, including preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems

  • Reproductive health services (excluding infertility treatments, surrogate parenting, reversal of voluntary sterilization)

  • Physical Therapy, Occupational Therapy, Speech and Language Pathology services: coverage limited to 20 visits per type of therapy per enrollment year (also covers up to 36 visits per enrollment year for cardiac rehabilitation provided by a physical therapist)

  • Transportation to and from a certified provider for a covered service

  • Routine Vision Exam: coverage limited to one eye exam per enrollment year, with refraction

These services will require a copayment. Failure to provide copayment may lead to refusal of your HMO to give you the service. To see how much copayments are required per service and if you are exempt from paying those, please visit http://www.dhs.wisconsin.gov/badgercareplus/benchmark.htm.

Core Plan

This plan is primarily for low-income adults without any children. However, Wisconsin has temporarily suspended enrollment of its residents in this plan due to the number of applications exceeding available slots. But if you still meet this plan’s requirements and want to avail of its services, you may opt to be placed in the waitlist and be contacted (through mail) when an opening becomes available to you.

Services covered by the Core Plan include:

  • Physician visits

  • Chiropractor services

  • Inpatient hospital services

  • Emergency room visits

  • Emergency dental services

  • Transportation towards a health facility in emergency cases

  • Hospice care

  • Home health care

  • Podiatry services

  • Prescription drugs (not all drugs are covered; please call 1-800-362-2002 or your HMO to inquire about the coverage of a certain drug)

  • Physical therapy (including cardiac rehabilitation), occupational therapy, speech and language services

  • Durable medical equipment

  • Disposable medical supplies

  • Dialysis and kidney disease-related services

Core Plan services also require copayments depending on the service you wish to receive. You can access a table of copayments here: http://www.dhs.wisconsin.gov/publications/P1/P10194.pdf

For a comprehensive comparison of all services covered by each plan (Standard, Benchmark, Core plans), please visit http://www.uhccommunityplan.com/assets/WI-CoveredServicesComparisonChart.pdf.

Family Planning-Only Services

This service has been established in order to prevent unwanted pregnancies and stop the spread of sexually-transmitted infections. Under federal law, interested clients who want to receive family planning services are given the freedom to choose where to get it. Therefore, you can receive family planning services even outside your HMO as long as the institution accepts the ForwardHealth ID card which would be issued to you.

Services included in this plan are:

  • Contraceptives

  • Natural family planning supplies

  • Family planning pharmacy visits

  • Pap tests

  • Tubal ligation

  • Tests and treatment for STDs (e.g. chlamydia, gonorrhea, herpes, syphilis) and certain other lab tests

  • Routine preventive primary services related to family planning.

Family-planning services for males are also available:

  • Family planning-related office visits

  • Condoms (needs a prescription from a doctor or nurse practitioner)

  • Testing and treatment of sexually transmitted diseases/infections (STDs/STIs)

  • Voluntary sterilizations for men 21 years old and above

Receiving this service also entitles you to the following protections:

  • Written information can be sent to an address other than your current residence

  • If you are under age 19:

    • You will not be referred to the child support agency.

    • The agency will not contact your parents or guardians about your family planning enrollment or services

Prenatal Services

This plan is exclusive for pregnant women and includes:

  • Prenatal care

  • Doctor and clinic visits

  • Dental care

  • Prescription drugs, including prenatal drugs

  • Labor and delivery care

Beneficiaries will be enrolled in an HMO upon approval of your application. This HMO will be responsible for providing you with your healthcare needs covered by BC+. However, you may get BC+ services outside the HMO you enrolled in under the following cases:

  • You are a tribal member who opts not to enroll in an HMO

  • You are in an emergency medical situation

  • Your doctor refers you to another HMO

  • Your HMO does not offer the BC+ service you need (e.g. dental services)

  • You want to receive family planning services

  • You are a migrant worker

  • You are living in a Wisconsin area with no available HMOs

Once you, and your family members, are approved for BC+ you all will be issued a ForwardHealth ID which beneficiaries can present to all types of healthcare providers included in BC+. If your card gets lost, stolen, or damaged, simply call Recipient Services at 1-800-362-3002 and request for a new one.

There have been updates as to several guidelines in each BC+ plan. You can keep yourself informed with these updates and avoid problems with your BC+ plan by visiting http://www.dhs.wisconsin.gov/badgercareplus/Updates/p-00324.htm.

In addition to the vast health benefits you can get from being a BC+ member, you also get the following rights:

  • Right to obtain information about your HMO and how they work

  • Right to fair treatment

  • Right to ask questions and file complaints

If you feel that your rights as a BC+ member have been violated or you feel that you disagree with certain actions taken on your application, you may request for a fair hearing trial by downloading a form at http://dha.state.wi.us/home/WFS/WFSHrgReqForm.pdf and sending it no later than 45 days since the incident to:

Department of Administration

Division of Hearing and Appeals

P.O. Box 7875

Madison, WI 53707-7875

You may also call state Ombudsmen at 1-800-760-0001 for your complaints or grievances.

