OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

MC10014

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MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:___Wisconsin______________________________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

_______________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Karen Timberlake Position/Title: Secretary, Department of Health and Family Services Name: Jason A. Helgerson Position/Title: Wisconsin State Medicaid Director Name: Richard Albertoni Position/Title: Wisconsin SCHIP Director

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2 Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3

A combination of both of the above.

1.2 Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

The State assures that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3 Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130)

The state assures that it complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35.

1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Original State Plan effective date: April 1, 1999

Amendment #1 Effective date:

July 1, 1999 Implementation date: July 1, 1999 Amendment #2 Effective date:

October 18, 2001

Amendment #3 Effective date:

July 14, 2004

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Amendment #4 Effective date:

November 1, 2005 Implementation date: January 1, 2006

Amendment #5 Effective date:

January 14, 2008

Implementation date: February 1, 2008 Amendment #6 Effective date:

February 1, 2008

Implementation date: February 1, 2008 Amendment #7 Effective date:

July 1, 2008

Implementation date: July 1, 2008

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Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1.1 Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

The Wisconsin Department of Health and Family Services conducts an annual Family Health Survey managed by the Department’s Division of Public Health. The Wisconsin Family Health Survey was initiated in 1989 to provide reliable estimates of health status, health problems, health insurance coverage, and use of health care services among Wisconsin residents. A random sample of households is telephoned by trained interviewers, who speak with the household member most knowledgeable about the health of all household members. This respondent provides information for all people living in the household at the time of the interview.

The survey provides descriptive information about health insurance coverage among Wisconsin residents. To monitor health status and health care utilization issues, survey questions ask about the current health status, chronic conditions, and physical limitations of all household members, as well as the last visit to a doctor, visit to a dentist, and any use of an emergency room in the past year. Demographic characteristics, such as age, race, poverty status, and education, also are obtained for all persons in the household.

According to the Family Health Survey, in 2005 there were about 1,376,000 children under 19 years of age in Wisconsin. Approximately 1,170,000 (85% of these children) were white (majority) and 206,000 (15%) were minority or multiple race.

The 2004 Family Health Survey estimates that 8% of Wisconsin's population was living in a household below 100% of the Federal Poverty Level (FPL). That is, Wisconsin had an estimated 445,000 people in poverty in 2005. The survey estimated that 12% of children (165,000) were below 100% FPL, and 19% of all children (261,000) were below 200% FPL.

According to the 2005 Wisconsin Family Health Survey, 5% of Wisconsin household residents had no health insurance during all of the previous 12 months, and 5% of household residents had no health insurance for part of the previous 12 months. At any one time, 7% of Wisconsin household residents had no health insurance.

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Information from the 2005 Family Health Survey provides estimates of the number of uninsured children by FPL. An estimated 72,000 children under age 19 were uninsured at any one time in 2005.

Wisconsin consistently has one of the lowest rates of uninsured residents in the nation. Moreover, even with broad eligibility coverage under Medicaid, the proportion of residents insured by Medicaid is also lower in Wisconsin than nationally (12.4% vs. 14.4%).

2.2 Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42 CFR 457.80(b))

2.2.1 The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state- only child health insurance):

Wisconsin Medicaid is the State's major public health program for children. Medicaid is a federal/state health care program for low-income families, elderly and disabled individuals. It serves many of the poorest and most vulnerable citizens of Wisconsin.

In the 1997-1999 biennium, Medicaid was the largest program supporting non- governmental entities funded by Wisconsin general purpose revenue (GPR). The Medicaid GPR budget for the biennium is approximately $1.85 billion. This amount represents roughly 40% of total program costs; federal funds support the remaining 60% of costs.

Wisconsin Medicaid offers one of the most comprehensive benefit packages of any state Medicaid program and covers most individuals eligible under federal regulations. At the same time, Wisconsin Medicaid is a very cost-effective program.

The Wisconsin Department of Health Services is the largest single provider of direct as well as support services for uninsured and Medicaid-enrolled children and adolescents. Direct services for this population include: preventive child health services (well-child check-ups), prenatal services, Women Infants and Children Supplemental Nutrition (WIC) program services, preventive health education, immunizations, and family planning program services. Support services include case management services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family Planning program funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative

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appropriations, some local government appropriations, and a small amount of patient fee revenue.

The State of Wisconsin has increased the percentage of low-income families with health insurance through a variety of initiatives:

• Healthy Start Expansion. Wisconsin has increased the Medicaid income limit for low-income pregnant women and children under age six since 1988 when the program began, from 120% of FPL to the current level of 185% FPL. In 1989, the asset test was eliminated for Healthy Start.

• W-2 Health Plan. Provisions of 1995 Wisconsin Act 289 authorized the W-2 welfare reform program. As part of this reform, Wisconsin created the W-2 Health Plan, which was designed to provide health care to low-income families, dependent children, and working parents who could not afford health insurance. The program was designed as a bridge to self sufficiency, providing affordable health insurance to low-income, working families and assuring a transition to private health insurance. The program applied to persons in W-2 work programs and other low-income families. The federal waiver required for Wisconsin to implement this health care component was not granted.

BadgerCare. Provisions of 1997 Wisconsin Act 27, enacted on October 11, 1997, authorized statutory language and state matching funds from state GPR (tax revenues) to create the BadgerCare program. BadgerCare began July 1, 1998.

Prenatal Care for Unborn Children. Provisions of 2005 Wisconsin Act 25 enacted on July 25, 2005, authorized the Department of Health and Family Services to provide BadgerCare benefits to unborn children of women who are not otherwise eligible for Medicaid, such as non-qualifying aliens.

BadgerCare Plus. Provisions in the 2007-2009 Biennial Budget, which was enacted on October 26, 2007, will authorize statutory language and state matching funds from state tax revenues to create the BadgerCare Plus program. This program, to begin February 1, 2008, will provide a consolidated, streamlined program for all children, pregnant women, parents and caretaker relatives. It also expands coverage for pregnant women to 300% FPL, caretaker relatives and parents to 200% FPL and covers all uninsured children. Under SCHIP we are requesting coverage of those children with incomes that exceed Medicaid income limits, but do not exceed 300% FPL.

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Many of the families with children who are currently eligible for Family Medicaid or BadgerCare and have chosen not to enroll, need to be provided with information that shows that the program is easier to understand and easier to access. The State’s full-time outreach coordinator is responsible for making sure that everyone in Wisconsin who has a child knows that Family Medicaid and BadgerCare are available to help them meet their health care needs. Using data on population, family health and the uninsured, the outreach coordinator has identified specific geographic locations in Wisconsin with low health care penetration rates and is working collaboratively with local and statewide groups, including the Robert Wood Johnson-funded Covering Kids and Families Initiative, to identify and enroll children who meet program requirements in those areas.

In addition, BadgerCare Plus proposes to simplify the program rules through Medicaid and SCHIP State Plan amendments and modify the current BadgerCare waiver by removing income disregards and deductions in ways that make the program easier for the average parent to understand and allows them to ascertain on their own that their income meets the limits being proposed.

