State of Wisconsin Department of Health Services

Release 25-02 April 9, 2025

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37.4 Cost Sharing

37.4.1 Group A

Group A members are Medicaid eligible via SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. (including SSI-ESupplemental Security Income Exceptional Expense Supplement and 1619aProvisions of the Social Security Act which allow certain employed people who would otherwise be ineligible to retain SSI status. The Social Security Administration certifies people for 1619(a) and 1619(b) eligibility. People with 1619(a) or 1619(b) status retain their MA eligibility under the SSI related category if they received MA the month before certification for 1619(a) or 1619(b).1 and 1619bProvisions of the Social Security Act which allow certain employed people who would otherwise be ineligible to retain SSI status. The Social Security Administration certifies people for 1619(a) and 1619(b) eligibility. People with 1619(a) or 1619(b) status retain their MA eligibility under the SSI related category if they received MA the month before certification for 1619(a) or 1619(b).) or a full-benefit Medicaid subprogram (see Section 21.2 Full-Benefit Medicaid) other than HCBW Medicaid.

Members who have met a deductible are eligible for community waivers as Group A. The member remains eligible as Group A until the end of the deductible period. At the next review the member will be able to make a choice between meeting the deductible to receive Medicaid (remaining a Group A) or becoming eligible for community waivers as Group B or B Plus with a potential cost share.

Individuals eligible as Group A have no CARES cost share obligation.

37.4.2 Group B and B Plus

Group B members are defined as those not in Group A, but who have gross income at or below the nursing home institutions categorically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).

Group B Plus members are defined as those not in Group A, who have gross income above the nursing home institutions categorically needy income limit, but whose income does not exceed the cost of the appropriate institutional care by more than the medically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).

Group B and B Plus members do have a cost share, including CLTS participants who are enrolled in HCBW Medicaid.

37.4.3 Calculating a Cost Share for HCBW Members

Cost sharing is the monthly amount a HCBW member may have to contribute to the cost of their waiver services. Only the income of the member is counted when calculating the cost share.

CWA staff submits the Medicaid Waiver Eligibility and Cost Sharing Worksheet, F-20919 to IM at application or review when an individual needs a CARES source of Medicaid. The cost share amount for HCBW Medicaid is calculated in CARES following the process outlined in Section 28.6.4 Cost Share Amount.

Note:

Not all deductions apply to CLTS participants who are under age 18. Do not apply the special housing amount or the family maintenance allowance to minors. If the CLTS participant is married, spousal impoverishment policies do apply.

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030