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)