Finally, we realize that some families find the application for assistance at their county human or social services office to be a barrier to their participation. In 1999, Wisconsin allowed each applicant and program participant to choose how they want to apply. Families can apply through the mail, over the phone or in- person. In addition, beginning in 2006 Wisconsin had deployed an innovative tool, www.access.wisconsin.gov, that allows for a five to ten minute assessment of eligibility, the ability to apply on-line in twenty to thirty minutes, the ability to see case information and manage your own case and to report changes to the eligibility worker from an Internet-connected personal computer or laptop. At this time, 14% of our applications are done using ACCESS. With BadgerCare Plus we plan to use our marketing and outreach efforts to aggressively push ACCESS as the preferred method for interaction between the program and the member. We also have begun working to identify community partners, including clinics, hospitals, schools, food pantries, churches, etc., who can use ACCESS to help those low-income families who come to their organization for help to apply for and manage their public assistance Under state and federal law, we allow for an electronic signature for applications made using ACCESS.

2.2.2 The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership.

See 2.2.1

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2.3 Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low- income children to increase the number of children with creditable health coverage. (Previously 4.4.5) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42 CFR 457.80(c))

Applicants are eligible for BadgerCare Plus if they meet all of the following conditions:

- They are not currently enrolled in any group or individual health insurance plan as defined in HIPAA. - They have not been enrolled in a group or individual health plan meeting HIPAA criteria during the past six months. - They have not had access to a State employee’s health benefits plan in the previous 12 months. - They have not had access to a group or individual health insurance plan in the previous 12 months in which their employer pays at least 80 percent of the premium. Good cause is granted to family members of those individuals who have been or are currently covered, if the individual, through whom the insurance was available, has involuntarily lost their job with the employer providing that insurance, or the employer providing the health insurance coverage does not pay 80% or more of the premium; Persons who have access to employer health insurance that meets HIPAA standards and for which the employer pays at least 40 % but no more than 80% of the cost will be eligible for the health insurance premium purchase under BadgerCare Plus to assure that BadgerCare Plus does not substitute for private coverage. These provisions apply to the SCHIP expanded population only.

In families, where the state purchases employer subsidized family group health plan for a household that includes both Medicaid funded and SCHIP funded members, we will prorate the cost of the plan based upon the number of members in the family who are funded through SCHIP and the members funded through Medicaid. For example, if a family with a mother and two children, ages seven and nine, applies for BadgerCare Plus and we determine that their family income is 130% of the FPL, we will check with their employer to determine if we should enroll them in HIPP. If their family premium is $99 per month and that proves to be cost effective, the Department will purchase their employer's group health plan for the family and say that $66 of the premium that is intended for the two children will come from SCHIP and $33 will come from Medicaid funds.

The Department will comply with the applicable SCHIP premium assistance rules when determining whether the Department will pay for the employee portion of an employer- subsidized health insurance plan that covers SCHIP children.

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Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42 CFR 457.490(a))

BadgerCare Plus Enrollment Process. Enrollment for BadgerCare Plus will use the same enrollment process that is currently used for Medicaid. We believe it is necessary to have coordinated eligibility determinations and subsequently enrollment into Medicaid managed care (or fee-for-service when required) for both Medicaid and BadgerCare Plus because we expect many families to have both Title 19 and Title 21 eligibles. Applications can be made using an Internet application, available at www.access.wisconsin.gov, that allows families to apply for Medicaid, SCHIP and Food Stamps on-line, in-person at county human services offices or through the mail.

Like Medicaid, for most recipients, health care benefits will be delivered through a managed care system. In areas of the State that do not have HMO services available, and in counties where there is only one HMO in operation (except in areas designated as rural exception counties), BadgerCare Plus is available on a fee-for-service basis.

Recipients determined eligible for BadgerCare Plus are provided a packet of informational materials regarding the plans available to them in their area and will be required to select an HMO. The enrollment date is the earliest possible month after a family has chosen an HMO. Recipients will be covered on a fee-for-service basis until HMO enrollment is effective.

As described in sections 2.3 and 5.1 of this document, has streamlined the process to the greatest extent possible to allow families to apply for BadgerCare Plus at locations convenient to them that fit their schedule, through an Internet website (https://access.wisconsin.gov/) and through telephone and mail-in application processes.

Current Medicaid Managed Care Process. All AFDC Medicaid, AFDC-related Medicaid and Healthy Start eligible recipients throughout the state are eligible to participate in the Wisconsin BadgerCare Plus HMO program.

Once eligibility is established, recipients receive an enrollment packet including a list of available HMOs, how to choose an HMO and who to contact for assistance in

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determining if their current health care provider is participating in an HMO. Recipients may enroll by phone or by mailing in the HMO enrollment choice form. Recipients may make a choice at any time within the process by sending in the enrollment form or contacting the enrollment contractor and enrolling over the telephone.

If a recipient has not chosen an HMO within two weeks of receiving an enrollment packet, a reminder card is sent encouraging them to send in their HMO choice form or contact the enrollment contractor for assistance. At the same time, the enrollment contractor is supplied the list of recipients who were sent reminder cards for the purpose of telephone and mail outreach.

If a recipient has not chosen an HMO after four weeks, the recipient is assigned to an HMO certified to provide services in the zip code the recipient resides. An enrollment form is sent with the notice of auto-assignment, giving the recipient a final opportunity to change HMOs if they are not satisfied with their assigned HMO. Recipients also receive a notice confirming enrollment in their assigned HMO for the following month, then later receive a BadgerCare Plus HMO identification card. Recipients are covered under fee-for-service until they are enrolled into an HMO.

Recipients are auto-assigned to HMOs on a random and equal basis up to each HMO’s enrollment limit. For example, if there are three available HMOs in a zip code, each will receive one-third of auto-assigned cases.

In addition, once recipients are in their first month of enrollment in an HMO, whether they have chosen or have been assigned, they still have the opportunity to change to a different HMO during that month.

Enrollment Contractor. Wisconsin contracts with a statewide enrollment contractor to provide assistance, education and outreach to BadgerCare Plus and Medicaid recipients regarding the managed care program. The enrollment contractor’s role is to perform enrollment, education, outreach and advocacy for Medicaid managed care enrollees. The enrollment contractor is a knowledgeable single point of contact for enrollees, solely dedicated to managed care issues. It is a resource where enrollees can receive help in making the appropriate choices and resolving problems. Recipients may call a toll free phone number to obtain assistance in selecting an appropriate HMO or may have a face- to-face meeting at numerous sites across the State.

The State intends to expand the services of the enrollment contractor and incorporate additional outreach and education functions to support enrollment for BadgerCare Plus. These additional functions will include after-hours availability. Currently the enrollment contractor is available by phone from 8:00 a.m. to 6:00 p.m. and in person at six regional sites from 8:00 a.m. to 4:30 p.m.

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Disenrollments and Exemptions. Wisconsin Medicaid and BadgerCare Plus have short term and long term exemptions from HMO participation. In some situations a recipient may be exempt from joining an HMO. Exempted recipients receive fee-for-service care for all Medicaid-covered services. Exemptions are granted to an individual who meets the specific criteria. The exemptions currently allowed for BadgerCare and Medicaid will also be allowed for BadgerCare Plus. See Appendix B for a list of HMO exemptions.

Prenatal Care and Delivery Service. Services provided to unborn children under the separate SCHIP program will not be provided through HMOs, but on a fee-for-service basis.

