Medicaid: Explaining and Exploring Wisconsin Medicaid

What is Medicaid?

Medicaid is an important public benefits program that serves children and adults with disabilities, children in foster care, pregnant women, people with low income, and older adults who meet certain federal and state eligibility rules.

Medicaid is funded by both the state of Wisconsin and the Federal Government. Dollars spent by Wisconsin are matched by federal dollars and there is no limit, or cap, on funding. Unlike other programs that have waitlists, everyone who’s eligible can be covered by Medicaid. In addition, enrollment to Medicaid is always open so there’s no waiting for “open enrollment” season.

In Wisconsin, Medicaid is also known as: Medical Assistance (MA), BadgerCare Plus, Title 19 and Katie Beckett.

Medicaid may be important for your child, or whole family, if you:

¨ Do not have access to private insurance;

¨ Can’t afford the additional out-of-pocket costs of private insurance; or,

¨ Need services not covered by your private insurance plan.

Medicaid provides comprehensive and affordable coverage that ensures your child will receive all medically necessary services. If a child has both private health insurance and Medicaid, Medicaid acts as the secondary payer to provide wrap-around coverage, and helps reduce out of pocket costs.

Medicaid Funded Programs:

There are important Medicaid waiver programs that can help a child at home and in their community, like the Children’s Long-Term Support (CLTS) Program and county-based mental health programs, that require a child or teen to be covered by Medicaid in order to gain access. Also, at age 18 your child must be covered by Medicaid to qualify for adult long-term support programs including Family Care and IRIS.

Doorways into Medicaid:

Income: A child whose family meets low-income requirements may qualify for BadgerCare Plus. Children in a household whose income is less than 306% of the Federal Poverty Limit (FPL) and single adults over the age of 18, whose income is under 100% FPL, may qualify. To learn more, go to dhs.wisconsin.gov/badgercareplus.

Disability: A child with “marked and severe” physical or mental health limitations, but whose family income is too high for BadgerCare Plus, may qualify through the Katie Beckett Program. To learn more about Katie Beckett visit dhs.wisconsin.gov/kbp, or read our Fact Sheet, What is the Katie Beckett Program?

Disability and Income: A child who meets both the disability and income requirements may be eligible for Supplemental Security Income (SSI). SSI provides a monthly check and gives a child or family access to Medicaid. For information visit the Social Security Administration’s disability site ssa.gov/disability/disability_starter_kits_child_eng.htm or read our SSI and Children with Disabilities Fact Sheet.

What if My Child Qualifies for More than One Medicaid Program?

A child may qualify for Medicaid through several “doorways.” This can be very helpful, especially if your family’s income changes over the year. For example, a child may be eligible through SSI and Katie Beckett. Having Katie Beckett as a “backup” to keep your child’s FowardHealth card may be a good idea!

Can My Child Have Both Private Insurance and Wisconsin Medicaid?

The Answer is YES! Families who have private insurance may wonder whether applying for and maintaining Medicaid coverage for their child is helpful.

While a private health plan or HMO covers many important health services and therapies, a child with a disability or chronic health condition may benefit from medically related services and supports not covered by private insurance plans.

Your private insurance coverage might change from year-to-year, so having Medicaid for a child with higher medical needs helps to keep these needs and prescriptions fully covered and maintains the continuity of care.

Some of the Benefits of both Private Insurance and Medicaid

Medicaid can be used to pay co-pays, deductibles or other out-of-pocket expenses from private insurance.
Medicaid can cover additional therapy visits if there are annual limits from your private health plan.
Medicaid covers supplies, like diapers as well as other incontinence supplies, or special formulas that are not typically covered by most health plans.
Medicaid may pay for prescription medications, not on a private plan’s formulary, and therefore not covered.
Medicaid’s HealthCheck “Other Services” benefit can be used to cover the cost of most over-the-counter medications, if a child’s doctor deems them medically necessary and writes a prescription.
Medicaid can help cover the costs for transportation to appointments, whether in town or hundreds of miles away, which your private plan likely won’t pay!

Tip for Families

Coordinating Private and Medicaid Coverage: Fully using both private insurance and your child’s ForwardHealth (Medicaid) card can raise a lot of questions about how claims will be paid. The most important thing to know is that Medicaid is the payer of last resort. This means that all claims must be billed to private insurance first. If your private insurance has denied payment of the claim, or paid only some of the claim, then Medicaid will be billed.

If you have questions, contact your Regional Center for Children and Youth with Special Health Care Needs. To find your center, go to dhs.wisconsin.gov/cyshcn/regionalcenters.htm or call 800.642.7837.