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Wisconsin Medicare assistance program options

Some Wisconsin residents with income too high to qualify for Medicaid can use the spend-down program to gain access to coverage six months at at time

Josh Schultz | October 4, 2020

Reviewed by our health policy panel.

As a Medicare beneficiary, where you live – meaning your state of residence – can have a significant impact on the care that you receive and how you pay for that care during your “golden years.” This page explains how Wisconsin’s regulations and policies are likely to affect your bottom line.

Does Wisconsin help with my Medicare premiums?

Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In Wisconsin, these programs pay for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.

  • Qualified Medicare Beneficiary (QMB): The income limit is $1,063 a month if single and $1,437 a month if married. QMB pays for Part A and B cost sharing, Part B premiums, and – if a beneficiary owes them – it also pays their Part A premiums.
  • Specified Low-Income Medicare Beneficiary (SLMB): The income limit is from QMB levels up to $1,276 a month if single and $1,724 a month if married. SLMB pays for Part B premiums.
  • Qualified Individuals (QI): The income limit is from SLMB levels up to $1,436 a month if single and $1,940 a month if married. QI pays for Part B premiums.
  • Qualified Disabled and Working Individuals (QDWI): The income limit is $2,127 a month if living alone and $2,874 a month if living with one other person. QDWI pays for Part A premiums (but not Part B premiums) owed by certain disabled beneficiaries who have returned to work. (Note that few qualify for this program – and those who are eligible usually prefer to enroll in other Medicaid benefits available to disabled workers, such as Medicaid “buy-in” programs for working people with disabilities.)

MSP asset limits: The asset limit for QMB, SLMB or QI is $7,860 if single and $11,800 if married. QDWI has an asset limit of $4,000 if living alone and $6,000 if living with others.

Who's eligible for Medicaid for the aged, blind and disabled in Wisconsin?

Medicare covers a great number services – including hospitalization, physician services, and prescription drugs – but Original Medicare doesn’t cover important services like vision and dental benefits. Some beneficiaries – those whose incomes make them eligible for Medicaid – can receive coverage for those additional services if they’re enrolled in Medicaid for the aged, blind and disabled (ABD).

In Wisconsin, Medicaid ABD covers an extensive set of dental services for adults.

Medicaid ABD also pays for one comprehensive ophthalmologic exam per year and will cover eyeglasses without prior-authorization. However, prior-authorization is required for routine low-vision exams.

Medicaid ABD  is called SSI-Related Medicaid in Wisconsin.

Income eligibility: The income limit is $1,132.50 a month if single and $1,525.83 a month if married.

Asset limits: The asset limit is $2,000 if single and $3,000 if married.

Medicaid spend-down for regular Medicaid for the aged, blind and disabled benefits in Wisconsin

Applicants with incomes too high to qualify for SSI-Related Medicaid can enroll in the Medicaid spend-down. (This is called the Medicaid Deductible Program in Wisconsin.)

Medicaid spend-down enrollees activate their coverage by submitting medical bills equal to their ‘excess income’ – or the amount their income exceeds the spend-down program’s income limit.

Wisconsin approves an enrollee’s spend-down benefits in six month increments – with additional coverage periods requiring new medical expenses to be submitted. The state allows enrollees to activate their coverage by paying their excess income directly to Medicaid if they don’t have enough incurred medical expenses.
Enrollees have to satisfy the asset test that applies to other SSI-Related Medicaid enrollees.

The income limit for the Medicaid spend-down is higher than the limit for regular SSI-Related Medicaid benefits in Wisconsin. This means applicants may be eligible to receive ‘full’ Medicaid benefits through the spend-down pathway – even if their income is above the cutoff used for regular SSI-Related Medicaid benefits.

This document contains additional information about the Medicaid spend-down in Wisconsin.
The Medicaid spend-down in Wisconsin does cover LTSS.

Wisconsin also has a spend-down program as part of SeniorCare, which is a state resource that helps Wisconsin seniors afford their prescription drugs.

Income eligibility: The income limit is $1,063 a month if single and $1,437 a month if married.

Asset limits: The asset limit is $2,000 if single and $3,000 if married.

Extra Help with prescription drug costs in Wisconsin

Medicare beneficiaries who receive Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help – a federal program that lowers the prescription drug costs under Medicare Part D. Individuals can also apply for Extra Help through the Social Security Administration if they don’t receive assistance automatically.

The income limit for this program is $1,615 a month for singles and $2,175 a month for couples, and the asset limit is $14,610 for individuals and $29,160 for spouses.

How does Wisconsin regulate long-term services and supports (LTSS)?

Medicare beneficiaries increasingly rely on long-term services and supports (LTSS) – or long-term care – which is mostly not covered by Medicare. Twenty percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015, and the portion of beneficiaries who will need these services will continue increasing as the population ages.

Medicaid fills this gap in Medicare coverage for long-term care, but its complex eligibility rules can make qualifying for benefits difficult. What’s more – eligibility rules vary significantly from state to state.

Long-term care Medicaid applicants usually have to undergo a level of care assessment.

Medicaid nursing home coverage in Wisconsin

Income limits: The income limit is $2,742 a month if single and $5,484 a month if married (and both spouses are applying).

When only one spouse needs Medicaid, the income limit for single applicants is used – and only the applicant’s income is counted.

However, this income limit doesn’t mean an applicant can keep all of their income up to the limit. Nursing home enrollees must pay nearly their entire income toward their care, other than a small personal needs allowance and money to pay for health insurance premiums (such as Medicare Part B and Medigap).

