Page 43

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42 CFR 457.570 and 457.505(c)) Premiums Each family is sent an invoice in the tenth day of the month prior to the month in which the premium is due. When a family does not pay their premium by the date required (the 10th of the month for which it is due), the family is sent a termination notice that indicates that they must pay the premium by the end of the calendar month or lose eligibility for those members for whom the premium is owed. If they pay by the end of the month, eligibility is not interrupted. If the family pays the premium by the end of the following month, their eligibility is restored without any gaps. However, if the family does not pay by the end of the month after the calendar month in which the premium was due, the individuals for whom the premium was owed cannot be restored to benefits until:

1. The end of the six month after which benefits were lost, so long as they pay the premium arrears or 12 months after benefits were lost without paying the premium arrears amount; 2. The beginning of the month following an adult caretaker’s absence from the home for 30 consecutive days; 3. The beginning of the month in which the family's income dips below the premium requirement limit of 200% of the Federal Poverty Level; or 4. Immediately, if the reason the premium payment was not made was beyond the control of the family.

Good cause reasons for not paying the BadgerCare Plus premium are: • Problems with the financial institution. • System problem. • Local agency problem. • Wage withholding problem. • Fair hearing decision.

Copayments Applies only to groups with incomes above 200% FPL, listed in Benchmark Plan: Providers are permitted to require the payment of any cost sharing as a condition for the provision of care, items, or services. In addition, providers are permitted to reduce or waive cost sharing on a case-by-case basis.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or

WISCONSIN

Effective Date:

Approval Date: 43