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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
The date of discovery of the overpayment is the date the worker creates the overpayment claim in the system and an overpayment notice is triggered to be sent to the member.
Most recoverable health care overpayments will have a look back period of 12 months prior to the date of discovery. The look back period for health care overpayments based on fraud convictions or a member receiving duplicate benefits is limited to six years prior to the date of discovery.
Duplicate benefits are defined as situations in which a member moved out of state, enrolled in another state’s Medicaid program, and then BadgerCare Plus or Wisconsin Medicaid paid HMO capitation fees or fee for service claims were incurred more than two months after the member moved out of state.
| Example 1 | Max applied for BadgerCare Plus and was determined eligible starting April 1, 2022. In October 2022, Max started a new job but did not report this to his IM agency. Max didn’t complete his renewal, so his BadgerCare Plus ended on March 31, 2023. In August 2024, the IM agency discovered his job that was not reported and that his income was over the income limit for BadgerCare Plus. However, the IM agency found that Max misunderstood the change reporting requirements and there was no intention to commit fraud. There is no fraud conviction. The 12-month lookback period applies in this situation. Since the overpayment period is more than 12 months prior to the date of discovery, the overpayment is not recoverable. |
The minimum threshold for each claim is $500 for recoverable health care overpayments. If the overpaid amount is less than $500, no claim will be established unless it meets one of these criteria:
Duplicate benefits are defined as situations in which a member moved out of state, enrolled in another state’s Medicaid program, and then BadgerCare Plus or Wisconsin Medicaid paid HMO capitation fees or fee for service claims were incurred more than two months after the member moved out of state.
| Example 1 | John and his family were determined eligible for BadgerCare Plus starting January 1. John accepted a new job in South Carolina, and he and his family moved there on July 20. John and his family enrolled in Medicaid in South Carolina starting August 1. John did not report their change in state residency to his IM agency in Wisconsin, so capitation payments continued to be made for John and his family. John didn’t complete a BadgerCare Plus renewal, so BadgerCare Plus closed December 31. Giving 10 days to report and following adverse action logic, the case would have closed August 31 had John reported the change timely to his IM agency. Two years later, the IM agency discovered that John and his family had duplicate benefits in Wisconsin and South Carolina for more than two months after the move. Since this is a duplicate benefits situation, the lookback period is six years, and the minimum threshold doesn’t apply, fee-for-service claims and any HMO capitation payments for September, October, November, and December are recoverable. |
See Section 28.4 Overpayment Calculation for information on determining the overpayment amount.
BadgerCare Plus overpayments resulting from any of these reasons are subject to recovery:
Applicant or member error
Applicant or member error occurs when an applicant, member, or any other person responsible for giving information on the applicant's or member’s behalf unintentionally misstates or omits facts at application or renewal, and this results in the member receiving a benefit that they are not entitled to or more benefits than they are entitled to. This can include having lower premiums or other cost share amounts than the member should have had.
Applicant or member error also occurs when the member, or any person responsible for giving information on the member’s behalf, fails to report required changes in financial (income, expenses, etc.) (see SECTION 27.3 INCOME CHANGE REPORTING REQUIREMENTS) or nonfinancial (see SECTION 27.2 NONFINANCIAL CHANGE REPORTING) information that would have adversely affected eligibility, the benefit plan, or the premium amount.
See SECTION 28.3.5 ELIGIBILITY AND PREMIUM DETERMINATIONS BASED ON REASONABLE COMPATIBILITY for information about when members with eligibility or premium determinations based on income that was reasonably compatible can be subject to overpayments after failing to report required changes in financial information.
| 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 January 1 that Joe was required to report by February 10. Because of the new family income, Olivia’s monthly premium increased to $82. The worker entered the new income in CARES and confirmed the increase in the premium amount for December. Because Joe did not report the increase in income, the premium amount for March through November is incorrect. Following the overpayment calculation policies in Section 28.4 Overpayment Calculation, the worker determined that the overpayment amount is $648, which is the difference between the correct premium for March through November (total of $738) and the premium amount that was paid (total of $90). This is a recoverable overpayment because it is within the 12-month lookback period and is for an amount that is at least $500. |
| Example 2 | 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. 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. This amount is $750. This is a recoverable overpayment because it is within the 12-month lookback period and is for an amount that is at least $500. |
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:
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).
Overpayments based on fraud convictions have a look back period of six years preceding the date of discovery. The minimum threshold does not apply for these overpayments.
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.
This page last updated in Release Number: 22-02
Release Date: 08/01/2022
Effective Date: 08/01/2022
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