39.11 SeniorCare Income Limits and Participation Levels

39.11.1 SeniorCare Income Limits Introduction

For applicants determined eligible, SeniorCare pays for a portion of covered prescription drugs (See 33.6 SeniorCare Financial Requirements), depending on the person’s participation level.

Effective with benefit periods starting September 1, 2003 there are four participation levels. The level of benefits an applicantA person who has submitted a request for coverage for whom no decision has been made regarding eligibility receives depends on his or her annual income and, for some, on the amount they spend on covered prescription drugs during their 12-month benefit period.

The participation levels are:

Level 1: Co-Payment (Annual income is at or below 160% of the FPLFederal Poverty Level.)
Level 2a: Deductible $500 (Annual income is greater than 160% of the FPL and less than or equal to 200% of the FPL.)
Level 2b: Deductible $850 (Annual income is greater than 200% of the FPL and less than or equal to 240% of the FPL.)
Level 3: Spenddown (Annual income is above 240% of the FPL.)

Note: The FPL is set annually by the Department of Health Services see 39.5 FPL Table

If the FPL changes during the eligibility determination process or before a redetermination can be completed, the new levels will be used.

SeniorCare Levels of Participation
Income Limits*	Annual Out-of-Pocket Expense Requirements and Benefits
Level 1 Income at or below 160% of FPL At or below $18,672 per individual or $25,168 per couple annually.*	No deductible or spenddown. $5 co-pay for each covered generic prescription drug. $15 co-pay for each covered brand name prescription drug.
Level 2a Income above 160% and at or below 200% FPL $18,673 to $23,340 per individual and $25,169 to $31,460 per couple annually.*	$500 deductible per person. Pay the SeniorCare rate for drugs until the $500 deductible is met. After $500 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug.
Level 2b Income above 200% - and at or below 240% of FPL $23,341 to $28,008 per individual and $31,461 to 37,752 per couple annually.	$850 deductible per person. Pay the SeniorCare rate for most covered drugs until the $850 deductible is met. After $850 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug.
Level 3 Annual income is above 240% of the FPL $28,009 or higher per individual and $37,753 or higher per couple annually.*	Pay retail price for drugs equal to the difference between your income and $27,577 per individual or $37,224 per couple. This is called “ spenddown.” Covered drug costs for spenddown will be tracked automatically. During the spenddown, there is no discount on drug costs. After spenddown is met, meet an $850 deductible per person. Pay SeniorCare rate for most covered drugs until the $850 deductible is met. After the $850 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug.

* These income amounts are based on the 2014 federal poverty guidelines, which increase by a small amount each year.

39.11.2 Level 1: Co-Payment

SeniorCare will pay for covered prescription drugs purchased from participating pharmacies except for participant co-payments.

Level 1 participants are required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.

When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.

If a participant has private insurance with a higher co-payment per prescription than SeniorCare, the SeniorCare co-payment rules will apply and benefits will be coordinated with the private insurance company. Providers who have questions regarding billing/benefit coordination should contact Provider Services Hotline at 1-800-947-9627.

Residents of nursing homes and community based residential facilities will have to pay the usual SeniorCare co-payment even when they are required to purchase drugs on less than a monthly basis.

39.11.3 Level 2a: Deductible

Participant has an annual deductible of $500. Participant will get a discount off the retail price for most covered prescription drugs during the deductible period. The discount amount depends on the particular drug prescribed.

After this deductible is met, a level 2a participant is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.

When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.

39.11.4 Level 2b: Deductible

Participant has an annual deductible of $850. Participant will get a discount off the retail price for most covered prescription drugs during the deductible period. The discount amount depends on the particular drug prescribed.

After this deductible is met, a level 2b participant is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.

When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.

