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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
Overpayments for periods prior to the lookback period are not recoverable.
Claims under $500 can only be recovered if the claim meets one of the following criteria:
Duplicate benefits are defined as situations in which a member moved out of state, enrolled in another state’s Medicaid program, and received services under BadgerCare Plus or Wisconsin Medicaid more than two months after the move occurred.
Overpayments resulting from non-member errors are not recoverable, including these situations:
| Example 1 |
Susan and her daughter Kathy are open for BadgerCare Plus. Susan reported a change in income on April 1. The worker did not process the change until April 28, so it was not effective until June 1. There is no overpayment for May since the change was reported timely, but not acted on by the worker until after adverse action. |
Overpayments for any months when rules preventing health care terminations during the COVID-19 public health emergency were in effect are not recoverable. This means benefits issued March 2020 and any months after March 2020 for which continuous coverage due to the COVID-19 public health emergency is in effect for that member. This includes individuals whose health care was granted, extended, or both due to agency or state error.
In addition, some BadgerCare Plus childless adults were granted health care eligibility effective February 1, 2020 in error. For these individuals, do not initiate recovery for a Medicaid overpayment starting February 2020 and any months after February 2020 when the prevention of terminations policy is in effect.
If a member fails to correctly report income or a change in income which results in monthly income making the member ineligible, an overpayment doesn’t exist if the member could have been eligible under gap filling rules.
For this reason, when researching a potential overpayment due to excess monthly income for a given calendar year, an IM agency must determine that the person surpassed 100% of the FPL based on his or her annual income before an overpayment can be established. A denial letter from the FFM, gap filling indicator, or specific gap filling request by the member is not required to determine eligibility during the overpayment period under gap filling rules. If the person's annual income has not yet surpassed 100% of the FPL, do not establish an overpayment until there is evidence that the person has surpassed 100% of the FPL. Establishing the overpayment may require waiting until the end of the calendar year for actual income to become available to determine if the person surpassed 100% of the FPL.
| Example 2 |
Richard became eligible for BadgerCare Plus as a childless adult in March of last year and had no countable income. At his renewal in February, Richard reports that he has been working since April of last year. Verification shows that Richard’s salary of $2,500 per month came to a countable income total of $22,500. Although Richard exceeded his reporting limit in April, the worker must look at what would have happened had he reported the change timely when determining whether an overpayment occurred. The worker finds that Richard was required to report his change in income no later than May 10. Since verification of his actual income for last year shows that he was over the annual income limit for gap filling, there is an overpayment for June 1–December 31. The worker then evaluates the overpayment for January and February of the current year. So far, Richard has only received $5,000 in countable income. Because the IM agency doesn't have any information to indicate that Richard’s job will not continue for the rest of the year, he would not be found eligible under gap filling rules. However, for benefit recovery purposes, he hasn't yet exceeded the 100% of the FPL annual income limit, so the IM agency can't say definitively that he wouldn't have been eligible under gap filling rules. The worker can't establish an overpayment for his eligibility in the current year until Richard’s income has been found to be over the annual limit for gap filling coverage. The worker must manually track the case to review the case in January of the next year. In January of the next year, the worker reviews Richard’s case for a potential overpayment from January 1–February 28 of last year and determines his annual income. His earned wages were $6,700 for the first quarter, $5,100 for second quarter, and $4,250 for the third quarter. His fourth quarter wages haven't been updated yet. Based on the information available, Richard has surpassed the annual income limit for last year. His total wages through the third quarter total $16,050. There is an overpayment for the period of January 1–February 28. |
| Example 3 |
Kimmy was eligible for BadgerCare Plus as a childless adult beginning in October of last year. In August of this year, the worker is processing a discrepancy created in July showing that Kimmy has unreported wages from the first quarter of this year. The worker requests verification from Kimmy, which shows that she works 32 hours per week and earns $15 per hour for a total of $1,920 per month. Had Kimmy reported her income timely by February 10, she would have been over the monthly income limit for BadgerCare Plus. SWICA shows that Kimmy has already earned $13,700 this year. Since the worker has evidence that Kimmy has surpassed the annual income limit for this year, the worker can proceed with establishing an overpayment for March 1–June 30. |
While an agency is waiting to verify if a person has surpassed the annual income limit for a potential overpayment, that person could experience changes in circumstances, including but not limited to, changes in income or assistance group size. If more current information is available at the time of determining an overpayment, these changes must be taken into consideration in the determination.
| Example 4 |
Effective February 1, Delia was eligible for BadgerCare Plus as a childless adult with an assistance group size of one. In August, she reports that her 8-year-old daughter, Zoe, has moved into the household, and she plans to claim Zoe as a tax dependent. Beginning in September, Delia is determined eligible as a parent or caretaker adult with an assistance group size of two. In February of the next year, a worker is reviewing a SWICA discrepancy showing that Delia began a job in March of last year, which she did not report. The worker verifies that Delia’s income is over the monthly income limit for April–November and sees that she had an annual income total of $14,700 for last year. For part of that period, Delia was in a group size of one and surpassed the annual income limit for a group size of one. However, starting in September of last year, Delia’s group size increased when Zoe was added to the case. Taking into consideration the change in group size during the overpayment period and Delia’s annual income ($14,700) compared to the annual FPL for a group size of two, there is no overpayment since Delia will be ending the tax filing year with a group size of two and will be below the annual income limit for a group size of two. |
This page last updated in Release Number: 22-01
Release Date: 04/04/2022
Effective Date: 04/04/2022
The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.
Publication Number: P-10171