3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42 CFR 457.490(b)). Utilization controls in the Wisconsin plan (BadgerCare Plus) for targeted low-income children will vary depending on the health care delivery system from which targeted low-income children receive health care. If these children are enrolled in HMOs which participate in Medicaid/ BadgerCare Plus, their utilization will be reviewed and monitored based on the standard requirements for Utilization Control that are established by the BadgerCare HMO contract. These requirements are as follows: • The HMO must have documented policies and procedures for all Utilization Management (UM) activities that involve determining medical necessity, and the approval or denial of medical services. Qualified medical professionals must be involved in any decision-making that requires clinical judgment. Criteria used to determine medical necessity and appropriateness must be communicated to providers. • If the HMO delegates any part of the UM program to a third party, there must be documented agreement, which includes a description of the delegated activities and reporting mechanisms for submitting data and information to the HMO. • The HMO must provide active oversight and evaluation of all aspects of performance of the delegated UM organization's activities, particularly in the area of provider and member satisfaction. Other areas of HMO Quality Improvement contract requirements, which are quite detailed, would apply to BadgerCare Plus utilization controls. If these children are enrolled in an employer's group health plan through a subsidy

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provided by the BadgerCare Plus program, BadgerCare Plus will provide "wraparound" services up to the Medicaid benefit level for these childrenWe will also apply the standard Medicaid fee-for-service utilization review policy and procedures to these "wraparound" services. The standard Medicaid fee-for-service utilization review policies and procedures are encompassed in the currently certified and operational MMIS Surveillance/Utilization Review subsystem.

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1 The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42 CFR 457.305(a) and 457.320(a))

4.1.1

Geographic area served by the Plan:

Statewide.

4.1.2

Age: Separate SCHIP: Children from age 1 through age 5 with family income above 185% FPL up to and including 300%FPL and Children ages 6 through age 18 with family income above 150% FPL up to and including 300% FPL Unborn children from conception to birth up to and including 300% FPL.

Medicaid Expansion:

Children ages 6 through 18 with family income from above 100%FPL up to and including 150% FPL.

4.1.3

Income: Wisconsin has a 300% of the Federal poverty level gross income test without any deductions.

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4.1.4 Resources (including any standards relating to spend downs and disposition of resources):

There is no resource test.

4.1.5

Residency (so long as residency requirement is not based on length of time in state):

Be physically present in Wisconsin with the intent to reside in the state.

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

Not applicable.

4.1.7

Access to or coverage under other health coverage:

Unborn Children

May not be covered under a group health plan or under health insurance coverage, as defined in section 2791 of the Public Health Service Act during the month of application or in the previous three calendar months, unless a good cause exemption is granted.

May not have access to a State employee’s health benefits plan or to an employer’s group or individual health insurance plan in the month of application or in the three calendar months following the month of an application, annual review or the start of new employment, or in the previous 12 months, unless a good cause exemption is granted.

A good cause exemption is granted to those unborn children with past or present coverage or access to a health insurance or a group health plan, if the insurance only covers services provided in a service area that is beyond a reasonable driving distance from the individual’s residence.

A good cause exemption is granted to those individuals who were covered by a group health plan or health insurance coverage in the three months prior to application, if insurance did not pay for pregnancy-related services or if: o The individual through whom the insurance was available involuntarily lost their job with the employer providing that

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insurance, or voluntarily ended their job because of the incapacitation of the individual or because of an immediate family member’s health condition, o Employment of the individual through whom the insurance was available changed and the new employer does not offer health insurance coverage, or the employer discontinued health plan coverage for all employees o COBRA continuation coverage was exhausted in accordance with federal regulations, o Coverage was lost due to the death or change in marital status of the policy holder, or o The insurance was provided by someone not residing with the unborn child;

A good cause exemption is granted to individuals with current, future or past access to an employer’s group health plan, if the available insurance is through a person who is not a member of the unborn child’s household or the employer contributes less than 80 percent of the premium cost. The percentage of employer contribution is not applicable for the State employee’s health plan.

A good cause exemption is granted to those unborn children who, in the past 12 months, had access to a group health plan or had access to access to a State employee’s health benefits plan if: o Employment of the individual through whom the insurance was available ended, or the employer discontinued health plan coverage for all employees; or o At the time the individual failed to enroll in the employer’s health insurance coverage, one or more members of the individual’s family were covered through: o A private health insurance policy or Medicaid, and o No one in the family was covered through SCHIP.

Children covered under Separate SCHIP

May not be covered under a group health plan or under health insurance coverage, as defined in section 2791 of the Public Health Service Act, during the month of application or in the previous three months, unless a good cause exemption is granted.

May not have access to a State employee’s health benefits plan or to an employer’s group health plan at the time of application or within the three calendar months following the month of an application, annual review or

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the start of new employment, or in the previous 12 months, unless a good cause exemption is granted.

A good cause exemption is granted to those children who are covered by health insurance or a group health plan during the month of application or in the previous three months, if the individual is covered by health insurance: o That only covers services provided in a service area that is beyond a reasonable driving distance from the individual’s residence, o Provided by someone who is not a member of the child’s household, or o Which is not a group health plan, or for which an employer contributes less than 80 percent of the premium cost. This reason does not apply to State employee’s health benefits plan.

A good cause exemption is granted to those children who were covered by a group health plan in the three months prior to application, if: o The individual through whom the insurance was available involuntarily lost their job with the employer providing that insurance, or voluntarily ended their job because of the incapacitation of the individual or because of an immediate family member’s health condition, o Employment of the individual through whom the insurance was available changed and the new employer does not offer health insurance coverage, or the employer discontinued health plan coverage for all employees, or o Coverage was lost due to the death or change in marital status of the policy holder.

A good cause exemption is granted to individuals with current, future or past access to an employer’s group health plan, if the available insurance is through a person who is not a member of the child’s household or the employer contributes less than 80 percent of the premium cost. The percentage of employer contribution is not applicable for the State employee’s health plan.

A good cause exemption is granted to those individuals who, in the past 12 months, had access to a group health plan or a State employee’s health benefits plan, if: o Employment of the individual through whom the insurance was available ended, or the employer discontinued health plan coverage for all employees; or

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o The individual through whom the insurance was available failed to enroll in the employer’s health insurance coverage because one or more members of the individual’s family were covered through: o A private health insurance policy or Medicaid, and o No one in the family was covered through SCHIP.

Other good cause exemptions, consistent with the above reasons, may be approved by the Department of Health Services on a case by case basis.

4.1.8

Duration of eligibility:

Eligibility lasts until the birth of the baby for unborn children covered under SCHIP and for 12 months or until determined ineligible for all other children.

4.1.9

Other standards (identify and describe):

An SSN is not required for non-qualifying immigrants, but is required for all others.

Wages and availability of employer-sponsored health insurance must be verified by the employer.

4.2 The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42 CFR 457.320(b)) 4.2.1

These standards do not discriminate on the basis of diagnosis.

4.2.2

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income.

4.2.3

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3 Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42 CFR 457.350)

The methods of establishing eligibility and continuing enrollment are the same as under Title XIX.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any).

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(Section 2106(b)(7)) (42 CFR 457.305(b))

Check here if this section does not apply to your state.

