Page 305

Example 2: 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 his or her income tier. Example 3: Sean and Sandra are a married couple. Sean is enrolled in SeniorCare and Sandra is enrolled in medically needy SSI-related MA. The countable income for Sandra’s SSI-Related Medicaid assistance group is 72% of the FPL, which puts this assistance group in the >50-100% of FPL income tier. Because Sean is enrolled in a program that has no copay limit, Sandra will pay the full individual copay limit of the 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. Example 4: Dwayne is eligible for both SSI-Related Medicaid and Medicare. He also qualifies for QMB. Under SSI- Related Medicaid, Dwayne’s income is in the >50-100% of FPL tier. His copay limit is $26 per month based on his SSI-Related Medicaid eligibility. Since QMB is a limited benefit program, no copay limit will be set for QMB. If Dwayne were only eligible for QMB, his copay limit would be set based on the income used to determine his eligibility for QMB. 21.11.3.1 Determining Copay Limits for Community Waivers Group B and B Plus For Group B and B Plus Home and Community Based Waiver members, the copay limit will be based on the member’s cost share amount for Waiver services rather than the income used to determine the member’s eligibility. • If the Waiver services cost share amount is less than $27 (the full individual copay limit for the >50-100% of FPL income tier plus one dollar), the Group B or B Plus Waiver member will have the copay limit for the 0-50% of FPL income tier ($0). • If the Waiver services cost share amount is $27 or greater, the Group B or B Plus Waiver member will have the copay limit for the >50-100% of FPL income tier ($26). Example 7: Marge is a Group B waiver member. Her Waiver cost share amount is $15. Because this amount is less than $27, Marge’s copay limit is $0, which means that she will not be charged any copays.

Example 8: George is a Group B waiver member. His Waiver cost share amount is $120. George’s copay limit is $26 because his cost share amount is greater than $27.