Wisconsin
BadgerCare Plus
HMO Guide
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Overview of BadgerCare Plus HMOs
Introduction
What is an HMO?
What is the dierence between HMO coverage
and fee-for-service coverage?
Which BadgerCare Plus members can choose to
join an HMO?
BadgerCare Plus Covered Services
Identication Card for BadgerCare Plus
Identication Card for HMOs
Your HMO Choice
Choosing an HMO
Ways to Join or Change an HMO
BadgerCare Plus HMOs Available in Your Area
Commonly Asked HMO Questions
What happens after I join an HMO?
What if I forget to choose an HMO?
What if I am not happy with the HMO I join?
How to Get Help
HMO Enrollment Specialists
HMO Member Advocates
Ombuds
Online BadgerCare Plus Information
HMO Contact Information
BadgerCare Plus HMO Ratings
Overview
Star Rating System
BadgerCare Plus HMO Ratings
Contents
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Introduction
You got this guide because you are getting BadgerCare Plus, and most BadgerCare Plus
members must join an HMO. You can learn which members must join an HMO on page 4. The
purpose of this guide is to give you information about HMOs, explain ways you can join an
HMO, answer commonly asked HMO questions, and provide contact information for help with
BadgerCare Plus. If you must join an HMO, you should use the information in this guide to make
your HMO choice.
What is an HMO?
HMO stands for health maintenance organization. Your HMO is also called your health plan. An
HMO has a network of doctors, clinics, and hospitals that you can get health care services from.
Joining an HMO can help you with:
• Understanding the health care system.
• Finding the right types of doctors for your needs.
• Scheduling appointments.
• Supporting and managing your health care needs for specic conditions like diabetes or
pregnancy.
HMOs also oer additional benets, such as no-cost health and wellness programs. The
additional benets oered by HMOs vary.
Overview of BadgerCare Plus HMOs
3
What is the dierence between HMO coverage and fee-for-service
coverage?
Depending on if you do or do not join an HMO, you will get health care coverage for services by
one of two ways:
1. HMO coverage
2. Fee-for-service coverage
If you join a BadgerCare Plus HMO, you get HMO health care coverage. Most BadgerCare Plus
members join an HMO. When you join an HMO, you get services oered through your HMO’s
network. Your HMO will work with BadgerCare Plus to decide if a service should or should not be
covered. If the service should be covered, your HMO pays the cost of the service. You can learn
more about covered services on page 5.
If you do not join an HMO, you get fee-for-service health care coverage. With fee-for-service
coverage, you get services from any doctor or provider who accepts BadgerCare Plus. Your
doctor will work with BadgerCare Plus to decide if a service should or should not be covered. If
the service should be covered, then BadgerCare Plus would pay the doctor for the service. If you
have fee-for-service coverage, you do not get access to the additional HMO benets such as no-
cost health and wellness programs.
Which BadgerCare Plus members can choose to join an HMO?
Most BadgerCare Plus members must join an HMO. If you do not t into a group below and do
not choose an HMO to join, one will be chosen for you. If you do not join an HMO and are not
required to join one, you will get fee-for-service coverage.
You are not required to join an HMO but may choose to join one if you:
• Are Native American, American Indian, Alaskan Native, or a member of a federally recognized
tribe.
You cannot join an HMO if you:
• Have Medicare in addition to BadgerCare Plus.
• Are participating in a home and community-based program such as Family Care, Family Care
Partnership, IRIS (Include, Respect, I Self-Direct), Program of All-Inclusive Care for the Elderly
(PACE), or Children Long-Term Support (CLTS) Waiver Program.
• Live in a nursing home or medical facility at the time of initial eligibility.
4
All BadgerCare Plus members have access to the same services. HMOs provide access to health
care 24 hours a day, seven days a week. HMOs must make sure you have access to the following
providers:
• Primary care provider
• OB/GYN
• Mental health provider
• Hospital
• Urgent care
• Dental in some counties
All HMOs must provide the following services and supplies to BadgerCare Plus members when
medically necessary:
• Disposable medical supplies, such as tube feeding equipment, catheter supplies, and
disposable gloves
• Durable medical equipment, such as wheelchairs, walkers, shower chairs, and commodes
• HealthCheck screenings for children and young adults*
• Hearing services
• Home care services, such as personal care workers and home health aides
• Inpatient hospital services
• Mental health treatment
• Nursing home services
• Outpatient hospital emergency room services
• Outpatient hospital services
• Physical, occupational, and speech therapies
• Physician services
• Prenatal and maternity care
• Routine vision care
BadgerCare Plus Covered Services
5
There are a few other reasons when you do not have to join an HMO and can instead get fee-for-
service coverage, two common reasons are:
• You need to complete a course of treatment with a provider not enrolled in the HMO network
before you are enrolled in a BadgerCare Plus HMO.