4.4 Describe the procedures that assure that:

4.4.1 Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42 CFR 457.350(a)(1)) 457.80(c)(3))

Eligibility is determined in Wisconsin’s automated eligibility system, CARES. CARES determines eligibility and benefits for Medicaid, BadgerCare Plus, SeniorCare, Food Stamp, and TANF (Wisconsin Works, Child Care and SSI Caretaker Supplement) programs. In determining eligibility for Medicaid and BadgerCare Plus, CARES will configure the group, check nonfinancial factors of eligibility, add together the appropriate financial resources of the group and determine eligibility, regardless of whether the individual would be Medicaid or BadgerCare Plus eligible. Once eligibility is determined, CARES checks nonfinancial factors, whether the individual is a child (under age 6 or age 6 to under age 19), parent, adult caretaker relative or pregnant woman and then determines which the federal poverty level for the individual based upon the family’s income and size. CARES then assigns a medical status code, which indicates whether the individual’s benefit and administrative costs are Title 19, or Title 21 or 100% state funded, for MMIS and MSIS.

4.4.2 The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42 CFR 457.350(a)(2))

See 4.4.1

4.4.3 The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42 CFR 431.636(b)(4)) Any applicant or enrollee who is found ineligible for Medicaid services (based on the eligibility of his or her mother) and appears eligible for the separate child health program is automatically reviewed for SCHIP eligibility.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42 CFR 457.805) (42 CFR 457.810(a)-(c))

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4.4.4.1

Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Persons who are covered by employer health insurance plans that meet the Health Insurance Portability and Accountability Act (HIPAA) standards (and have not demonstrated good cause) will not be eligible for BadgerCare Plus. The eligibility worker will collect insurance information from the household to verify coverage and access. The HIPAA standard will be included in a question to the applicant family asking whether this is a major medical health insurance plan. EDS, Wisconsin Medicaid’s fiscal agent, will then verify coverage through the eligibility exchange system currently in use, and through written and phone contacts with employers. When previously unreported insurance coverage is discovered, EDS will inform the worker who will close BadgerCare Plus coverage.

Persons who have coverage under employer health insurance that meets HIPAA are ineligible for BadgerCare Plus, unless they are able to demonstrate good cause. Persons who have access to employer health insurance that meets HIPAA standards and for which the employer pays 80% or more of the cost are also ineligible for BadgerCare Plus. Persons who have access to employer health insurance that meets HIPAA standards and for which the employer pays at least 40 % but no more than 80% of the cost will be eligible for the health insurance premium purchase under BadgerCare Plus to assure that BadgerCare Plus does not substitute for private coverage.

4.4.4.2

Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. As part of the 2003-2005 Biennial Budget Act, Wisconsin implemented a mandatory employer verification of earnings and health insurance access/coverage at:

• Application for BadgerCare; • Annual Renewal of BadgerCare; • Upon entry into a new job; and, • When a family moved from Medicaid to BadgerCare.

The process involved sending a pre-printed form to recipients asking them to verify with their employer their earnings and their health insurance status. We required the employer to sign the form. When the form was returned, the

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information was entered into Wisconsin’s automated eligibility system, CARES, where eligibility could be determined and confirmed. Within the first six months of implementation, BadgerCare enrollment dropped by 25%.

In response to this drastic change, the Department completed an evaluation and found that the most common reasons for the decrease was that employers were not completing the form that verified health insurance status and that some recipients simply did not attempt to complete the verification process. Interviews with employers revealed that they were too busy to comply and that completing the form was not a priority. Interviews with recipients revealed that they had not read the notice explaining what they needed to do or that, because of other factors in their lives, they were unable to comply. At this time, it was decided that with the 2007-2009 Biennial Budget, the Wisconsin Medicaid agency would seek a new solution.

With BadgerCare Plus, we employ a new process that does not rely on county/tribal eligibility workers or on applicant/recipients. The Department has built an employer health insurance database with all of the employers of BadgerCare Plus parents, caretakers and pregnant women. The database, which has been and will be populated using information from employers, contains information about whether the employer offers any insurance, rules for which employees have access to the benefit, the individual and family premium amount, and the amount the employer pays for the premium. At the time of application and review, when the family identifies their employer in the automated eligibility system, the system will automatically check the employer health insurance database. If the employer does not offer health insurance to anyone or offers health insurance at 80% or more of the premium to all, this information will be passed back to CARES and eligibility will be determined and confirmed. If the employer has rules about whom and when employees have access to their insurance and the employer pays 80% or more of the premium for that insurance, that information will be passed back to the worker who will use it to enter data into CARES at which time eligibility can be determined and confirmed. If the employer has not supplied complete information needed to make a determination, we (not the county or tribal eligibility worker) will contact the employer to request the information. By state law, if the employer does not supply the information within the time period allowed, usually 30 days, BadgerCare Plus eligibility will be granted and the employer will be fined an amount equivalent to the BadgerCare Plus per member per month cost until the information is supplied. (For those months, there will be no benefit cost to either the state or federal government). Employers are granted a fair hearing if they disagree with the fiscal penalty. There are maximum values for all employers that vary based upon the number of employees.

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4.4.4.3 3 Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. Wisconsin uses the same methologies indicated in Section 4.4.4.2 to monitor substitution and to prevent substitution.

4.4.4.4 If the state provides coverage under a premium assistance program, describe: The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. The minimum employer contribution. The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Wisconsin has a long-standing working relationship with tribal health directors in the State. From statewide HMO implementation, Medicaid staff met with tribal health directors over an 18-month period to coordinate HMO expansion with the needs of the tribes and with Indian Health Service responsibilities. A special disenrollment procedure was developed for tribal members that involves close coordination with Indian Health Clinics, tribal members, and the Medicaid HMO enrollment broker. A special payment system was developed so that non- HMO affiliated Indian Health Clinics could still be reimbursed by Medicaid for fee-for-service funds for services provided to tribal members enrolled in HMOs, and so that Indian Health Service funds would not be jeopardized by the expansion of the HMO program.

We continue to hold regular meetings with tribal leaders to discuss health care related issues. We intend to use these meetings to solicit input and provide information to the tribes on BadgerCare Pus.

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Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42 CFR 457.90)

The expansion of the BadgerCare Plus program will take advantage of the outreach efforts that are already under way (see 2.2.1). The Department of Health and Family Services has developed a comprehensive plan for outreach. The Department is undertaking a major outreach effort to inform eligible families of the availability of Medicaid and to assist them in enrolling in the program. These efforts transcend implementation of BadgerCare Plus. The Department's outreach plan will reach out to families potentially eligible for Medicaid under the old AFDC standards and establish the foundation for education and enrollment of families into BadgerCare Plus, highlighting the simplicity of the new program rules and new ways to apply for benefits. These efforts are highlighted by the following initiatives, described in detail in this section:

- Implementation of the ACCESS internet tools (Am I Eligible, Apply for Benefits, Check My Benefits, and Report My Changes). - Hiring of a full-time outreach coordinator. - Development of an outreach plan to increase BadgerCare Plus enrollment and to implement strategies to promote public health.

Strategies to Promote Public Health. The Department is developing strategies to promote the health of the population through a variety of initiatives. These include the following:

- Assuring that eligible families are enrolled in Medicaid.

- Extending health care coverage to working families with BadgerCare.

- Establishing a medical home and access to quality preventive services through statewide expansion of managed care.

- Creating incentives for managed care organizations to support healthy living incentives and to pay for quality performance.

Outreach Plan. The Outreach Plan has four major components:

- Statewide public information campaign.

- Expanded training.

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- Improved case-specific problem resolution.

- Systems changes.

The outreach program for BadgerCare Plus will complement and build upon current Medicaid outreach initiatives that are underway to respond to federal welfare reform. This plan has been developed over the past six months with significant public input.

Our goals in developing the outreach plan are to:

- Assure the participation of eligible families in Medicaid and BadgerCare Plus.

