WI – State Seeks CMS’ Permission to Implement Medicaid Eligibility Limit

May 2017 ~

Wisconsin has announced plans to seek federal approval to implement eligibility and other changes to its Medicaid program.

According to the waiver summary, Wisconsin plans to submit an application to amend its Medicaid demonstration that would enable the state to impose monthly premiums for beneficiaries with incomes above 20% of federal poverty level, ranging from $1 to $10 per household based on household income.

In addition to the request for premiums, the amendment application will seek CMS’ permission to:

  • Establish “health behavior incentives”
    • Health behavior incentives allow beneficiaries “the opportunity to have their monthly premiums reduced by 50% if they engage in healthy behaviors.”
  • Request that beneficiaries complete a “health risk assessment” as a way to “identify healthy behavior and health risks.”
    • Beneficiaries would not have to complete the assessment in order to be eligible for Medicaid, but members who do not complete the assessment and are subject to premiums would have to “pay the full standard premium” for coverage.
  • Implement copayment requirements for beneficiaries who use an emergency department (ED).
    • $8.00 for a beneficiary’s first ED visit; $25.00 for subsequent visits over a period of 12 months.
  • Implement “a 48-month eligibility limit” for Medicaid beneficiaries.
    • Under the limit, beneficiaries enrolled in Medicaid for a cumulative 48 months would have their coverage discontinued for a period of six months.
    • If beneficiaries participate in an employment training program or work for a minimum of 80 hours per month, the state would not count the amount of time the beneficiaries spend in training or working toward the 48-month cumulative coverage limit.
    • Beneficiaries who do not participate in job training or work would reach the eligibility limit quicker than those who do participate in training or work.
  • Require beneficiaries “to complete a drug screening assessment and, if indicated, a drug test.”
    • Beneficiaries who do not complete the screening would be ineligible for Medicaid until they do complete the screening.
    • Beneficiaries who test positive for drugs would not be ineligible for Medicaid and the state would refer to a substance use disorder treatment program.
  • Expand Medicaid coverage for substance use disorder treatment in an effort to bolster participation in treatment programs.
  • Begin including full coverage for substance use disorder treatment via Medicaid by requesting
    • a federal waiver to allow the state to use federal Medicaid funding to pay for such services and
    • “a waiver of the 15-day limit” on coverage for such services that is mandated under Medicaid managed care regulations.

Public comments will be included in the waiver request submitted to CMS on May 26, 2017, and will also be available on DHS’s website.

For complete details, see the BadgerCare Reform Demonstration Project Waiver Amendment overview (pdf).


Source(s): American Health Line; Modern Healthcare; Wisconsin Department of Health Services;