This program also prohibits discriminatory actions against all applicants as mandated by federal law and the Department of Agriculture. If you feel that you have been discriminated in any way, you may write to:

Wisconsin Department of Health Services

Affirmative Action/Civil Rights Compliance

1 W. Wilson, Room 555

Madison, WI 53707-7850

 

You may also call them at (608) 266-9372 or 1-888-701-1251.

Eligibility Requirements

Each BC+ plan has different requirements that must be satisfied in order for you to receive their benefits. These are:

For STANDARD/BENCHMARK PLANS:

  • Family income must be at or below 200% of the Federal Poverty Level*

  • You are a child or young adult under 19 years old leaving foster care, regardless of income

  • You have a child in foster care or are currently taking care of a child within your home

  • You are a pregnant woman living up to 300% of the Federal Poverty Level*

  • You are a Wisconsin resident

  • You are a US citizen or qualifying immigrant**

For CORE PLAN (waitlist only):

  • You are within 19-64 years old

  • You do not have any dependent children under 19 years old living with you

  • You are not pregnant

  • Your family income is at or below 200% of the Federal Poverty Level*

  • You are a Wisconsin resident

  • You are a US citizen or qualifying immigrant**

  • You currently do not have health insurance or have availed of one in the past 12 months, whether private or through an employer

  • You have not quit your job and in the process have lost your health insurance provided by the employer

  • You do not have access to health insurance within 3 months following the date of application

  • You do not have access to insurance through your current employer in the past 12 months

  • You are able to pay a non-refundable application fee (if you are homeless or are eligible to get Indian Health Services, you no longer need to pay this)

For special cases and other requirements for Core Plan enrollment, please visit http://www.dhs.wisconsin.gov/publications/p0/p00062.pdf.

For FAMILY-PLANNING ONLY SERVICES:

  • You must be a US citizen or a qualifying immigrant

  • Your family gross income must be at or below 300% of the Federal Poverty Level*

  • You must not be receiving ForwardHealth services for the elderly, blind, or disabled

  • You must not have any dependent children

  • You must not be currently enrolled in BC+ Standard or Benchmark Plans

 

* To see the current Federal Poverty Limits per family size (as of July 2012), please visit http://www.badgercareplus.org/fpl.htm.

** If you are not a US citizen or a qualifying immigrant, you may be able to receive other services through Emergency Services or BadgerCare Plus Prenatal Services Plan (for pregnant women). Your immigration status will not be shared with the US Citizenship and Immigration Services (USCIS).

To further check for your eligibility in getting BC+ benefits, visit https://access.wisconsin.gov/ and click on “Am I Eligible?” at the leftmost side of the site and input your particulars for assessment.

BadgerCare Application Instructions

There are various ways to apply for BC+:

  • Via telephone: Call Member Services at 1-800-362-3602 and set up an appointment where you can go through the application process. You may also call your local agency directly for appointments with them. For a list of the telephone numbers of the agency handling BC+ applications in your area, please go to http://www.dhs.wisconsin.gov/em/imagencies/index.htm.

  • Online: Just go to http://access.wi.gov and log in with your Wisconsin username and password before proceeding with the online application. If you don’t have a username and password yet, just click on “Create an Account” at the rightmost side of the site.

Aside from submitting a completed application form, you also need to submit proof of your identity, US citizenship, tribal membership (if applicable), monthly income, pregnancy (if applicable), child support, current health insurance plans, and medical costs and expenses. Coordinate with your local agencies as to what documents they will accept as proof of these.

Your application will then be immediately processed and you can expect a reply from your local agency within 30 days. Also, you can still apply for BC+ benefits even if you have been denied before. Simply follow the same steps discussed above.

However, in the following cases, you may be able to receive “backdated coverage” for your medical bills up to three months prior to your BC+ application:

  • You are a pregnant woman

  • You are a young adult under 19 years old about to leave foster care

  • You have a monthly income of less than 150% of the Federal Poverty Level and are currently caring for a child

STANDARD AND BENCHMARK PLANS

For Standard and Benchmark plans, you and your family members will be enrolled in one of the BC+ HMOs after approval. These HMOs would be responsible for providing you and your family with your primary health needs and other covered services. You will receive an HMO Enrollment Packet (such as this: http://www.dhs.wisconsin.gov/publications/p1/p12020.pdf) that would give you a list of HMOs in your area plus details about the HMOs you plan to enroll in. You may be able to change your HMO within 90 days of your enrollment, which is termed as the “open enrollment” period. Afterwards, you need to stick with your HMO for nine months (termed as “lock-in” period) after which you may opt to switch HMOs.

For questions regarding HMO enrollment, you may contact the Enrollment Specialist at 1-800-291-2002.

CORE PLANS

In the case of Core Plans, please note that you will not be directly enrolled in the program; you will simply be placed on a waitlist. You also do not need to provide proof of anything until a slot opens up for you. At which time you can start the enrollment process.

TEMPORARY FAMILY-PLANNING ONLY SERVICES

You can receive this benefit when a qualified family planning service provider sees that you meet the criteria for enrollment in the program but decides to give you the services right away. This enrollment is valid only for two months, starting from the date you filled out an application form. For a list of qualified family planning service providers, you may contact Member Services at 1-800-362-3602.