- Invest in proven activities that will support access to health care for families.

- Improve the health status of the Wisconsin population.

Through our outreach plan, we hope to ensure that all uninsured families in Wisconsin are aware of the health care coverage that is available to them. As a result, we expect to enroll eligible families into Medicaid and BadgerCare Plus.

Public Information Campaign. A comprehensive and coordinated effort is underway to assure that accurate information is available to potential program members and agencies that work with them about the new streamlined and easy-to-use BadgerCare Plus program.

A new recipient brochure aimed specifically at potential members of the BadgerCare Plus program, accompanied by posters and potentially radio ads, will be distributed in late 2007.

Fact sheets describing various BadgerCare Plus program components are being developed as the basis for various informational materials and training. This approach will also be used to support BadgerCare Plus implementation. Promotional materials such as business cards, brochures (provider and recipient), posters and decals have already been created for ACCESS.

DHFS materials for beneficiaries are tested with focus groups. The Department translates these materials, as appropriate, into Spanish and Hmong, and distributes these materials based upon the demographics of particular communities, to reach out to individuals for whom English is not their primary language. Existing advocacy networks and mailing lists are continually updated to assure timely and accurate information about the impact of welfare reform.

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The Department has created a BadgerCare Plus advisory group whose members include:

Bevan Baker City of Milwaukee Health Department John Chianelli Milwaukee County Department of Health and Human Services Melissa Duffy Wisconsin Federation of Cooperatives Donna Friedsam University of Wisconsin Population Health Institute Jason Helgerson Dept. of Health & Family Services Kathy Kaelin Automated Health Ed Kamin Kenosha County Department of Human Services Danyel McNeil City of Milwaukee Health Department Dr. John R. Meurer Medical College of Wisconsin Mark Miller State Senator Fr. Thomas Mueller St. Cyril and Methodist Orthodox Church, Milwaukee Paul Nannis Aurora Health Care Jon Peacock Wisconsin Council on Children and Families Bobby Peterson Advocacy & Benefits Counseling for Health Lori Pidgeon Ho-Chunk Nation Jon Richards State Representative David Riemer The New Hope Project Bill Smith National Federation of Independent Business Dr. Susan Turney Wisconsin Medical Society Nancy Wenzel Wisconsin Association of Health Plans Paul Zimmerman Wisconsin Farm Bureau Federation

This group has met since 2006 on a bi-monthly basis to discuss the various components of the BadgerCare Plus program and to provide the Department with feedback on the program.

At more than 22 town hall meetings, the Governor, Department Secretary and/or the State Medicaid Director have described Wisconsin’s BadgerCare Plus proposal and received input from citizens, doctors, nurses, public and private health clinic

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administrators, HMO/insurance administrators, , health care advocates and Medicaid/BadgerCare eligibility agency administrators, and used that input to guide the BadgerCare Plus program creation.

Training. New training materials and presentations on BadgerCare Plus eligibility are being developed. Training for health care providers will be offered by the state’s Medicaid fiscal agent, EDS. Training packages that can be used by other groups to reach their members will be available, for example, for staff of medical clinics and school nurses.

Training for advocacy groups and community-based agencies will be developed and offered by the Department. Training for workers in county agencies will be developed by the Department and should take place between December 1, 2007 and January 15, 2008.

Systems Changes. Changes are being made to the CARES eligibility determination system, the ACCESS system and to the MMIS system to accommodate BadgerCare Plus rules. In addition, improvements to recipient notices generated by CARES will be completed by February 1, 2008, as one component of the State’s outreach strategy.

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1 The state elects to provide the following forms of coverage to children: (Check all that apply.) (42 CFR 457.410(a))

6.1.1

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) * 6.1.1.1 FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.)

6.1.1.2 State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.1.3

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2 Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3 Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

Wisconsin will provide the same benefits package to recipients of its BadgerCare Plus program as is currently provided to Wisconsin Medicaid recipients under Title XIX for those children with family incomes at or below 200% FPL. For those children with family incomes exceeding 200% FPL, but no greater than 300% FPL, Wisconsin will provide a Benchmark-Equivalent Plan benefit.

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6.1.4.1

Coverage the same as Medicaid State plan

The coverage for children with family incomes no greater than 200% FPL is the same as our Medicaid benefit plan.

6.1.4.2

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3 Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population

6.1.4.4 Coverage that includes benchmark coverage plus additional coverage

6.1.4.5 Coverage that is the same as defined by existing comprehensive state- based coverage

6.1.4.6 Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) The Benchmark-Equivalent Plan which is provided to children with family incomes greater than 200% FPL is substantially equivalent to the most widely available and most widely purchased commercial plan in Wisconsin, the United Health Care Plan. We have reviewed the United Health Care Plan benefits and modified them slightly in regard to the copayments and service limits. This modified plan has been adopted as the Benchmark Plan for both children eligible for SCHIP with incomes greater than 200% FPL, but also for pregnant women, eligible under Medicaid, with incomes that exceed 200% FPL.

The benchmark-equivalent plan we’re providing has slightly better benefits and cost sharing then the parent plan, United Health Care Group Health Plan, since we lowered the cost sharing and then added a more comprehensive mental health/substance benefit from the State Employee’s Group Plan.

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Wisconsin ensures that children covered through premium assistance receive benefits that are equivalent to the United Health Care Group Health Plan, with mental health and substance abuse treatment benefits from our state employee’s plan. When a child is enrolled in an employer’s group health plan, the benefits of the Standard or Benchmark Plan, whichever they are qualify for, are wrapped around that health plan to ensure a benefit that is at least equivalent to the benefit they would have received had they not been bought into the employer’s plan.

6.1.4.7 Other (Describe)

6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42 CFR 457.490)

For the unborn child, the State covers pregnancy related services and services that if not treated could complicate the pregnancy. The list of services provided for our separate SCHIP unborn population is listed in the attached addendum.

The services checked below are for our separate SCHIP population of children from birth to 19 years up to and including 300% FPL. Children with family income at or below 200% FPL receive the Medicaid or Standard Plan benefit package, while children with family income greater than 200% FPL but no greater than 300% FPL receive a Benchmark-Equivalent Plan benefit package. Details about the amount, duration and scope of the covered services are provided in Attachment 3.

6.2.1

Inpatient services (Section 2110(a)(1))

6.2.2

Outpatient services (Section 2110(a)(2))

6.2.3

Physician services (Section 2110(a)(3))

6.2.4

Surgical services (Section 2110(a)(4)) See Physician Services in Attachment 3

6.2.5

Clinic services (including health center services) and other ambulatory health care services (Section 2110(a)(5)) See Physician Services in Attachment 3

6.2.6

Prescription drugs (Section 2110(a)(6))

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6.2.7

Over-the-counter medications (Section 2110(a)(7))

6.2.8

Laboratory and radiological services (Section 2110(a)(8))

6.2.9

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

6.2.10

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

6.2.11

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

6.2.12

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13

Disposable medical supplies (Section 2110(a)(13))

6.2.14

Home and community-based health care services (See instructions) (Section 2110(a)(14))

6.2.15

Nursing care services (See instructions) (Section 2110(a)(15)) See Physician Services in Attachment 3

6.2.16

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.17

Dental services (Section 2110(a)(17))

6.2.18

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

6.2.19

Outpatient substance abuse treatment services (Section 2110(a)(19))

6.2.20

Case management services (Section 2110(a)(20))

6.2.21

Care coordination services (Section 2110(a)(21)) See Case Management services in Attachment 3.

