Public Notices
Health and Family Services
(Medicaid 2014 Demonstration Project)
The State of Wisconsin reimburses providers for services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and ss.
49.43 to
49.47, Wisconsin Statutes. This program, administered by the State's Department of Health Services, is called Medical Assistance (MA) or Medicaid. In addition, Wisconsin has expanded this program to create the BadgerCare and BadgerCare Plus programs under the authority of Title XIX and Title XXI of the Social Security Act and ss.
49.471,
49.665, and
49.67 of the Wisconsin Statutes. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for reimbursement of covered services. A plan that describes the reimbursement system for the services (methods and standards for reimbursement) is now in effect.
Section 1115 of the Social Security Act provides the Secretary of Health and Human Services broad authority to authorize Research & Demonstration Projects, which are experimental, pilot, or demonstration projects likely to assist in promoting the objectives of the Medicaid statute. Flexibility under Section 1115 is sufficiently broad to allow states to test substantially new ideas of policy merit.
In September, the Wisconsin Department of Health Services provided on its website an outline of its proposal to initiate what is now called the Medicaid 2014 Demonstration Project, which will be a Research & Demonstration Projects under the authority of Section 1115. Public comment was invited at that time as well as at the public hearings held on October 19 and 21. You may now receive the official waiver request and will have another opportunity to comment before it is legislatively approved and submitted to the federal government. The Medicaid 2014 Demonstration Project will be an initiative to test the policy impacts of the federal law on Medicaid to go into effect in 2014, including crowd-out policies, cost-sharing requirements, income determination methods, adverse selection provisions, the relevance of Transitional Medicaid and the impact of real-time eligibility on verification requirements and retroactive and presumptive determinations.
The Patient Protection and Affordable Care Act (PPACA) will fundamentally change policies that govern state Medicaid programs. Wisconsin is submitting this federal 1115 waiver to pilot several policies that will prepare our BadgerCare Plus programs to better align with the pending changes in federal law. The following paragraphs detail the key elements of this initiative.
Crowd Out
Lower-income families above the poverty line will be disqualified from eligibility for government-subsidized health coverage if they have access to an employer-sponsored plan that does not require cost sharing in excess of 9.5% of household income. The waiver evaluation will look at how individuals not eligible for BadgerCare Plus based on this crowd-out provision subsequently interact with the private health care market, in the hopes of determining whether or not individuals with access to an employer-sponsored plan follow through with maintaining coverage at the expected levels of cost-sharing.
In addition, lower-income young adults above the poverty line will be disqualified from eligibility for government-subsidized health coverage if they have access to coverage under a parent's employer-sponsored insurance plan. The Medicaid 2014 Waiver will implement BadgerCare Plus crowd-out provisions to test whether or not young adults subsequently enroll in their parents plan and maintain access to health coverage.
Cost Sharing
PPACA requires families and individuals to purchase insurance that will require premium and copayment contributions. According to a recent study released by the Urban Institute, the estimated average annual premium cost for families with incomes between 138% and 200% FPL is $1,559 in 2014, with additional estimated out-of-pocket expenses of $457.
Wisconsin's Medicaid 2014 waiver will move toward aligning BadgerCare Plus cost-sharing provisions with those authorized by PPACA. This will demonstrate the impact of cost-sharing provisions on lower-income families above the poverty line. Questions the waiver evaluation will address will include whether or not participants will pay cost sharing, as well as whether or not the cost-sharing requirements will slow the growth of health care spending. The demonstration will consider policy choices related to the alignment of benefits and the equity of cost-share provisions for Medicaid, the Basic Health Plan and subsidized insurance.
Transitional Medical Assistance
Transitional Medical Assistance (TMA) has existed for many years to support the transition from welfare to work. TMA allows individuals to maintain their Medicaid coverage for 12 additional months once their income changes from an amount that would have qualified them for benefits under the former Aid to Families with Dependent Children (AFDC) cash assistance program to an amount above that income threshold.
In Wisconsin, the AFDC income threshold is 100% of the federal poverty level (FPL). TMA policy in Wisconsin has never been adjusted to reconcile to expanded eligibility criteria for Medicaid. Beginning in 2008, parents with incomes up to 200% FPL became eligible for BadgerCare Plus.
Under PPACA, the program's authorization expires before 2014. Continuation of TMA will introduce inequities because it will result in families with the same income experiencing different eligibility outcomes.
