Medicaid - Wisconsin

Medicaid is a government health insurance program that helps certain people get health care services at a lower cost. There are different Medicaid programs in Wisconsin for different groups of people.

What does Wisconsin Medicaid cover?

Wisconsin Medicaid pays for routine and acute health care services. This includes:

• Visits to health care providers (including physicians and nurse practitioners)
• Inpatient and outpatient hospital services
• Early and periodic screening, diagnostic, and treatment services
• Preventive care (e.g., vaccinations)
• Lab tests and X-rays
• Dialysis services
• Mental health services
• Substance use treatment
• Rural health clinic services
• Medical transportation
• Long-term care (e.g., nursing facility care, home health services)

Most states also cover optional services such as:

• Physical, respiratory, and occupational therapy
• Home- and community-based care
• Case management
• Prescription drugs
• Dental and vision care
• Hearing services
• Podiatry services
• Hospice care

Since the program serves those with limited income and resources, people with Wisconsin Medicaid pay few to no out-of-pocket costs for their benefits. To get coverage once you are enrolled, you must go to health care providers that take part in the Wisconsin Medicaid program.

In Wisconsin, Medicaid is administered by the Wisconsin Department of Health Services (DHS). Call DHS at 1-608-266-1865 to learn more about the coverages provided.

How do I know if I qualify for Medicaid in Wisconsin?

In general, to be eligible for Medicaid, you must:

• Be a Wisconsin resident
• Be a U.S. citizen or a qualified non-citizen
• Meet the income and/or asset limit for your coverage group

What are the different Medicaid programs in Wisconsin?

You may be able to get health coverage if you fall into one of the following categories.

Nursing Home Medicaid

Nursing Home Medicaid in Wisconsin covers health care and support services in a nursing home or other medical facility. It may cover room and board as well as nursing care, rehabilitation services, and social services. You may be able to get this coverage if you have limited income and resources. You must also have a medical condition that requires the skills of a licensed nurse on a regular basis.

IRIS (Include, Respect, I Self-Direct) Medicaid Waiver Program

IRIS is a Medicaid waiver program that provides you access to health care and support services so that you can stay in your own home or a community setting of your choice. This will help you avoid having to move into a nursing home. These services may include homemaking, personal care, and home-delivered meals. IRIS also provides you a budget that you maintain so you can self-direct your choice of program services.

An IRIS program consultant will work with you to help manage your budget and determine which services you will need so that you can stay at home. This person will help you understand program requirements and complete necessary paperwork. They will also answer general questions about the program.

Medicaid Purchase Plan (MAPP)

If you have a disability and are working, the Wisconsin Medicaid Purchase Plan (MAPP) may provide you with health care benefits. In some situations, working and earning money could prevent you from getting public benefit programs such as Medicaid. MAPP lets you work, keep money in savings, and still get health care coverage. You may have to pay a monthly premium.

Medically Needy Program (Medicaid Spend-Down)

This program lets you get Wisconsin Medicaid even if your income is higher than Medicaid program guidelines. It works by letting you spend down your income so that you meet Medicaid income limits. The spend-down amount is the amount of income that is over the Medicaid limit. This amount is different for each person.

To get Medicaid benefits, you must submit current paid or unpaid medical bills equal to or greater than your monthly spend-down amount. Once your medical bills reach this amount, you will get Medicaid coverage for the rest of the calendar month. While using Medicaid to pay for your medical expenses, be sure to use a health care provider who takes part in the Medicaid program.

Some examples of medical expenses you can use to meet your share of cost include:

• Unpaid medical bills that have not been used to meet the share of cost before
• Health insurance premiums
• Medical bills you paid within the last three months
• Medical bills that will not be paid by health insurance (or any other source)
• Co-pays for medical bills
• Medical services prescribed by your doctor
• Transportation by ambulance, bus, or taxi to get health care services

Some examples of medical expenses you cannot use to meet your share of cost include:

• Premiums for insurance policies that pay you for hospitalization
• Over-the-counter medical supplies (e.g., cold medicine, bandages)

Note: Certain health care providers do not accept Wisconsin Medicaid or the Medically Needy Program. Be sure to tell your provider that you take part in the Medically Needy Program before making an appointment.

How do Medicare and Medicaid work together?

If you get Medicare, you may also be able to get help from Wisconsin Medicaid. This is called being “dual eligible.” Medicaid pays for some services not covered by Medicare such as eyeglasses, hearing aids, and dental care.

If you have Medicare and qualify for full Medicaid coverage, the state will pay your Medicare Part B (Medical Insurance) monthly premiums.

Depending on the level of Wisconsin Medicaid you qualify for, the state might also pay for:

• Your share of Medicare costs, like deductibles, coinsurance, and copayments
• Part A (Hospital Insurance) premiums, if you have to pay a premium for that coverage

In addition, if you are dual-eligible for Medicare and Medicaid:

• You will automatically be signed up for the Low-Income Subsidy (LIS)/Extra Help program through Medicare Part D (prescription drug coverage). This program helps people with low income pay for their medicines.
• You may be able to get your coverage through a Medicare Advantage Special Needs Plan (SNP) instead of having original Medicare with separate Medicaid coverage. This plan can help you manage the health care services you need. SNPs may also offer more benefits than what you already get from original Medicare. In some cases, you may have no monthly premiums and/or you may pay lower co-payments. All SNP plans are different, so check with the plans to see what they cover and if you can enroll.

Note: SNPs are not available in every community. To find out if there is an SNP in your area, visit the Medicare website or call 1-800-633-4227 or 1-877-486-2048 (TTY).

How do I prepare to apply for Medicaid in Wisconsin?

When you apply for Medicaid in Wisconsin, you’ll be asked for important information to help determine if you qualify for benefits.

Before you start, gather some basic information to make your application process easier: 

• A document that shows your age, such as your birth certificate or driver’s license
• Your Social Security card
• Pay stubs for anyone in your household who has earned income
• Documentation that shows any other form of income, such as letters from Veterans Affairs (VA) or the Social Security Administration (SSA)
• Information about your financial assets, such as bank account or investment account statements

How do I apply for Medicaid in Wisconsin?

There are a few different ways you can apply for Medicaid in Wisconsin. Read below to learn more about which option might be right for you.

Apply Online

The quickest and easiest way to apply for Medicaid in Wisconsin is online through the ACCESS website. All your personal information is kept 100% confidential and protected by special security technology. 

Apply through ACCESS

Apply by Phone or in Person

Call or visit your local county or Tribal agency during their operating hours. Find your local office here.

Apply by Mail

You can download and print a benefits application, complete it, and mail or fax it to DHS. The instructions for doing so are below.

If you live in Milwaukee County, mail or fax your application to:

MDPU
6055 N 64th St.
Milwaukee, WI 53218
Fax: 888-409-1979

If you do not live in Milwaukee County, mail or fax your application to:

CDPU
P.O. Box 5234
Janesville, WI 53547-5234
Fax: 855-293-1822

How can I get help with my Wisconsin Medicaid application?

There are a few ways to get help filling out your Medicaid application:

• Contact your county or Tribal office.
• Call DHS at 1-608-266-1865.
• Visit a Benefits Enrollment Center (BEC), if there’s one near you. See if there’s one in your area.

NCOA also has a HelpLine you can call to get free support. To get started today, call  1-800-794-6559.