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6.2.22

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

6.2.23

Hospice care (Section 2110(a)(23))

6.2.24

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (See instructions) (Section 2110(a)(24))

6.2.25

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26

Medical transportation (Section 2110(a)(26))

6.2.27

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) See Transportation Services in Attachment 3.

6.2.28

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480)

6.3.1

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2 The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1 Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42 CFR 457.1005(a)):

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6.4.1.1 Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42 CFR 457.1005(b))

6.4.1.2 The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis.

(Section 2105(c)(2)(B)(ii)) (42 CFR 457.1005(b))

6.4.1.3 The coverage must be provided through the use of a community - based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42 CFR 457.1005(a))

6.4.2 x Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42 CFR 457.1010)

We propose to use the state employee standard benefit package which meets the requirements of a benchmark plan under Title XXI to compare the cost of covering two low-income children in an average three-person BadgerCare Plus family to the cost of covering the entire three-person family under a BadgerCare Plus /Medicaid HMO plan. The state employee standard benefit package meets the requirements of a benchmark plan under Title XXI. Our comparison of costs of children under the benchmark plan as opposed to the cost of families under BadgerCare Plus meets the cost effectiveness requirements of the law. It should be noted, however, that the State employee plan and other employer-based, commercial coverage are frequently limited to two options, single (employee only) or family (employee plus family members). Coverage for children only is generally not available unless family coverage is elected by the employee.

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We propose to implement BadgerCare Plus by emphasizing the importance of providing health insurance coverage to low-income families in order to facilitate and expand access to health care coverage for children under Title XXI. Our BadgerCare Plus proposal creates a seamless program of family health insurance by using both Titles XIX and XXI in order to provide insurance for the whole family.

Title XXI, Section 2105 provides CMS with the authority to waive requirements prohibiting the purchase of family coverage under Title XXI. This is possible provided the following two conditions are met: (1) such coverage is cost-effective relative to the amounts that the State would have paid to obtain comparable coverage only of the targeted low-income children involved; and (2) the coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. In order to demonstrate compliance with Section 2105, we are providing the actuarial analysis found in section 6.3.2.1, which follows. The crowd-out provisions for BadgerCare Plus assure that only children who are not now covered would be eligible for health care.

6.4.2.1 Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42 CFR 457.1010(a))

We have identified a benchmark health insurance plan that is available to all state employees. For purposes of assuring the reasonableness of access to the plan, for the basis of comparison, we chose the State Employee Standard Plan. The Standard Plan is the only health insurance option that is available to all state employees in all seventy-two Wisconsin counties.

Demographic assumptions. We assumed the following about the average BadgerCare family size, based on Wisconsin-specific 2000 U.S. Census data:

Children 1.91 Adults 1.14 Total 3.05

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Wisconsin will only provide premium assistance when it is proven to be cost effective to do so. This means that the cost of providing family coverage is no greater than the cost of SCHIP direct coverage for the children. For instance, with a per member per month cost of $105 per child under BadgerCare Plus, we would not purchase family insurance that would cover three children if our cost was more than $315 per month.

Therefore, the cost of covering the entire family under BadgerCare Plus is less than the cost of covering children under the Standard Plan, as required under Section 2105(c)(3)(A).

6.4.2.2 The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42 CFR 457.1010(b))

BadgerCare Plus coverage of families will provide coverage for children who do not currently have access to affordable health care coverage. It will not substitute for coverage which currently covers the children but does not cover the parents.

6.4.2.3 The state assures that the coverage for the family otherwise meets title XXI requirements. (42 CFR 457.1010(c))

The State provides “wrap-around” benefits that cover any services not provided through the family coverage plan that are part of the regular SCHIP services provided under the plan.

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Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1 Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well- child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42 CFR 457.495(a))

Quality assurance mechanisms

BadgerCare Plus will include several quality assurance mechanisms to evaluate and improve the quality of medical care provided to BadgerCare Plus recipients. Every managed care organization under contract with the State will be required to have an active quality assurance system, including designated quality assurance staff devoted to evaluation of the care provided to BadgerCare Plus recipients.

The quality assurance activities carried out in BadgerCare Plus will focus on specific medical service delivery concerns. These medical and service delivery concerns will include the following:

• Access to care • Timeliness of care • Appropriateness of care • Appropriateness of setting • Appropriateness of amount of care • Consistency with current standards of medical practice • Education and communication with recipients • Ethnic and cultural responsiveness

Improvements to Care and Service

In addition, each BadgerCare Plus managed care organization will be required to demonstrate how the organization has attempted to improve care and service for BadgerCare recipients enrolled in their program. The state will monitor compliance with the contract standards for BadgerCare Plus (as with Medicaid) in a number of ways:

• An independent contractor will review a sample of recipient medical records annually to determine the adequacy of care and services being provided. The

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documentation in the medical record will be compared to specific criteria and standards developed by the Wisconsin Medicaid medical consultants with provider input.

• Medical consultants who are specialists in the area under review will conduct a number of on-site administrative and clinical audits.

• Grievance audits and reviews of grievances received from recipients and providers will assure that the contracted managed care organizations are complying with the rules of BadgerCare Plus.

• The Wisconsin Medicaid contract will continue to require each HMO to employ at least one full-time internal advocate for recipients to help ensure that the HMO remains responsive to recipients' concerns.

KEY ELEMENTS:

Performance-based contract

Defines roles, structure and process

Includes QAPI program, access and other requirements

Includes data system, encounter data and reporting requirements

Enforcement tools-intermediate sanctions up to termination To view the HMO contract, go to: http://www.dhfs.state.wi.us/medicaid7/providers/pdfs/mc10051.pdf

Automated performance measures:

Wisconsin monitors MCO performance using automated clinical performance measures called MEDDIC-MS (Medicaid Encounter Data Driven Improvement Core Measure Set). The measure set has been evaluated by AHRQ (the Agency for Healthcare Research and Quality) and approved for inclusion in the National Quality Measures Clearinghouse. Using the system, the state can monitor 59 indicators, including private accreditation status. Wisconsin publicly reports the clinical indicator data on its Medicaid managed care website. Reporting is done annually.

Non-clinical performance indicators: Wisconsin reports non-clinical performance data based on enrollee satisfaction surveys which are done by the DHFS bi-annually on a state-wide basis. In addition, the DHFS monitors grievance and complaint data. Other non-clinical data sources include:

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• Disenrollment rates • Encounter data validity audit (DVA) • External Quality Review (EQR)

Performance improvement projects: Each HMO must report in detail on at least two performance improvement projects conducted by the organization in the previous year. Topics may be clinical or non-clinical and should relate to priority areas specified by the DHFS in the HMO contract.

Other performance improvement tools include: • MEDDIC-MS Goal-setting Process • Care Analysis Projects • Best practices symposium-diffusion of innovation • HMO Report Card • New Enrollee Health Needs Assessment (NEHNA) survey • Stay Safe & Healthy enrollee safety education initiative • External Quality Review reports • Technical assistance, training • Biannual QAPI recertification audit reports • HMO performance improvement projects • DHFS Strategic plan and biannual strategic plan assessment • HMO Accreditation Incentive Program • Other pay-for-performance incentives are in development.

