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Page 44 Wisconsin BadgerCare Reform Demonstration Approval Period: October 29, 2024 through December 31, 2029

Implementation of a utilization management approach such that (a) beneficiaries have access to SUD services at the appropriate level of care (b) interventions are appropriate for the diagnosis and level of care (c) there is an independent process for reviewing placement in residential treatment settings Wis. Admin. Code ch. DHS 75 requires all certified programs to establish intake procedures so that (a) individuals access services at the appropriate level of care and (b) interventions are appropriate for the diagnosis and level of care. DHS Division of Quality Assurance (DQA) (c) conducts site visits and documentation review to ensure providers comply with these standards. Certification reviews take place for the provider’s initial application and renewal applications, including a site visit and license holder and employee background checks. Providers must update their program documentation at least annually and apply for certification renewal at least every 2 years. Wisconsin Medicaid requires prior authorization (PA) of SUD treatment for day treatment programs at the intensive outpatient level of care. PA requests are reviewed by licensed behavioral health clinicians to determine medical necessity, including determining that the DQA will continue to survey certified SUD treatment programs for compliance with provider credentialing standards, including requirements for use of patient placement criteria. Wisconsin Medicaid will develop utilization management policies (e.g. service authorizations) for Medicaid reimbursement in the design of the residential treatment benefit. The benefit design team will establish policies that balance the need to verify a clinically- appropriate assessment has been performed prior to admitting the individual into residential treatment, including the use patient placement criteria, with the need to rapidly connect individuals with treatment to prevent recurrence of use. The Medicaid team consulted with residential treatment providers in July and August 2019 to solicit their input on the referral, screening, assessment, and admissions process for their programs. Using this information, the benefits team is developing Wisconsin Medicaid will establish utilization management policies. Wisconsin Medicaid will publish authorization requests forms by December 2019 and provide training to residential treatment programs on request submission. Target date to implement coverage is no later than February 2020.