28.2 Recoverable Overpayments

Initiate recovery for a BadgerCare Plus overpayment, if the incorrect payment resulted from one of the following:

ApplicantA request for BadgerCare Plus coverage. The request must be on the Department's or Federally-facilitated Marketplace’s application, registration form or account transfer (from Federally-facilitated Marketplace) and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process./Member Error

Applicant/Member error exists when an applicant, member or any other person responsible for giving information on the member’s behalf unintentionally misstates (financial or non-financial) facts, which results in the member receiving a benefit that he or she is not entitled to or more benefits than he or she is entitled to. Failure to report non-financial facts that impact eligibility or cost share amounts is a recoverable overpayment.

Applicant/Member error occurs when there is a:

Misstatement or omission of facts by a member, or any other person responsible for giving information on the member’s behalf at a BC + applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. or review.

1. 1. Failure on the part of the member, or any person responsible for giving information on the member’s behalf, to report required changes in financial (27.3) (income, expenses, etc.) or non-financial (27.2) information that affects eligibility, premium, patient liability or cost share amounts.

An overpayment occurs if the change would have adversely affected eligibility, the benefit plan or the premium amount.

Example 1: Joe and his family were determined eligible for BadgerCare Plus with a $100.00 total group premium in July. In November, Joe’s worker learned that Joe had received a raise September 1st that Joe was required to report by October 10th. The amount of the new family income increased the premium amount to $130.00. The worker entered the new income in CARESThis system supports the Income Maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs. and confirmed the increase in the premium amount for December.

What can now be recovered?

Because Joe did not report the increase in income to his worker, the premium amount for November is incorrect. The overpayment amount would be the difference between the correct premium for November and the premium amount that was paid.

Example 2: Sally was determined eligible for BadgerCare Plus Standard Plan in January. In May, the worker discovered that at application Sally had not reported the income from a part time job. The unreported income would have put Sally into the Benchmark Plan with a $30.00 premium. The worker entered the income in CARES and confirmed the premium and the change from the Standard plan to the Benchmark plan effective June 1st.

What can now be recovered?

The overpayment for the months of January through May is the $30.00 per month premium amount plus the difference in the co-pays and deductibleThe amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. amounts for services that she should have paid under the Benchmark plan.

Example 3: John and his family were determined eligible for BadgerCare Plus in June. John accepted a new job in South Carolina and the family moved out of state on July 20th. Since they were no longer residents of Wisconsin, they were no longer eligible for BadgerCare Plus. However, because their move to South Carolina was not reported, capitation payments continued to be made for John and his family until the worker closed the case effective December 31st.

What can now be recovered?

Giving 10 days to report and following AA logic, the case would have closed August 31. Fee-For-Service claims and/or HMO capitation payments for September, October, November and December are recoverable.

Example 4: Susan was determined eligible for BadgerCare Plus in January. She was pregnant with a due date of August 15th. On February 3rd, she miscarried but did not report this change to her worker. Her BadgerCare Plus eligibility continued until the worker closed the case effective October 31st. Once she was no longer pregnant, she would only have remained eligible for an additional 60 days after the last day of pregnancy through the end of the month in which the 60th day occurs. Susan was not eligible for the months May through October.

What can now be recovered?

The change should have been reported in February. Allowing for the 2 month extension, BadgerCare Plus should have closed April 30. The overpayment amount is the amount of the Fee-For-Service claims and the capitation payment made for her from May through October.

Fraud

Fraud is also known as Intentional Program Violation (IPV).

Fraud exists when an applicant, member or any other person responsible for giving information on the member's behalf does any of the following:

1. Intentionally makes or causes to be made a false statement or representation of fact in an application for a benefit or payment.
2. Intentionally makes or causes to be made a false statement or representation of a fact for use in determining rights to benefits or payments.

1. Having knowledge of an event affecting initial or continued right to a benefit or payment and intentionally failing to disclose such event.

1. Having made application to receive a benefit or payment and intentionally uses any or all of the benefit or payment for something other than the intended use and benefit of such persons listed on the application.

If there is a suspicion that fraud has occurred, see 28.6 for information about referral to the District Attorney (DA).

Member Loss of an Appeal

Benefits a member receives as a result of a fair hearing request order can be recovered, if the member loses the appeal.

A member may choose to continue to receive benefits pending an appeal decision. If the appeal decision is that the member was ineligible, the benefits received while awaiting the decision can be recovered. If an appeal results in an increased patient liability, cost share,or premium, recover the difference between the initial amount and the new amount.

This page last updated in Release Number: 12-02

Release Date: 10/05/12

Effective Date: 07/01/12