Under the waiver, those who would otherwise be exempt from cost-sharing under TMA will be expected to make modest premium and other cost-sharing contributions to maintain their Medicaid coverage. This simulates how a Medicaid to subsidized insurance transition would work for these same individuals if TMA is ended nationally.
Restrictive Re-Enrollment
Currently under BadgerCare Plus, a member for whom a premium is owed for the current month who leaves BC+ by quitting or not paying a premium may be subject to a restrictive re-enrollment period. A restrictive re-enrollment period means the member cannot re-enroll in BC+ for six months from the termination date while their income remains high enough to owe a premium.
One of the issues a restrictive re-enrollment period is intended to address is the fact that consumers may have financial incentives to selectively purchase coverage for specific months in which they anticipate high utilization. This is true even with the tax penalties envisioned under PPACA for failure to comply with the insurance mandate. The Wisconsin 2014 waiver will test the impact of applying restrictive re-enrollment as a measure of protection against adverse selection.
The waiver will evaluate the impact of the policy on premium payment compliance and the overall PMPM for BadgerCare Plus members in populations subject to this policy.
Real-Time Eligibility
PPACA envisions an eligibility process for Medicaid and subsidized insurance to happen in as close to real-time as possible in 2014.
A key component of Wisconsin's Medicaid 2014 waiver will be to implement real-time eligibility during Demonstration Year 1. The Medicaid 2014 waiver will test the impact on eligibility by replacing retroactive and presumptive eligibility policies with a real-time, online application system designed to facilitate immediate access to Wisconsin's health care safety net.
The real-time system will redefine and modernize the logic of outdated methods used to calculate a recipient's eligibility begin date and end date. Wisconsin's Medicaid 2014 Waiver will demonstrate the potential efficiency of operating a real-time eligibility system and the potential savings states can achieve by avoiding the unnecessary costs associated with arbitrary backdating and end-dating.
To assure program integrity and the effective use of public tax dollars, the accuracy of online eligibility determinations must be supported by a strong back end quality control process. In our Medicaid 2014 Waiver, Wisconsin proposes to demonstrate the interaction of real-time eligibility with a back end verification process by strengthening our state residency verification requirements.
Redefining Household Income
“Modified Adjusted Gross Income" (MAGI) is a new method to measure income for Medicaid eligibility purposes. Based on Internal Revenue Service (IRS) rules, this method will be used under the authority of PPACA beginning in 2014.
To accurately capture the total sum of household resources available to applicants and recipients of Wisconsin's Medicaid program, Wisconsin will request authority to pilot an alternative methodology that considers the resources of all adults living in the household of the person who is filing the application. Income from grandparents and adults temporarily living in the household will be exempt.
In doing this, Wisconsin will gather data significant to assessing whether MAGI comprehensively captures household resources. This demonstration will also help Wisconsin assess the expected total Medicaid enrollment in 2014 based on a clearer picture of how the income methodology affects household eligibility.
Proposed Changes - Implementing Wisconsin's Medicaid 2014 Waiver
As previously noted, the Wisconsin Department of Health Services is proposing to initiate the Medicaid 2014 Demonstration Project, which will be a Research & Demonstration Projects under the authority of Section 1115.
As required under federal law, Early and Periodic Screening & Diagnostic Treatment Benefit (EPSDT) services are to be provided to individuals under 21 years of age as an additional benefit under section 1937 of the Act.
In addition to this public notice, Wisconsin's tribes were consulted at a meeting of the Tribal Health Directors on October 25, 2011. The effective date of this change will be July 1, 2012. The projected fiscal effect of this initiative is an annual savings of $54 million general purpose revenue (GPR) and $81 million federal match (FED) for a total savings of $135 million all funds (AF) beginning July 1, 2012.
Copies of Proposed Changes
A copy of the proposed Medicaid program changes may be obtained free of charge by calling or writing as follows:
Regular Mail
Marlia Mattke
Division of Health Care Access and Accountability
P.O. Box 309
Madison, WI 53707-0309
Phone
Marlia Mattke
(608)266-9749
FAX
(608)266-1096
E-Mail
Written Comments
Written comments are welcome. Written comments on the changes may be sent by FAX, e-mail, or regular mail to the Division of Health Care Access and Accountability. The FAX number is (608) 266-1096. The e-mail address is
Marlia.Mattke@dhs.wisconsin.gov.
Regular mail can be sent to the above address.
The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin.
Health and Family Services
(Medical Assistance Reimbursement for Services Provided Under Benchmark Plans Implementing Medical Home Initiatives)
The State of Wisconsin reimburses providers for services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and ss.
