Exemptions 

Do I have to join an HMO? 
Many Medicaid recipients in Wisconsin must join HMOs. However, some people can get an exemption. An exemption lets you not enroll in an HMO. If you are given an exemption you will get a letter in the mail telling you so. You will then be able to see any doctor or specialist who accepts Medicaid recipients. 

Exemptions are not easily given. Instead of giving an exemption, an HMO may have to provide the care through an out-of-plan referral, if the care is not available within the HMO. 

Some reasons why you may want to request an exemption: 

You are a woman who is between seven and nine months pregnant and your doctor is not in the HMO. You are a person with severe mental health needs. You need Methadone treatment for drug abuse. You are enrolled in the county’s Birth-to-Three Program. You have HIV. You are ventilator dependent. You have a serious medical condition for which your HMO can not provide adequate care.

How do I get an exemption? 
If you feel you need an exemption, you should contact the Enrollment Specialist at 800-291-2002 who will help you ask for an exemption. You will need to fill out some forms and provide a letter from your doctor or specialist stating why you need the exemption. The letter should say what your medical condition is, why you need this special treatment, how long you have been receiving treatment from this specialist and why you cannot get this treatment through your HMO. The Enrollment Specialist will send your request to the state. The state will decide whether or not you can get an exemption. 

If you have good reasons for requesting an exemption and the state refuses to give you an exemption, you can contact the Ombuds program at 800-760-0001 and request a fair hearing if you are not satisfied. 
See REQUESTING A FAIR HEARING