• You have commercial insurance that limits the doctors or providers you see.
You can contact an HMO enrollment specialist at 800-291-2002 for more information about not
joining an HMO.
*You can learn more about HealthCheck at dhs.wi.gov/forwardhealth/healthcheck.htm.
• Substance use disorder treatment
• Dental services in Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha
counties
There are some services that HMOs do not provide. These services are instead provided through
fee-for-service coverage. This means you can get these services from any doctor or provider that
accepts BadgerCare Plus. These services include:
• Behavioral treatment services, including treatment for autism spectrum disorder
• Chiropractic services
• County-based mental health programs including community recovery services, community
support program benets, and crisis intervention services
• Dental services in counties other than Kenosha, Milwaukee, Ozaukee, Racine, Washington,
and Waukesha
• Pharmacy services, such as prescription drugs and diabetic supplies
• Prenatal care coordination services
• Residential substance use disorder treatment
• School-based services, such as audiology, physical therapy, and speech therapy supplied by a
school
• Transportation to and from covered services
• Tuberculosis treatment
You may have copayments for covered services that cost 50 cents to $3. To learn more about co-
payments go to dhs.wi.gov/badgercareplus/services.htm.
Identication Card for BadgerCare Plus
Each BadgerCare Plus member gets a ForwardHealth card in the mail. Show your ForwardHealth
card each time you get health care services. Members can also view the card on the MyACCESS
mobile app. Learn more about MyACCESS at dhs.wi.gov/forwardhealth/myaccess.htm.
Identication Card for HMOs
Some HMOs have their own identication cards. If the HMO you join has an identication
card, it will be mailed to you. If you get an HMO identication card, you should bring both
your ForwardHealth card and your HMO identication card with you when you get health care
services.
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Your HMO Choice
7
Choosing an HMO
It is important to choose an HMO that meets your health care needs. When you join an HMO,
you must see doctors and other providers who are in your HMO’s network, unless you have an
approved referral from your HMO or you have a medical emergency. Below are examples of
things you may want to consider when choosing an HMO.
Your Current Doctors or Health Care Providers
Your current doctors or health care providers may not all belong to the same HMO. If they
do not, you may want to choose the HMO that includes the provider that is most important
to you. Your health care providers may include a:
• Primary care doctor
• Mental health provider
• Specialty doctor
• Personal care provider
• Home health care provider
• Clinic
• Hospital
You may also want to consider the oce hours for the doctors, clinics, and other providers
in an HMO.
Other Health Insurance
If you have other health insurance, it may be considered your primary insurance. Let your
HMO know if you have other health insurance so they can help you coordinate your care
with doctors that accept your primary insurance.
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HMO Ratings
HMO ratings are based on major areas of care, which measure the quality of health care
provided by an HMO. You can see the most recent BadgerCare Plus HMO ratings on page 15.
Wait Times
Some HMOs may be able to schedule your appointments sooner than others. You can call
an HMO enrollment specialist at 800-291-2002 to ask about HMO wait times.
Ways to Join or Change an HMO
You can join or change an HMO online, by mail, fax, phone, or in person. If you do not make an
HMO choice and are required to join an HMO, one will be chosen for you.
You can change your HMO during the rst 90 days of joining. This is called “open enrollment.”
When your open enrollment period is over, you cannot change your HMO for nine more months.
This is called a “lock-in” period. You will be sent a letter telling you when your lock-in period will
end. When your lock-in period has ended, you may change to a dierent HMO for any reason. If
you have problems getting the health care you need during your lock-in period, you should call
an HMO enrollment specialist to see if you can change your HMO or get fee-for-service coverage.
Online
To join or change your HMO online, go to access.wi.gov, log in, and go to
Manage My HMO.
Phone
To join or change your HMO by phone, call an HMO enrollment specialist
at 800-291-2002.
Mail or Fax
To join or change your HMO, complete the HMO Enrollment Choice form,
F-12025, that came with this guide and follow the mailing instructions or
fax it to 608-416-1860.
