Wis. ForwardHealth Online Handbook, Hospice, Topic #601

Commercial health insurance is defined as any type of health benefit not obtained from Medicare or Wisconsin Medicaid and

BadgerCare Plus. The insurance may be employer-sponsored or privately purchased. Commercial health insurance may be

provided on a fee-for-service basis or through a managed care plan.

Common types of commercial health insurance include HMOs, PPOs (preferred provider organizations), POS (point-of-service)

plans, Medicare Advantage plans, Medicare supplemental plans, dental plans, vision plans, HRAs (health reimbursement

accounts), and LTC (long term care) plans. Some commercial health insurance providers restrict coverage to a specified group of

providers in a particular service area.

When commercial health insurance plans require members to use a designated network of providers, non-network (for example,

providers who do not have a contract with the member's commercial health insurance plan) will be reimbursed by the commercial

health insurance plan only if they obtain a referral or provide an emergency service.

Except for emergency services and covered services that are not covered under the commercial health insurance plan, members

enrolled in both a commercial health insurance plan and BadgerCare Plus or Wisconsin Medicaid (for example, state-contracted

MCO (managed care organization), fee-for-service) are required to receive services from providers affiliated with the commercial

health insurance plan. In this situation, providers are required to refer the members to the commercial health insurance plan's

network providers. This is necessary because commercial health insurance is always primary to BadgerCare Plus.

BadgerCare Plus and Wisconsin Medicaid will not reimburse the provider if the commercial health insurance plan denied or

would deny payment because a service otherwise covered under the commercial health insurance plan was performed by a

provider outside the plan. In addition, if a member receives a covered service outside their commercial health insurance plan, the

provider cannot collect payment from the member.