Structure and process tools-in contract (subject to certification and recertification review) • Written HMO access and availability standards • HMO must provide written assurance of network adequacy • Geo-access review of HMO provider network • Coordination and continuity of care policies • UM/UR, denial criteria and policies • Clinical practice guidelines; development, update and dissemination policies • Enrollee rights protections and policies • Medical records content and confidentiality protections and policies • Enrollment and disenrollment policies • Grievance and complaint policies • Internal advocate and grievance processes, formal and informal • Delegation policies and agreements • Demand management system (nurse line or phone triage) policies • Provider/practitioner credentialing/recredentialing policies

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DHFS Oversight activities & tools • Certification and recertification audits • Quality of care audits (internal & external) • Data validity audits • Complaint & grievance monitoring, audits and follow-up • External quality review

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1  Quality standards 7.1.2  Performance measurement 7.1.3  Information strategies 7.1.4  Quality improvement strategies

7.2 Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42 CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42 CFR 457.495(a))

MEDDIC-MS includes a clinical performance measure for each of the following, which is monitored program-wide and on an HMO-specific basis annually: • EPSDT (well-child visits) for children two years of age and younger getting 5, 6 and 7 or more visits in the look-back period and visits for children age two to twenty years of age; • Non-EPSDT well-child visits; • Immunizations on a program-wide and HMO-specific basis in the look-back period; • Primary care visits for children. • Blood lead toxicity screening tests for children age one and two years;

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42 CFR 457.495(b))

MEDDIC-MS includes a clinical performance measure for each of the following, which is monitored program-wide and on an HMO-specific basis annually:

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• General and specialty inpatient care, including maternity, surgical, medical, psychiatric, substance abuse and neonatal) • General and specialty outpatient care (including emergency department care without admission, vision, primary care, audiology care, and general dental care) • Dental preventive care; • Women’s health measures, including screening mammograms, Pap tests (and malignancy detection rates), maternity care, perinatal substance abuse care and HIV screening, prenatal care coordination)

Data on Medicaid HMOs is collected and published annually, and audit findings indicate steady improvement in the provision of primary care by managed care organizations.

In linking BadgerCare Plus recipients to a “medical home” and in requiring strong quality assurance efforts, Wisconsin Medicaid plans to continue this progress and improvement in health care outcomes in the BadgerCare program.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42 CFR 457.495(c))

MEDDIC-MS includes a clinical performance measure for each of the following, which is monitored program-wide and on an HMO-specific basis annually: • Ambulatory care for diabetes (including HbA1c and lipid profiles) • Asthma care including monitoring of prevalence, inpatient and ED care for asthma • Follow-up ambulatory care by specialists and PCPs for mental health and substance abuse diagnoses within 7 days and 30 days of discharge from inpatient care for those conditions; • Mental health and substance abuse evaluations and day/outpatient care by specialists and PCPs.

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7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42 CFR 457.495(d))

Wisconsin’s performance-based contract provides as follows:

Qualified medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03 (96m) Wis. Adm. Code.

HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decisions, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the HMO must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (interrater reliability).

a. Within the time frames specified, the HMO must give the enrollee and the requesting provider written notice of:

1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision. 2) The enrollee’s right to file a grievance or request a state fair hearing.

b. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires:

1) Within 14 calendar days of the receipt of the request, or 2) Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain maximum function. One extension of up to 14 calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more information.

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Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1 Is cost-sharing imposed on any of the children covered under the plan? (42 CFR 457.505)

8.1.1

YES

8.1.2

NO, skip to question 8.8.

8.2 Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b) & (c), 457.515(a)&(c))

8.2.1 Premiums:

Premiums will be imposed upon children with monthly family income greater than 200% FPL. The rate is based upon family income and will not exceed 5% of monthly family income. Recipients will receive a notice telling them how much their premiums will be. Children ages 1 – 18, with Incomes at or above 200 percent up to, but not including 230 percent of the FPL: $10; Incomes at or above 230 percent up to, but not including 240 percent of the FPL: $15; Incomes at or above 240 percent up to, but not including 250 percent of the FPL: $23; Incomes at or above 250 percent up to, but not including 260 percent of the FPL: $34; Incomes at or above 260 percent up to, but not including 270 percent of the FPL: $44; Incomes at or above 270 percent up to, but not including 280 percent of the FPL: $55; Incomes at or above 280 percent up to, but not including 290 percent of the FPL: $68; Incomes at or above 290 percent up to, but not including 300 percent of the FPL: $82; Incomes at 300 percent of the FPL: $97.53.

8.2.2 Deductibles:

A $200 deductible will apply for covered dental services, except preventive and diagnostic services, provided to children ages 1 to 18 with incomes from 200 - 300% FPL. Preventive and diagnostic dental services which include oral examinations, prophylaxis and topical fluoride applications, sealants and x-rays do not apply to the deductible. The deductible applies to fillings and other restorative services. The deductible is applied lies on a per member basis and is based on Benchmark Plan maximum allowable fees and is counted towards the enrollee’s 5 percent cost-sharing cumulative maximum, described in section 8.5.

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8.2.3 Coinsurance or copayments:

Description of Children Affected

Premium Co-payments Children ages 1 - 5 with incomes >185 FPL up to and including 200% FPL None See Attachment 1, included at the end of Section 8 Children ages 6 - 18 with incomes > 150% FPL up to and including 200% of FPL None Children ages 1 - 18 with incomes from 200 - 300% FPL 200 < 230% FPL - $10 230 < 240% FPL - $15 240 < 250% FPL - $23 250 < 260% FPL - $34 260 < 270% FPL - $44 270 < 280% FPL - $55 280 < 290% FPL - $68 290 - 299.99% FPL - $82 300% FPL – $97.53 See Attachment 2, included at the end of Section 8

No cost sharing will be applied to unborn children.

8.3 Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42 CFR 457.505(b))

Outreach and application forms will include this information. Sections 2.2.1, 5.1, and 9.9 provide detailed descriptions of our outreach efforts. In addition, the State informs providers and members (beneficiaries) of allowable cost sharing amounts via Provider Updates and member Enrollment and Benefits booklet.

8.4 The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1  Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42 CFR 457.530) 8.4.2  No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42 CFR 457.520) 8.4.3  No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42 CFR 457.515(f))

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8.5 Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42 CFR 457.560(b) and 457.505(e))

As an interim process, we are notifying families in the Enrollment & Benefits booklet that the Department will monitor their cost sharing expenditures on a quarterly basis to identify any family with out of pocket premium and co-payment costs that exceeded 5% of their income and will issue a refund in the amount that co-payments exceeded their family limit.

Once our system enhancements our implemented, the CARES Notices of Decision will include a new section to inform the recipients of the maximum dollar amount that their families have to contribute as a share of the cost of the SCHIP/Medicaid benefits they are receiving. This maximum will be 5% of their countable income as calculated by CARES.

The Medicaid Management Information System (MMIS) will be used to track the cost sharing expenses and let providers know when copayments are to no longer be charged to the families.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost- sharing. (Section 2103(b)(3)(D)) (42 CFR 457.535)

The state ensures that American Indian and Alaska Native children, eligible for the separate SCHIP benefit, are excluded from cost-sharing by assigning them an eligibility code that identifies them as such. This identifying information is retained in the Medicaid Management Information System (e.g., claims processing and eligibility file) which automatically exempts all cost-sharing.

Providers are notified of this requirement via written Updates and through the various eligibility verification methods available in the state. Families identify their children as Alaskan Natives or American Indian Tribal members through the application process.