Note: If married persons in the same FTGfiscal test group with annual income above 160% of FPL are determined non-financially eligible at different times, the deductible amount is prorated for the spouseA spouse is that person recognized by Wisconsin law as another person's legal husband or wife. Wisconsin does not recognize common law marriage. who applies later. (See 33.9.3.1 FTG Changes at Level 2a and 2b)

39.11.5 Level 3: Spenddown

Level 3 participants must meet a spenddown. The amount of spenddown is the difference between the FTG annual income and 240% of the FPL corresponding the size of the FTG. The SeniorCare program tracks the amount spent on covered prescriptions drugs that can be applied to an applicant’s spenddown.

39.11.5.1 Level 3: FTG of One

A SeniorCare participant considered as a FTG of one with gross annual income above 240% FPL pays retail prices for covered prescription drugs until those payments equal the spenddown amount.

After the spenddown has been met by purchasing drugs at regular prices the participant has an annual deductible of $850. During the deductible period the participant will get a discount off the retail price for most covered prescription drugs during the deductible period.

After this deductible is met, he or she is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.

When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.

Example 1: Dorothy’s annual income is $29,009. This is $1,000 more than 240% of the FPL for a FTG of one. Her spenddown amount for the 12-month benefit period is $1,000. Dorothy pays the retail price for her covered prescription drugs until those payments equal the spenddown amount.

If Dorothy meets the spenddown during her benefit period, she can begin purchasing covered prescription drugs at the discounted rate. These costs are applied toward the $850 deductible.

After this deductible is met, Dorothy purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period

39.11.5.2 Level 3: FTG of Two

Married persons considered as a FTG of two with annual income greater than 240% FPL and in which both spouses are determined non-financially eligible at the same time pay retail price for covered prescription drugs until the spenddown requirement is met. In this case, the spenddown amount is shared, and covered prescription drugs purchased for either person in the married couple will count toward meeting the spenddown requirement, when both are eligible.

After the spenddown has been met, each spouse must meet a separate $850 deductible requirement. Participants will get a discount off the retail price for most covered prescription drugs during the deductible period. Only the covered prescription drugs purchased for an individual spouse may count toward that spouse’s deductible.

After a spouse has met his or her deductible, he or she is required to pay a $5 co-payment for each covered generic prescription drug, and a $15 co-payment for each covered brand name prescription drug.

When there is no generic equivalent, the participant will still have to pay the $15 brand name co-pay.

Example 2: Bob and Alice’s annual income is $39,753, which is $2,000 more than 240% of the FPL for a FTG of two. Both spouses are eligible and, for the 12-month benefit period, their joint spenddown amount is $2,000.

Bob and Alice pay for their covered prescription drugs at retail price until the $2,000 spenddown is met. Covered prescription drugs purchased for either Bob or Alice will count toward the spenddown requirement.

After Bob and Alice meet the spenddown, each person has a $850 deductible. Only covered prescription drugs purchased for Bob count toward his deductible, and only covered prescription drugs purchased for Alice count toward her deductible.

Bob meets his deductible in two months. He then purchases covered prescription drugs at the co-payment amounts for the remainder of his benefit period. Alice meets her deductible in three months. She then purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period.

If only one spouse in a married couple is determined eligible, only his or her costs count toward the spenddown. He or she pays retail price for covered prescription drugs until the spenddown requirement is met.

Example 3: Tracy and Dave’s annual income is $39,753, which is $2,000 more than 240% of the FPL for a FTG of two. Because Tracy is 63 years old, only Dave is eligible for SeniorCare. For the 12-month benefit period Dave’s spenddown amount is $2,000.

Tracy and Dave pay for their covered prescription drugs at retail price. Only covered prescription drugs purchased for Dave count toward the spenddown requirement.

After Dave has met the $2,000 spenddown, he has a $850 deductible. Only covered prescription drugs purchased for Dave count toward his deductible. After Dave meets his deductible, he purchases covered prescription drugs at the co-payment amounts for the remainder of her benefit period.

This page last updated in Release Number: 14-01

Release Date: 05/01/14

Effective Date: 02/01/14