WI · guidance
Wis. ForwardHealth Online Handbook, Hospice, Topic #224
Situations When Member Payment Is Allowed
Providers may not collect payment from a member, or authorized person acting on behalf of the member, except for the
following:
• Required member copays for certain services.
• Other health insurance (for example, commercial health insurance, Medicare, Medicare Advantage Plans) payments made
to the member.
• Spenddown.
• Charges for a private room in a nursing home if meeting the requirements stated in Wis. Admin. Code § DHS 107.09(4)
(k), or in a hospital if meeting the requirements stated in Wis. Admin. Code § DHS 107.08(3)(a)2.
• Noncovered services if certain conditions are met.
• Covered services for which PA (prior authorization) was denied (or an originally requested service for which a PA request
was modified) if certain conditions are met. These services are treated as noncovered services.
• Services provided to a member in a limited benefit category when the services are not covered under the limited benefit and
if certain conditions are met.
If a provider inappropriately collects payment from a member, or authorized person acting on behalf of the member, that provider
may be subject to program sanctions including termination of Medicaid enrollment.
Provenance
- Source
- www.forwardhealth.wi.gov
- Retrieved
- 2026-10-02
- Edition
- forwardhealth-hospice-2026-10-01
- Content hash
5f6703bacf86f3364b1b3ad991f97b146d64becfac105004cffa1b6abc26163f
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