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38.8.3 Determining the Copay Limit For members enrolled in BadgerCare Plus or EBD Medicaid subprograms that have a copay limit, copay limits will be based on the assistance group’s income used to determine eligibility. Per-member copay limits will be set based on the income tiers (see CHAPTER 53 FIVE PERCENT COPAY LIMIT TIERS). If the member is married and both spouses are enrolled in a health care program that has a copay limit (and neither spouse is exempt from copays), the copay limit will be prorated between them. If one spouse is exempt from copays (for example, due to pregnancy), the other spouse will have the full individual copay limit for their income tier. Example 1 Jane and Benji are married with two children. The entire family is enrolled in BadgerCare Plus. The assistance group has counted income which puts their household income in the >50-100% of FPL income tier for an assistance group size of four. Since both parents are eligible and must pay copays, the $26 copay limit for the household will be prorated between Jane and Benji. They will each have a monthly copay limit of $13.

Example 2 Marianne, who is pregnant, and Joe are a married couple enrolled in BadgerCare Plus with income that falls in the >50-100% of FPL income tier for a group size of three. Marianne has a pregnancy due date of March 10. Marianne is exempt from copays beginning with the first month she is certified as a pregnant woman until March 31 of the following year, including 12-month postpartum coverage. While Marianne is certified as a pregnant woman and exempt from copays, Joe’s monthly copay limit is $26. After the end of the postpartum period, eligibility and copay limits will be redetermined. Beginning April 1, after Marianne's postpartum period ends, the household’s copay limit will be split between Marianne and Joe, and they will each have a $13 copay limit. If spouses are enrolled in two different health care programs (and both programs have a copay limit), the copay limit for the household will be calculated based on the assistance group with lower income and prorated between spouses. This will prevent the spouse with lower income from paying cost sharing expenses in excess of the 5% limit. Example 3 Dave, his wife Debbie, and their son Derek receive health care benefits. Dave is enrolled in SSI-Related Medicaid and Debbie and Derek are enrolled in BadgerCare Plus. Due to the different income budgeting rules for SSI-Related Medicaid and BadgerCare Plus:

The countable income for SSI-Related Medicaid is 69% of the FPL for a group size of two. That puts the SSI-Related Medicaid assistance group income in the >50-100% of FPL income tier.

The countable income for BadgerCare Plus is 48% of the FPL for a group size of three. That puts the BadgerCare Plus assistance group income in the 0-50% of FPL income tier. To determine the copay limit for the household, the lower BadgerCare Plus assistance group income tier of 0-50% of FPL will be used. Debbie, Dave, and Derek each have a $0 copay limit, meaning they will not be charged any copays. If a member who is enrolled in a health care program that has a copay limit is married to someone who is enrolled in a program that has no copay limit (MAPP or SeniorCare), the member will have the full individual copay limit for their income tier. For members who are eligible for both QMB and a full benefit health care program that has a copay limit, the income used to determine eligibility for the full benefit program will be used to calculate the member’s copay limit.