Wis. ForwardHealth Online Handbook, Hospice, Topic #16657

Medicaid During Inpatient Hospital Stays

As a result of 2013 Wisconsin Act 20, state prison inmates may qualify for BadgerCare Plus or Wisconsin Medicaid during

inpatient hospital stays.

Eligibility

Most individuals detained by legal process who are eligible for BadgerCare Plus or Wisconsin Medicaid benefits will have their

eligibility suspended during their detention period. During the suspension, ForwardHealth will only cover inpatient services

received while the member is outside of jail or prison for 24 hours or more.

To qualify for BadgerCare Plus or Wisconsin Medicaid, prison or jail inmates must meet all applicable eligibility criteria. The DOC

coordinates and reimburses inpatient hospital services for state prison inmates who do not qualify for BadgerCare Plus or

Wisconsin Medicaid.

Inmates whose BadgerCare Plus or Wisconsin Medicaid eligibility has been suspended will have coverage of inpatient services for

the duration of a hospital stay of 24 hours or more. This coverage begins on their date of admission and ends on their date of

discharge.

Inmates are not eligible for outpatient hospital services, including observations, under BadgerCare Plus and Wisconsin Medicaid.

Inmates may only be eligible for ER (emergency room) services if they are admitted to the hospital directly from the ER and are

counted in the midnight census; otherwise, ER services are considered outpatient services. Outpatient hospital services approved

by the DOC are reimbursed by the DOC.

Inmates are not presumptively eligible. Retroactive eligibility will only apply to dates of admission on and after April 1, 2014.

Enrollment

The DOC coordinates the submission of enrollment applications on behalf of state prison inmates.

Covered Services

The only services allowable by BadgerCare Plus or Wisconsin Medicaid for inmates are inpatient hospital services and

professional services provided during the inpatient hospital stay that are covered under BadgerCare Plus and Wisconsin

Medicaid. Providers with questions regarding services covered by BadgerCare Plus and Wisconsin Medicaid may refer to the

applicable service area or contact Provider Services.

Fee-for-Service

Inmates receive services on a fee-for-service basis; they are not enrolled in HMOs.

HMO

BadgerCare Plus and Medicaid SSI members who are incarcerated for 30 or more calendar days will be automatically enrolled in

fee-for-service Medicaid. These members will be removed from their previous enrollment in BadgerCare Plus and Medicaid SSI

HMOs. Members are identified as incarcerated if their circumstance meets the federal definition of inmate of a public institution,

per 42 C.F.R. § 435.1010.

When ForwardHealth is made aware of a member's incarceration status being longer than 30 days, it will retroactively disenroll

that member from any HMO. Medicaid fee-for-service coverage will begin the first day of the month when the member's

incarceration began. For example, if a member was incarcerated on October 10, HMO enrollment will be end-dated effective

September 30, and fee-for-service enrollment will be effective October 1.

ForwardHealth can disenroll a member from their HMO retroactive to as many as 12 months.

Members incarcerated for less than 30 days will remain enrolled in their HMOs. However, providers must bill any inpatient

hospital stays and professional services associated with hospital stays for these members to fee-for-service Medicaid. These

claims must be submitted as extraordinary claims.

Prior Authorization

The DOC will assist inpatient hospital providers with their submission of PA (prior authorization) requests for any services

requiring PA. If PA is denied, the DOC is responsible for reimbursement of the services.

Enrollment Verification

Inmates are only enrolled for the duration of their hospital stay. Providers should always verify an inmate's enrollment in

BadgerCare Plus or Wisconsin Medicaid before submitting a claim.

Claim Submission

When submitting a claim for an inmate's inpatient hospital stay, providers should follow the current claim submission procedures

for each applicable service area.

Reimbursement

Acute care hospitals that provide services to inmates are reimbursed at a percentage of their usual and customary charge.

Critical access hospitals that provide services to inmates are reimbursed according to their existing Wisconsin Medicaid

reimbursement methodology.

Wisconsin Medicaid reimburses professional services related to an inmate's inpatient hospital stay (for example, laboratory

services, physician services, radiology services, or DME (durable medical equipment)) at the current maximum allowable fee.

Contact Information

Providers may contact the DOC at 608-240-5150 with questions regarding enrollment or PA for inmate inpatient hospital stays.