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Commonly Asked HMO Questions
BadgerCare Plus HMOs Available in Your Area
One or more HMOs will be available to you depending on where you live. You can see which
HMOs are available to you by:
• Looking on the HMO Enrollment Choice form that came with this guide.
• Going online to access.wi.gov.
• Calling the HMO enrollment specialist at 800-291-2002.
What happens after I join an HMO?
After you join an HMO, you will get a welcome packet from the HMO. The packet will explain the
services the HMO provides. Your HMO may also call you. This is a call to welcome you, share
information, and conrm your contact details. It’s important for you to talk with your new HMO
to make the most of your benets.
You can see the names of the doctors, hospitals, and clinics that belong to the HMO by going to
the HMO’s website, or you can ask the HMO to mail you the list.
If you have questions for your HMO, you can call them using the HMO’s phone number listed on
pages 12 and 13.
To get the best health care, you are responsible for:
• Telling the doctors and nurses how you feel.
• Getting medical care when you need it.
• Taking your medications and following the doctors’ advice.
• Following the HMO’s process for getting health services.
• Keeping the appointments you make.
• Asking questions to your doctor, HMO, or care coordinator.
• Telling your HMO what you think so that they can help you get the best health care.
What if I forget to choose an HMO?
If you are required to choose an HMO and do not, one will be chosen for you. You will get a
letter in the mail telling you which HMO was chosen for you. If an HMO is chosen for you, your
current doctors or clinics may not be in the HMO’s network. If you are not required to choose an
HMO and do not join one, you will get fee-for-service coverage. You can learn more about fee-
for-service coverage on page 4.
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How to Get Help
What if I am not happy with the HMO I join?
If you are not happy with the HMO you joined, you can change your HMO during the rst three
month of joining. This is called “open enrollment.”
When your open enrollment period is over, you cannot change your HMO for nine more months.
This is called a “lock-in” period. You will be sent a letter telling you when your lock-in period will
end. When your lock-in period has ended, you may change to a dierent HMO for any reason.
If you are having problems with quality of care or access to care during your lock-in period, you
should call an HMO enrollment specialist.
As a member of a BadgerCare Plus HMO, you have rights. You have the right to:
• Get information about your HMO and how it works.
• Ask questions, voice complaints, and le grievances.
• Receive fair treatment.
HMO Enrollment Specialists
An HMO enrollment specialist is a person who can answer your questions about HMOs. You
can call an HMO enrollment specialist at 800-291-2002 from 7 a.m. to 6 p.m., Monday through
Friday. You can email an HMO enrollment specialist at [email protected].
An HMO enrollment specialist provides language translations if needed.
An HMO enrollment specialist can:
• Tell you when you must choose an HMO.
• Find out which HMO(s) your doctor, hospital, or clinic belongs to.
• Help you access the lists of doctors, clinics, and other providers that are part of an HMO.
• Help you make an HMO choice by phone, mail, or online.
• Answer your questions about how your BadgerCare Plus HMO works.
• Help you change your HMO if you are not happy with it.
HMO Member Advocates
An HMO member advocate is a person who works for your HMO and is available to help you.
You can speak to an HMO member advocate by calling your HMO and asking to speak with an
HMO member advocate. See pages 12 and 13 for HMO phone numbers.
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An HMO member advocate can:
• Tell you the services the HMO provides.
• Find out which doctors and clinics you can use.
• Help you pick or change your primary care provider.
• Set up care appointments for you.
Ombuds
An ombud is a person who responds to grievances from HMO members. A grievance can be
submitted if you have a complaint or problem with your health care. An ombud may investigate
and resolve problems, as well as provide information, referrals, and consultations. You can call
an ombud at 800-760-0001 from 8 a.m. to 4:30 p.m., Monday through Friday.
An ombud can:
• Research and resolve your grievances about the care provided by your HMO.
• Help you with grievances.
• Help you understand your rights and responsibilities for HMO care.
• Represent your rights with HMOs.
• Communicate with both you and the HMO to help solve conicts.
Online BadgerCare Plus Information
For more information about BadgerCare Plus or any other Medicaid program, go to
dhs.wi.gov/forwardhealth/resources.htm.
