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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
Misstatement or Omission of Fact
If the overpayment is a result of a misstatement or omission of fact during an initial BadgerCare Plus application 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) within the applicable look back period (see Section 28.2.1 Date of Discovery and Look Back Period).
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 within the applicable look back period (see Section 28.2.1 Date of Discovery and Look Back Period).
The actual income that was reported or required to be reported is used in determining if an overpayment has occurred. If the information needed to determine if an overpayment exists is incomplete, the best available information is used to determine the overpayment. The amount of recovery may not exceed the amount of the BadgerCare Plus benefits incorrectly provided.
| Example 1 | Camila is enrolled in Badger Care Plus. On October 1, an IM worker discovers an unreported job for Camila through a SWICA wage match and requests verification of historical wages. The verification due date is October 30. Camila does not provide verification to IM by the due date of October 30. The worker must use the best available information to calculate the overpayment, which is the information from SWICA. |
If the case was ineligible for BadgerCare Plus, the overpayment amount is the amount of fee-for-service claims paid by the state and any HMO capitation payments the state paid, minus any premiums paid during the overpayment period.
If the case is still eligible for BadgerCare Plus for the time frame in question but there was an increase in the premium, the overpayment amount is the lesser of:
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 2 |
Tom and his daughter Candice are on a case. Candice is enrolled in BadgerCare Plus with no premium. Tom is not enrolled in BadgerCare Plus. A renewal for Candice’s BadgerCare Plus eligibility is due in June. At the renewal, Tom failed to disclose income from a new second job, which would have resulted in a $55 monthly premium for Candice. This new information was discovered the following March. Overpayment calculation: 10 months x $55 premium owed for each month (June - March) $550 total premium owed - $ 0 premium paid $550 overpayment The state paid the HMO $475 in capitation payments and $50 in claims each month during that 10-month period for Tom’s family for a total of $5,250. Because the difference in premium amounts is less than the claims and HMO capitation payments, the overpayment is the $550 difference in premiums. |
If a member error increases a deductible amount before the deductible is met, there is no overpayment.
If the member met the incorrect deductible and BadgerCare Plus paid for services after the deductible had been met, there is an overpayment. The overpayment amount is 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 prepaid the deductible but was actually ineligible for the deductible, the amount prepaid toward the deductible is deducted from the overpayment amount.
| Example 3 |
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 wouldn't 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 for the benefits that BadgerCare Plus already paid for the member.
Overpayments are collected from the BadgerCare Plus member, even if the member has authorized a representative to complete the application or renewal for them. Legally married spouses living in the household at the time the overpayment occurred are jointly liable for overpayments. Members under age 18 are not liable for overpayments. Dependent 18-year-olds are not liable for overpayments in cases where their parent or other caretaker relative is the primary person for the case.
If a member age 18 or younger received BadgerCare Plus in error, the member’s parent(s) or non-legally responsible relative is liable for the overpayment if the parent or non-legally responsible relative was living with the member at the time of the overpayment.
Other household members who were not enrolled in BadgerCare Plus on the same case during the time the overpayment occurred are not jointly liable for overpayments.
| Example 1 | 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. Danielle is liable for the overpayment. Even though Josie failed to report the information as the authorized representative, Josie is not liable. |
| Example 2 |
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. |
| Example 3 | Kevin and Linda are married, filing taxes jointly, and claiming their two children Grace (age 20) and Paul (age 22), who live with them as tax dependents. Kevin and Linda are enrolled in BadgerCare Plus as childless adults. Grace is enrolled in BadgerCare Plus as a childless adult on her own case. Paul is not enrolled in BadgerCare Plus. An IM worker discovers that Kevin and Linda earned more income than reported and it would have made them ineligible for BadgerCare Plus. Kevin and Linda are liable for the overpayment. Grace and Paul are not liable for the overpayment for Kevin and Linda’s BadgerCare Plus enrollment. |
| Example 4 | 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. Susan is liable for the overpayment for both her and Billy because she is his parent and was living with him at the time of the overpayment. |
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