49.43 to
49.47, Wisconsin Statutes. This program, administered by the State's Department of Health Services (the Department), is called Medical Assistance (MA) or Medicaid. In addition, Wisconsin has expanded this program to create the BadgerCare and BadgerCare Plus programs under the authority of Title XIX and Title XXI of the Social Security Act and ss.
49.471,
49.665, and
49.67 of the Wisconsin Statutes. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for reimbursement of covered services. A plan that describes the reimbursement system for the services (methods and standards for reimbursement) is now in effect.
This serves as public notice for eight benefit plans: seven Section 1937 benchmark plans and one Section 1945 plan.
Section 1937 of the Social Security Act provides authority for States to provide for medical assistance to one or more groups of Medicaid-eligible individuals, specified by the State in an approved state plan amendment, through enrollment in coverage that provides benchmark or benchmark-equivalent health care benefit coverage. Wisconsin established a benchmark plan effective February 1, 2008. Wisconsin will establish several more benchmark plans.
There are four medical home benchmark plan initiatives that are the subject of this notice:
•
Mental Health/Substance Abuse Medical Home (Alternative Benchmark Plan C)
•
Medical Home Pilot for Persons With Chronic Conditions (Alternative Benchmark Plan D)
• Medical Home Pilot for Persons with Severe Mental Illness Leaving Criminal Justice System and Mental Health Institutes (Alternative Benchmark Plan E)
•
Pregnant Women Medical Home Pilot (Alternative Benchmark Plan F)
For the medical home benchmark plans described above, the full benefit package under the Medicaid/Standard Plan are covered services. All of the medical homes add targeted benefits critical to manage the health care needs for the population identified in each individual plan, such as care coordination, medical assessments and medication therapy management.
There are two additional benchmark plans subject to this public notice:
•
Birth to Three Benchmark Plan (Alternative Benchmark Plan H)
•
Community Recovery Services (CRS) Benchmark Plan (Alternative Benchmark Plan I)
Section 1945 of the Social Security Act provides authority for a State, at its option as a State plan amendment, medical assistance to Medicaid eligible individuals with chronic conditions who select a designated provider, a team of health care professionals operating with such a provider, or a health team as the individual's health home for purposes of providing the individual with health home services. Wisconsin will establish a health home targeting individuals with AIDS/HIV. This health home initiative targeting individuals with AIDS/HIV is subject to this public notice.
Details of these plans are provided in the following paragraphs:
• Mental Health/Substance Abuse Medical Home (Alternative Benchmark Plan C)
Mental health disorders are an enormous social and economic burden to society by themselves, but are also associated with increases in the risk of physical illness. Among Wisconsin adults, the burden of chronic physical disease falls heavily on those with mental health problems, as evidenced by comparatively higher rates of cardiovascular disease and diabetes.
The Mental Health and Substance Abuse Medical Home will initially pilot a medical home to enroll fee-for-service individuals who meet the appropriate criteria of having a serious mental illness or substance use disorder that experience risk factors such as two or more hospitalization or emergency room visits in the past year or other risk factors to be developed, into the Mental Health and Substance Abuse Medical Home Alternative Benchmark Plan. This plan emphasizes health care and behavioral health coordination through a Medical Home and other additional services.
The projected fiscal effect of this initiative is an annual savings of $1.5 million GPR and $2.250 million FED for a total of $3.750 AF beginning on January 1, 2012.
• Medical Home Pilot for Persons With Chronic Conditions (Alternative Benchmark Plan D)
A medical home pilot targeting adult Fee-For-Service SSI members with multiple chronic conditions like asthma, diabetes or heart conditions (excluding mental health comorbidities) will enable this vulnerable population to receive the care coordination services they greatly need to improve health outcomes.
The projected fiscal effect of this initiative is an annual savings of $1.5 million GPR and $2.250 million FED for a total of $3.750 million AF beginning in spring of 2012.
•
Medical Home Pilot for Persons With Severe and Persistent Mental Illness Leaving Criminal Justice and Mental Health Institutes (Alternative Benchmark Plan E)
This medical home alternative benchmark plan targets three sets of individuals:
1) those eligible for Wisconsin Medicaid who have major mental illness and are placed in the community under supervision after leaving prisons and Mental Health Institutes
2) those eligible for Wisconsin Medicaid who have multiple chronic health conditions who are exiting the prison system
3) Medicaid Eligible individuals who are participants in the Department of Health Services' Conditional Release Program or the Department of Corrections' Opening Avenues to Re-entry Success (OARS) Program and placed within communities in the SE Region of the State.
