28.4 Overpayment Calculation

28.4.1 Overpayment Period
28.4.2 Overpayment Amount
28.4.3 Liability

28.4.1 Overpayment Period

Misstatement or Omission of Fact

If the overpayment is a result of a misstatement or omission of fact during an initial BadgerCare Plus 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 renewal, determine the period for which the benefits were determined incorrectly and determine the appropriate overpayment amount (see Section 28.4.2 Overpayment Amount). The ineligibility period could begin as early as the first month of eligibility, including any backdated benefits.

Failure to Report

For ineligible cases, if the overpayment is a result of failure to report a required change, calculate the date the change should have been reported and which month the case would have closed or been adversely affected if the change had been reported timely.

Fraud

For ineligible cases, if the overpayment was the result of fraud, determine the date the fraudulent act occurred. The period of ineligibility should begin the date the case would have closed or been adversely affected allowing for proper notice. If an overpayment exists, but the case is still being investigated for fraud, establish the claim so collection can begin promptly. Prosecution should not delay recovery of a claim.

28.4.2 Overpayment Amount

Use the actual income that was reported or required to be reported in determining if an overpayment has occurred. The amount of recovery may not exceed the amount of the BadgerCare Plus benefits incorrectly provided.

If the case was ineligible for BadgerCare Plus, recover the amount of fee-for-service claims paid by the state and any HMO capitation payments the state paid. Use ForwardHealth interChange data from the Total Benefits Paid by Medicaid Report(s). Deduct any amount paid in premiums for each month in which an overpayment occurred from the overpayment amount.

If the case is still eligible for BadgerCare Plus for the time frame in question but there was an increase in the premium, recover whichever is less of the following:

The difference between the premiums paid and the premium amount owed
The amount of claims and any HMO capitation payments the state paid for each month in question

When calculating the overpayment amount for premiums, the overpayment amount is the difference between the premium paid and premium owed, even if the premium that was paid was $0. Premium adjustments are only made on months where there is an overpayment. If there is a month in which there is no overpayment, then the premium calculation for that month should not be adjusted.

Example 1: Tom and his family recertified their eligibility for BadgerCare Plus in June without a premium. At his renewal, Tom failed to disclose income from a new second job, which would have resulted in the family entering an earned income extension and paying a $100 per month group premium. Everyone in the group would have remained eligible for BadgerCare Plus. This new information was discovered in July.

Overpayment calculation:

$100 premium owed for June

+ $100 premium owed for July

$200 total premium owed

- $ 0 premium paid

$200 overpayment

The state paid the HMO $475 in capitation payments and $50 in claims each month for Tom’s family. Because the difference in premium amounts is less than the claims and HMO capitation payments, the overpayment is the $200 difference in premiums.

If a member error increases a deductible amount before the deductible is met, there is no overpayment. Recalculate eligibility and notify the member of the new deductible amount.

If the member met the incorrect deductible and BadgerCare Plus paid for services after the deductible had been met, there is an overpayment. Recover the difference between the correct deductible amount and the previous deductible amount or the amount of claims and any HMO capitation payments the state paid over the six-month period (whichever is less).

If the member was ineligible for the deductible, determine the overpayment amount. If the member prepaid his or her deductible, deduct any amount he or she paid toward the deductible from the overpayment amount.

Example 2: Victoria had a deductible of $2,000 for a six-month period. She met the deductible by paying $1,000 and sending in verification of $1,000 in outstanding medical bills. An IM worker discovers that Victoria moved out of state but did not report the move. After determining her overpayment amount, the worker must decrease the amount overpaid by the $1,000 that Victoria prepaid toward her deductible. The worker would not decrease the overpayment amount by any of the medical bills that helped Victoria meet her deductible.

If the deductible was prepaid with a check that is returned for insufficient funds, an overpayment may have occurred. Discontinue the member’s eligibility, determine whether the state paid for any benefits on behalf of the member, and, if so, establish a claim for benefit recovery.

28.4.3 Liability

Except for minors, collect overpayments from the BadgerCare Plus member, even if the member has authorized a representative to complete the application or renewal for him or her. Legally married spouses living in the household at the time the overpayment occurred are jointly liable for overpayments.

Example 3: Josie is Danielle’s authorized representative, and Josie applied on behalf of Danielle for BadgerCare Plus in December. It was later found that Josie did not report some of Danielle’s income when she applied, which would have resulted in Danielle being ineligible for BadgerCare Plus. Danielle’s BadgerCare Plus case closed March 31. Danielle was determined to be ineligible for BadgerCare Plus from December–March. Recover from Danielle any benefits that were provided to her from December–March. Even though Josie failed to report the information as the authorized representative, Josie is not liable.

Example 4: Alice and Jonas are married, filing taxes separately, and eligible for BadgerCare Plus as childless adults. An IM worker discovers that Alice did not report a new job that would have made her ineligible for BadgerCare Plus. Both Alice and Jonas are jointly liable for Alice’s overpayment because they were married and living in the household during the time benefits were overpaid for Alice.

If a minor received BadgerCare Plus in error, make the claim against the minor’s parent(s) or legally responsible relative if the parent or legally responsible relative was living with the minor at the time of the overpayment.

Example 5: Susan applied for BadgerCare Plus for herself and her minor son, Billy, in January. Susan lives with Billy. Susan did not report some of her income when she applied, which would have resulted in her and Billy being ineligible for BadgerCare Plus. When the IM agency finds out about the income, Susan and Billy’s BadgerCare Plus case closes April 30. They were determined to be ineligible for BadgerCare Plus from January-April. Recover from Susan any benefits that were provided to her and Billy from January-April. Susan is liable for Billy’s overpayment because she is his parent and was living with him at the time of the overpayment.

This page last updated in Release Number: 18-01

Release Date: 04/13/2018

Effective Date: 04/13/2018