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Updates for local agencies, community-based organizations, and providers who provide assistance to members of Wisconsin's health and nutrition public assistance programs.
Patient Liability and Cost Share Change
Temporary Suspension
Under normal Medicaid rules, certain Medicaid, Family Care, Family Care Partnership, IRIS (Include, Respect, I Self-Direct), and PACE (Program of All-Inclusive Care for the Elderly) members must pay a monthly cost, called patient liability or cost share, to their nursing home, care facility, managed care organization, or fiscal employer agent for their long-term care.
In response to the COVID-19 pandemic, the Wisconsin Department of Health Services (DHS) temporarily changed Medicaid program rules to suspend both patient liability and cost share increases from April 2020 through January 2021. The temporary change was based on provisions in the federal Families First Coronavirus Response Act.
As a result of the change, one of the following applies to members subject to paying a patient liability or cost share:
- From April 2020 through January 2021, they paid the lowest patient liability or cost share calculated for them since April 1, 2020.
- They did not have any patient liability or cost share from April 2020 through January 2021.
Whether or not members had a patient liability or cost share was based on when they were enrolled in a program and when they became subject to paying patient liability or cost share.
Reinstatement of Increases
Starting February 1, 2021, DHS is reinstating normal Medicaid rules for patient liability and cost share calculations and increases. As a result, members subject to a patient liability or cost share may have an increased or newly established patient liability or cost share. The purpose of this reinstatement is to minimize disruption to enrollment at the end of the public health emergency. As detailed below, members who have a reduced patient liability or cost share may accumulate assets that can put them over the program’s asset limit.
Members will be sent a letter the week of December 28, 2020, as notification of the suspension and reinstatement of patient liability and cost share increases:
In mid-January 2021, members who will have an increased or newly established patient liability or cost share starting in February 2021 will be sent another letter titled “About Your Benefits” indicating the amount they must pay.
Member Impacts
Refunds
Nursing homes, care facilities, managed care organizations, and fiscal employer agents will be refunding members any increased patient liability or cost share amounts they paid from April 2020 through January 2021.
Asset Limit Considerations
Since patient liability and cost share increases were suspended from April 2020 through January 2021, members may have accumulated additional monthly income that would have been paid toward their monthly patient liability or cost share. This may cause some members to go over the Medicaid asset limit. For Medicaid, income is considered an asset if members have not spent the income by the month after they received it. To be eligible for Medicaid, Family Care, Family Care Partnership, IRIS, or PACE, members must have assets within the Medicaid asset limit.
As a reminder, Medicaid rules have been temporarily changed so members do not lose eligibility during the federal public health emergency unless they move out of state or ask to be disenrolled.
To remain eligible for Medicaid, Family Care, Family Care Partnership, IRIS, or PACE after the public health emergency ends, members need to spend the additional monthly income to be within the Medicaid asset limit by that time. If they do not, they will be disenrolled from their applicable program after the public health emergency ends and will need to pay for their long-term care services privately until they spend enough assets to be within the Medicaid asset limit. Once their assets are within the Medicaid asset limit, they can reapply for benefits.
If members receive a patient liability or cost share refund, they will have nine months to spend it before it is counted as an asset.
Member Options
To keep from going over the Medicaid asset limit before the public health emergency ends, members may be able to do the following, depending on their situation:
- Give the money to their spouse.
- Buy things they need for themselves or their home.
- If they are younger than age 55, make a payment to Medicaid. To do this, members should contact their income maintenance or tribal agency.
- If they are age 55 or older, make a voluntary recovery payment to the Estate Recovery Program. To do this, members should contact their income maintenance or tribal agency.
Members are encouraged to consult with an attorney or financial planner about these and other options, such as putting the additional income in a special trust or account. The options available to them depend on their age and whether or not they have a disability determination.
Members do need to be careful to not spend the income in a way that would be considered divestment. One form of divestment is giving away or transferring income and/or assets without receiving that same value in return. As an example, it would be considered divestment if a member were to gift the additional income to their grandchild.
If members spend the income in a way considered to be divestment, they are subject to a divestment penalty period after the public health emergency ends. During the divestment penalty period:
- Members who live in a nursing home would need to pay for their long-term care services privately. Medicaid will cover other services, such as health care services, that do not include long-term care.
- Members who do not live in a nursing home may be disenrolled completely from Family Care, Family Care Partnership, IRIS, or PACE or may be disenrolled and enrolled in another Medicaid program, such as one with a deductible, if they are eligible.
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