Department of Health Services
(Medicaid Reimbursement for PACE)
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 Plus programs under the authority of Title XIX and Title XXI of the Social Security Act and s. 49.471 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.
Change in Payment Methods
Among the services provided to recipients of services under Medical Assistance, BadgerCare, and BadgerCare Plus are the Programs of All-Inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits.
The Wisconsin PACE program covers enrollees if they meet the nursing home admission criteria and are age 55 or over. The PACE rates are based on encounter data and functional status for a nursing home eligible population age 55 years or over. The PACE regulation at 42 CFR 460.182(b)(1) requires that the capitation amount be less than the Amount that Would Otherwise have been Paid (AWOP) under the state plan if the participants were not enrolled in PACE. Starting with rate year 2019, the Department will update the methodology to calculate the AWOP by eliminating legacy waiver data from the calculation and instead use managed care data as allowed under Centers for Medicare and Medicaid Services (CMS) PACE rate guidance released in 2015. The Department is in the process of working with CMS to develop the exact calculation that will be used to ensure that PACE rates are lower than what would otherwise have been paid using recent Fee for Service and/or Managed Care data. Consistent with CMS guidance, the Department intends to rebase the AWOP annually but at least every 3 years.
The change to Medicaid will be effective January 1, 2019 and is projected to result in no change in expenditures.
Copies of Changes
Copies of the state plan amendment changes may be obtained free of charge by calling or writing as follows:
Bureau of Benefits Management
Division of Medicaid Services
P.O. Box 309
Madison, WI 53701-0309
Attention: Grant Cummings
Copies of the state plan change will be made available for review at the main office of any county department of social services or human services.
Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Division of Medicaid Services. The FAX number is (608) 266-1096. The e-mail address is DHSDMSSPAPublicFeedback@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.