19-01 Version of 28.2 Recoverable Overpayments

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

Applicant or member error
Applicant or member error exists when an applicant, member, or any other person responsible for giving information on the applicant's or member’s behalf unintentionally misstates (financial or nonfinancial) 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 nonfinancial facts that impact eligibility or cost share amounts is a recoverable overpayment.

Applicant or member error occurs when there is one of the following:
1. Misstatement or omission of facts by an applicant, member, or any other person responsible for giving information on the applicant's or member’s behalf at a BadgerCare Plus application or renewal.
2. 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 (see Section 27.3 Income Change Reporting Requirements) (income, expenses, etc.) or nonfinancial (Section 27.2 Nonfinancial Change Reporting) 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 daughter Olivia are on a case. Olivia is open for BadgerCare Plus with a monthly premium of $10. Joe is not open for BadgerCare Plus. In November, Joe’s worker learned that Joe had received a raise September 1 that Joe was required to report by October 10. Because of the new family income, Olivia’s monthly premium increased to $55.00. The worker entered the new income in CARES and confirmed the increase in the premium amount for December.

What can be recovered?

Because Joe did not report the increase in income, the premium amount for November is incorrect. The overpayment amount would be whichever is less of the following:

The difference between the correct premium for November and the premium amount that was paid
The amount of claims and any HMO capitation payments the state paid for each month in question

Example 2

John and his family were determined eligible for BadgerCare Plus in June. John accepted a new job in South Carolina, and he and his family moved there on July 20. Since John and his family 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 31.

Giving 10 days to report and following adverse action logic, the case would have closed August 31. Fee-for-service claims and any HMO capitation payments for September, October, November, and December are recoverable.

Example 3

Susan was determined eligible for BadgerCare Plus in January. She was pregnant with a due date of August 15. On February 3, she miscarried but did not report this change to her worker. Her BadgerCare Plus eligibility continued until the worker closed the case effective October 31. 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 May through October.

What can be recovered?

The change should have been reported in February. Allowing for the two-month extension, BadgerCare Plus should have closed April 30. The overpayment amount is the amount of the fee-for-service claims and the capitation payments made for her from May through October.

Fraud
Fraud exists when an applicant, member, or any other person responsible for giving information on the applicant's or 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.
3. Having knowledge of an event affecting initial or continued right to a benefit or payment and intentionally failing to disclose such event.
4. 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 Section 28.6 Refer to District Attorney 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 or the amount of claims and any HMO capitation payments the state paid for each month, whichever is less.

Note:

As of February 1, 2002, there should be no compromise of overpayment claims. If it is determined that a recoverable overpayment exists, recovery may not be waived.

This page last updated in Release Number: 19-01
Release Date: 04/19/2019
Effective Date: 01/01/2019