Many of these individuals may have chronic conditions like asthma, diabetes or heart conditions which need care coordination services to improve health outcomes. Individuals with serious mental illnesses and substance use disorders often find it difficult to manage the primary health care system due to the symptoms of their illness and receive care only at the point of a health care crisis which results in poor health care outcomes and increased cost to the health care system.
The projected fiscal effect of this initiative is an annual savings of $1.0 million GPR and $1.5 million FED for a total of $2.5 million AF beginning on July 1, 2012.
• Pregnant Women Medical Home Pilot (Alternative Benchmark Plan F)
Wisconsin has one of the worst infant mortality rates among African Americans in the country. Approximately eighty-five percent of African American births in Wisconsin are to mothers who are on Medicaid. The initiative will pilot a medical home to coordinate care for the pregnant mother and her baby to ensure a healthy pregnancy.
The projected fiscal effect of this initiative is an annual savings of $900,000 general purpose revenue (GPR) and $1.350 million federal match (FED) for a total of $2.250 million all funds (AF) beginning at a date to be determined in 2012.
•
Birth to Three Benchmark Plan (Alternative Benchmark Plan H)
The Birth to Three Program provides a comprehensive set of services for infants, toddlers with disabilities, and their families. This plan creates capacity for more services offered in the Birth to Three program to be eligible for federal funds. Children will continue to receive their current Medicaid Standard Plan benefits through their existing Medicaid delivery system. These Birth to Three services are an additional service provided through the county framework. Counties will continue to work with families who are eligible and develop individualized care plans based on the child's needs.
This initiative is budget neutral.
•
Community Recovery Services (CRS) Benchmark Plan (Alternative Benchmark Plan I)
The State of Wisconsin currently provides psychosocial rehabilitation services to support individuals with mental illness under the authority of section 1915(i) of the Social Security Act. The three components of this category of services are community living supportive services, supported employment, and peer/advocate supports. The Department intends to provide these services under the authority of section 1937 of the Social Security Act as a benchmark plan.
The fiscal impact of this proposal is zero, as the proposal is budget neutral.
• AIDS/HIV Health Home
The Department is developing a comprehensive care coordination health home pilot for Medicaid eligible individuals with AIDS/HIV.
Persons with AIDS/HIV are at risk for having additional chronic conditions. Managing co-morbidities makes this population vulnerable for receipt of fragmented care.
Medicaid eligible members will continue to receive their current benefit package under the Medicaid program as covered services. This health home provides additional benefits critical to manage the health care needs for this vulnerable such as care coordination, medical assessments, medication therapy management, and social and community services.
This initiative is projected to be budget neutral as it uses up to $3.5 million in existing state dollars to match federal funds for the care coordination fee.
A recent change to federal law required States to provide emergency and non-emergency transportation services to those receiving coverage under a benchmark plan. In addition, EPSDT services are to be provided to individuals under 21 years of age. EPSDT stands for Early & Periodic Screening & Diagnostic Treatment Benefit, and it is described in section 1905(r) of the Social Security Act. The services available under EPSDT are described at the following link:
http://www.cms.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.
EPSDT services are available under each of the proposed 1937 benchmark plans as an additional service.
The effective date of these proposals will instead be the dates specified above in calendar year 2012. In addition to this public notice, Wisconsin's tribes were consulted at a meeting of the Tribal Health Directors on October 25, 2011, in compliance with section 5006(e) of the American Recovery and Reinvestment Act of 2009, Public Law 111-5.
Proposed Change
The proposed change is to implement several medical home initiatives under benchmark plans for recipients of medical assistance.
The projected cumulative fiscal effect of these changes is an annual savings of $4.9 million GPR and $7.350 million FED for a total annual savings of $12.250 million AF.
Copies of the Proposed Change:
A copy of the proposed change may be obtained free of charge by calling or writing as follows:
Regular Mail
James Vavra
Bureau of Benefits Management
Division of Health Care Financing
P.O. Box 309
Madison, WI 53701-0309
Phone
James Vavra
(608) 261-7838
FAX
(608) 266-1096
Attention: James Vavra
A copy of the proposed change are available for review at the main office of any county department of social services or human services.
Written Comments:
Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Department. The FAX number is (608) 266-1096.
The e-mail address is
james.vavra@dhs.wisconsin.gov. Regular mail can be sent to the above address. All written comments will be reviewed and considered.
The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changed methodology based on comments received.