HMO Contact Information
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Anthem BlueCross BlueShield
855-690-7800 (TTY 711)
Group Health Cooperative of Eau Claire
888-203-7770
800-947-3529 TTY
Independent Care Health Plan
800-777-4376
800-947-3529 TTY
If you have questions about the health care services an HMO provides, questions about
providers, or other general questions about an HMO, call the HMO’s member services at the
numbers listed below.
Note: Starting July 1, 2024, all My Choice Wisconsin HMO members will become Molina HMO
members.
Chorus Community Health Plans
800-482-8010 (TTY 711)
Dean Health Plan
800-279-1301 (TTY 711)
Group Health Cooperative of South
Central
608-828-4853 (TTY 711)
MHS Health Wisconsin
888-713-6180
800-947-3529 TTY
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Network Health Plan
888-713-6180
800-947-3529 TTY
UnitedHealthcare Community Plan
800-504-9660 (TTY 711)
Molina Healthcare
888-999-2404 (TTY 711)
MercyCare Insurance Company
800-895-2421
800-947-3529 TTY
Security Health Plan
800-791-3044 (TTY 711)
Quartz
800-362-3310 (TTY 711)
BadgerCare Plus HMO Ratings
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Number of Stars Explanation
Excellent
HMO was among the top 25 percent of all BadgerCare Plus HMOs
in the nation; it performed better than 75 percent (or 3/4) of all
BadgerCare Plus plans. Or, if national data were not available, the
HMO performed at or above 110 percent of the state average.
Very Good
HMO was among the top 33 percent of all BadgerCare Plus HMOs
in the nation; it performed better than 67 percent (or 2/3) of all
BadgerCare Plus plans. Or, if national data were not available, the
HMO performed between 100 and 109 percent of the state average.
Good
HMO was among the top 50 percent of all BadgerCare Plus HMOs
in the nation; it performed better than 50 percent (or half) of all
BadgerCare Plus plans. Or, if national data were not available, the
HMO performed between 90 and 99 percent of the state average.
Overview
The table below provides ratings reecting the health care that Wisconsin Medicaid members
got from BadgerCare Plus HMOs in 2022 which is the most recent data available. It includes
health care ratings for ve major areas of care for BadgerCare Plus.
1. Hospital and emergency department visits: Reects the rate of having to re-enter the
hospital after being discharged for an inpatient stay
2. Living with illness: Reects controlling blood pressure in some patients and testing and
controlling HbA1c levels for diabetic patients
3. Mental health care: Reects care for alcohol and other drug dependence, follow-up care
after discharge from the hospital for mental health, follow-up care after discharge from the
emergency department for mental health and substance abuse, anti-depression medication
management, and antipsychotic medication for individuals with schizophrenia
4. Pregnancy and birth-related care: Reects timely care provided to women before and after
birth
5. Staying healthy: Reects immunization rates for children and adolescents, cancer screening
in adults (breast and cervical cancer), chlamydia screening, and screening for lead in children
Star Rating System
Each HMO got one to ve stars (more stars for better performance) in each major area of care,
based on how well it performed on specic measures compared to national benchmarks. The
following table explains each star rating.
Fair
HMO was below the national average; it performed better than 33
percent (or 1/3) of all BadgerCare Plus plans in the nation. Or, if
national data were not available, the HMO performed between 80 and
89 percent of the state average.
Poor
HMO performed in the lowest 1/3 of all BadgerCare Plus plans in the
nation. Or, if national data were not available, the HMO performed at
or below 79 percent of the state average.
BadgerCare Plus
HMO
Hospital
and ED
Remissions
Living with
Illness
Mental
Health
Pregnancy
and Birth
Staying Healthy Overall
Score
(out of 5)
UnitedHealthcare
Community Plan
Dean Health Plan
Group Health
Cooperative of
Eau Claire
MHS Health
Wisconsin
4.1
3.9
3.5
15
3.3
Security Health
Plan
Chorus
Community
Health Plans
Quartz
Group Health
Cooperative of
South Central
Molina Health
Care
Network Health
Plan
MercyCare
Insurance
Company
3.3
3.2
16
3.2
2.8
2.8
2.7
3.1
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*Starting July 1, 2024, all My Choice Wisconsin HMO members will become Molina HMO members.
**DHS data issues may have impacted Anthem’s 2022 results.
Anthem Blue
Cross Blue
Shield**
Independent
Care Health Plan
My Choice
Wisconsin Health
Plan*
All Wisconsin
BadgerCare
Plus HMOs
2.3
2.2
2.5
3.3
P-12020 (06/2024)