Assets limits: The asset limit is $2,000 per applicant. If only one spouse needs Medicaid, spousal impoverishment rules allow the other spouse to keep up to $126,800.

Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car. Applicants also are not allowed to have more than $595,000 in home equity.

Home and Community Based Waiver (HCBS) services

Every state’s Medicaid program covers community-based LTSS services. These services are called Home and Community-Based Waiver (HCBS) services because recipients continue living in the community, rather than entering a nursing home.

Income limits: The income limit is $2,742 a month if single and $5,484 a month if married (and both spouses are applying).

When only one spouse needs Medicaid, the income limit for single applicants is used – and only the applicant’s income is counted.

HCBS recipients in Wisconsin are allowed to keep $1,257 as a personal needs allowance as of 2018. Nearly all their remaining income must be paid toward their care.

Assets limits: The asset limit is $2,000 per applicant. If only one spouse needs Medicaid, spousal impoverishment rules allow the other spouse to keep up to $126,800.

An applicant’s first home will not disqualify them from receiving Medicaid LTSS if it is worth less than $750,000.

Spousal impoverishment protections in Wisconsin

Eligibility rules for Medicaid LTSS programs differ from other Medicaid benefits when only one spouse is applying. When this occurs, only the applying spouse’s income is counted. (Normally with Medicaid benefits, the income of both spouses is counted – regardless of who is applying.)

Spousal impoverishment rules allow community spouses of Medicaid LTSS recipients to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income.
In Wisconsin in 2020, these spousal impoverishment rules allow community spouses to keep:

  • An MMMNA of between $2,155 and $3,216 per month.
  • A Community Spouse Resource Allowance (CSRA) of up to $128,640.
  • A monthly housing allowance of up to $646.50.

Medicaid home equity limit in Wisconsin

Federal law requires states to limit eligibility for Medicaid nursing home and HCBS to applicants who have significant home equity. In 2020, states set this home equity limit based on a federal minimum of $595,000 and maximum of $893,000.

Wisconsin uses an intermediate limit on home equity – and applicants with more than $750,000 in home equity are not eligible for LTSS programs.

Penalties for transferring assets in Wisconsin

Because long-term care is expensive, individuals can have an incentive to give away or transfer assets to make themselves eligible for Medicaid LTSS. To curb these asset transfers, federal law requires states to institute a penalty period for Medicaid nursing home applicants who give away or transfer assets for less than their value. States can also have a penalty period for community-based LTSS.

Wisconsin has an asset transfer penalty for both nursing home care and HCBS. The state uses a 60-month lookback period to calculate this asset transfer penalty – meaning that asset transfers or gifts made during this period can make an applicant ineligible for LTSS. This penalty is calculated by dividing the value of asset transfers and gifts by the current average nursing home rate.

Estate recovery in Wisconsin

A state’s Medicaid agency is required to recover what it paid for LTSS and related medical costs while a enrollee was 55 or older. The law allows states to also pursue estate recovery against beneficiaries who did not receive LTSS.

Wisconsin has chosen to only recover the cost of Medicaid benefits when an enrollee receives LTSS beginning at age 55. The state will also recover from the estates of younger enrollees who have been permanently institutionalized.

When an enrollee’s Medicaid coverage was administered by a managed care organization (MCO), the state will attempt to recover what it paid the MCO. That means the estate recovery amount could be more (or less) than the actual cost of Medicaid services received.

Wisconsin will grant an exemption to estate recovery in cases where recovering from an estate would cause undue hardship to an enrollee’s heirs. For example, a hardship exemption would be granted if pursuing an estate recovery claim would cause an heir to become (or remain) eligible for SSI, FoodShare or Medicaid.

Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009. Medicaid will not try to recover what it paid for MSP benefits after that date, but could recover benefits paid beforehand if an enrollee received long-term care.

Where can Medicare beneficiaries get help in Wisconsin?

Wisconsin State Health Insurance Assistance Program (SHIP)

Free volunteer Medicare counseling is available by contacting one of two Wisconsin State Health Insurance Assistance Program (SHIP) helplines:

  • The Medigap Helpline provides counseling on Medicare, Medicare Advantage, Medigap and private long-term care insurance (LTCI) options. Its phone number is 1-800-242-1060.
  • The Medicare Part D and Prescription Drug Helpline provides counseling on Part D and other prescription drug coverage options. That helpline’s phone number is 1-855-677-2783.
  • A third resource – the Disability Drug Benefits Helpline – provides counseling to disabled Medicare beneficiaries who have issues with prescription drug costs. Its phone number is 1-800-926-4862.

The second page of this document contains several additional resources for Medicare beneficiaries in Wisconsin.

Elder law attorneys

Elder law attorneys can help individuals plan for Medicaid long-term care benefits. The National Academy of Elder Law Attorneys (NAELA) has a search feature beneficiaries can use to find an elder attorney locally.

Where can I apply for Medicaid in Wisconsin?

Wisconsin’s Medicaid program is administered by the Department of Health Services (DHS). Individuals can apply for Medicaid or an MSP using this website or by visiting one of the locations shown here.
An in-person interview is always required when applying for long-term care benefits, and some states require one for Medicaid ABD. However, interviews are no longer required for the MSP.

Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in Wisconsin City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He has also held consulting roles, including at Sachs Policy Group, where he worked with hospital, insurer and technology clients.

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