Health and Family Services
(Medical Services Benchmark Plan Benefits for Family Medicaid)
The State of Wisconsin provides access to health care for low-income and medically needy persons under the authority of Title XIX of the Federal Social Security Act and sections 49.43 to 49.47 and 49.688, Wisconsin Statutes. The Wisconsin Department of Health Services administers this program, which is called Medical Assistance or Medicaid (MA). In addition, Wisconsin has expanded this program to create the BadgerCare and BadgerCare Plus programs under the authority of Title XIX and Title XXI of the Social Security Act, which authorizes State Children's Health Insurance Programs (SCHIP) for certain children who otherwise would not be eligible for MA, and ss.
49.471,
49.665, and
49.67 of the Wisconsin Statutes. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for reimbursement of covered services. A plan that describes the reimbursement system for the services (methods and standards for reimbursement) is now in effect.
Sections 1937 and 2103 of the Social Security Act provided authority for States to provide for coverage to one or more groups of Medicaid- and SCHIP-eligible individuals, specified by the State in an approved state plan amendment, through enrollment in coverage that provides benchmark or benchmark-equivalent health care benefit coverage. Wisconsin did so, effective February 1, 2008. The current groups who receive benefits under Wisconsin's benchmark plan are pregnant women and infants with incomes between 200 and 300% of the Federal income poverty line, as well as newborns who are born to women with family incomes between 200 and 300% of the Federal income poverty line (FPL). As required under federal law, Early and Periodic Screening & Diagnostic Treatment Benefit (EPSDT) services are to be provided to individuals under 21 years of age as an additional service.
Proposed Changes - Additional Groups to be Added to those Receiving Benefits Under the Benchmark Plan
The proposed change is to enroll MA and SCHIP-eligible children and MA-eligible adults with income above 100% of the FPL into the BadgerCare Plus Benchmark benefit plan. The specific citations for these individuals are as follows:
•Caretakers and children above 100% of the FPL who are members of mandatory categorically needy low-income families and children and who are eligible under section 1925 of the Social Security Act (SSA) for Transitional Medical Assistance.
•Mandatory categorically needy poverty level infants eligible under 1902(a)(10)(A)(i)(IV) of the SSA whose family income is from 100 to 150% of the FPL.
•Mandatory categorically needy poverty level children aged 1 up to age 6 eligible under 1902(a)(10)(A)(i)(VI) of the SSA whose family income is from 100 to 185% of the FPL.
•Optional categorically needy poverty level infants eligible under 1902(a)(10)(A)(ii)(IX) of the SSA whose family income is from 150 to 200% of the FPL.
•Caretakers whose income is from 100 to 200% of the FPL who are members of the group optional categorically needy AFDC-related families and children eligible under 1902(a)(10)(A)(ii)(I).
•Children age 6-18 who are members of the group Medicaid expansion/optional targeted low- income children eligible under 1902(a)(10)(A)(ii)(XIV) of the SSA whose family income is between 100-150% FPL.
•Newborns who are deemed eligible under 1902(e)(4) and whose eligibility was determined under 1902(a)(10)(A)(ii) or 1902(a)(10)(C) whose income is from 150 to 200% of the FPL.
•The following groups of targeted low income children eligible for the separate SCHIP:
•Children aged 1-5 with incomes between 185-200% FPL.
•Children aged 6-18 with incomes between 150-200% FPL.
In addition to this public notice, Wisconsin's tribes were consulted at a meeting of the Tribal Health Directors in a meeting which was held on October 25, 2011.
Proposed Change
The proposed change is to enroll children and adults with income above 100% of the FPL into the BadgerCare Plus Benchmark benefit plan. The projected fiscal effect of this changes is an annual savings of $10 million general purpose revenue, or GPR, and $15 million federal match (FED) for a total savings of $25 million all funds (AF) beginning on January 1, 2012.
Copies of the Proposed Change:
A copy of the proposed change may be obtained free of charge by calling or writing as follows:
Regular Mail
James Vavra
Bureau of Benefits Management
Division of Health Care Financing
P.O. Box 309
Madison, WI 53701-0309
Phone
James Vavra
(608) 261-7838
FAX
(608) 266-1096
Attention: James Vavra
A copy of the proposed change are available for review at the main office of any county department of social services or human services.
Written Comments:
Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Department. The FAX number is (608) 266-1096.
The e-mail address is
james.vavra@dhs.wisconsin.gov. Regular mail can be sent to the above address. All written comments will be reviewed and considered.
The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changed methodology based on comments received.