This provision of the Separate SCHIP does not apply as Native Americans or Alaskan Natives as neither group could be considered as undocumented aliens.(explain)

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8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42 CFR 457.570 and 457.505(c)) Premiums Each family is sent an invoice in the tenth day of the month prior to the month in which the premium is due. When a family does not pay their premium by the date required (the 10th of the month for which it is due), the family is sent a termination notice that indicates that they must pay the premium by the end of the calendar month or lose eligibility for those members for whom the premium is owed. If they pay by the end of the month, eligibility is not interrupted. If the family pays the premium by the end of the following month, their eligibility is restored without any gaps. However, if the family does not pay by the end of the month after the calendar month in which the premium was due, the individuals for whom the premium was owed cannot be restored to benefits until:

1. The end of the six month after which benefits were lost, so long as they pay the premium arrears or 12 months after benefits were lost without paying the premium arrears amount; 2. The beginning of the month following an adult caretaker’s absence from the home for 30 consecutive days; 3. The beginning of the month in which the family's income dips below the premium requirement limit of 200% of the Federal Poverty Level; or 4. Immediately, if the reason the premium payment was not made was beyond the control of the family.

Good cause reasons for not paying the BadgerCare Plus premium are: • Problems with the financial institution. • System problem. • Local agency problem. • Wage withholding problem. • Fair hearing decision.

Copayments Applies only to groups with incomes above 200% FPL, listed in Benchmark Plan: Providers are permitted to require the payment of any cost sharing as a condition for the provision of care, items, or services. In addition, providers are permitted to reduce or waive cost sharing on a case-by-case basis.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or

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similar fees prior to disenrollment. (42 CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42 CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42 CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42 CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42 CFR 457.220) 8.8.2

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42 CFR 457.224) (Previously 8.4.5) 8.8.3

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42 CFR 457.626(a)(1)) 8.8.4

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42 CFR 457.622(b)(5))

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Attachment 1 Co-payment Table Wisconsin SCHIP children with family income that does not exceed 200% FPL

Service/Item Co-payment Limitations/Cumulative Maximum Ambulance Services $2 for non-emergency trip only n/a Ambulatory Surgery Services $3 per surgery n/a Case Management Services No co-payment n/a Chiropractic Services $0 to $3 per procedure Co-payment obligation depends on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service:

Fee

Co-payment $10 or less…………………….$0.50 $10.01 to $25………………....$1.00 $25.01 to $50………………....$2.00 $50.01 or more…………….….$3.00

Clozapine Management No co-payment n/a Community Support Program No co-payment n/a

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Service/Item Co-payment Limitations/Cumulative Maximum Comprehensive Community Services (CCS) No co-payment n/a Crisis Intervention No co-payment n/a Dental Services $0.50 to $3 per service Co-payment obligation depends on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service:

Fee

Co-payment $10 or less…………………….$0.50 $10.01 to $25………………....$1.00 $25.01 to $50………………....$2.00 $50.01 or more…………….….$3.00

Disposable Medical Supplies $0.50 per item n/a Drugs Over-the-counter (OTC): $0.50 Generic:

$1.00 Brand name:

$3.00  Co-payment obligation limited to $12 per month, per member, per provider

 OTCs are excluded from this $12 per month maximum

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Service/Item Co-payment Limitations/Cumulative Maximum Durable Medical Equipment $0.50 to $3 per service  Co-payment amount is based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the item:

Fee

Co-payment $10 or less……………….…….$0.50 $10.01 to $25…………………..$1.00 $25.01 to $50………………......$2.00 $50.01 or more……………..….$3.00

 DME rental items are not subject to co-payment.

Family Planning Services and Supplies No co-payment n/a HealthCheck Screenings (EPSDT) for Children under age 21 years. $1 per screen Co-payment obligation is limited to members who are 18, 19, and 20 years old. Hearing Services $0.50 to $3 per procedure  Co-payment amount depends on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less……………………$0.50 $10.01 to $25………………...$1.00 $25.01 to $50………………...$2.00 $50.01 or more……………….$3.00

 No co-payment obligation for hearing aid batteries

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Service/Item Co-payment Limitations/Cumulative Maximum Home Health Services No co-payment n/a Hospice Services No co-payment n/a Hospital Services - Inpatient $3 per day Co-payment obligation limited to $75 per stay. Hospital Services - Outpatient $3 per visit Multiple visits to the same provider on the same day are treated as a single visit. Mental Health and Substance Abuse Outpatient Treatment $0.50 to $3 per visit  Visit co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less………………….…$0.50 $10.01 to $25………………....$1.00 $25.01 to $50…………….…...$2.00 $50.01 or more…………….….$3.00

 Co-payment obligation limited to the first 15 hours or $500 of services, whichever comes first, per calendar year.

 No co-payment for services provided in a hospital setting. Mental Health Day Treatment Services $0.50 per day Co-payment obligation limited to the first 15 hours or $500 of services, whichever comes first, per calendar year.

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Service/Item Co-payment Limitations/Cumulative Maximum Narcotic Treatment Services No co-payment n/a Nursing Home Services No co-payment n/a Personal Care Services No co-payment n/a Occupational Therapy $0.50 to $3 per procedure  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less…………….………$0.50 $10.01 to $25……….………...$1.00 $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00

• Co-payment obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year. Physical Therapy $.50 to $3 per procedure  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less…………….………$0.50 $10.01 to $25……….………...$1.00 $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00

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Service/Item Co-payment Limitations/Cumulative Maximum • Co-payment obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year.

Physician Services (including Nurse Midwife, Nurse Practitioner, Laboratory and Radiology services)

$0.50 to $3 per service, except allergy testing co-payment is applied per date of service  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less…………….………$0.50 $10.01 to $25……….………...$1.00 $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00

 The co-payment obligation for physician services is limited to $30 per member, per provider, per calendar year.

 There is no co-payment for anesthesia services.

Podiatry Services $.50 to $3 per visit  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less…………….………$0.50 $10.01 to $25……….………...$1.00 $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00

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Service/Item Co-payment Limitations/Cumulative Maximum • Limited to $30 per member, per provider, per calendar year

Private Duty Nursing No co-payment n/a Respiratory Care Services No co-payment n/a Specialized Medical Vehicle (SMV) Services $1 per trip n/a Speech and Language Pathology $0.50 to $3 per procedure  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less…………….………$0.50 $10.01 to $25……….………...$1.00 $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00

• Co-payment obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year. Vision Care Services $0.50 to $3 per service  Co-payment based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

Fee

Co-payment $10 or less…………….………$0.50 $10.01 to $25……….………...$1.00

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Service/Item Co-payment Limitations/Cumulative Maximum $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00

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Attachment 2 Co-payment Table Wisconsin SCHIP children with family income above 200% up to and including 300% FPL

Service/Item Co-payment Ambulance Services $50 per trip Ambulatory Surgery Services $15 per visit Chiropractic Services $15 per visit Dental Services 50% of allowable charges

(A $200 deductible applies to all services except preventive and diagnostic.) Disposable Medical Supplies $0.50 per item Drugs $5 per item Durable Medical Equipment $5 per item, except rentals Family Planning Services and Supplies No co-payment Health Screenings (EPSDT) for Children under age 21 years No co-payment Hearing Services $15 per procedure

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Service/Item Co-payment Home Health Services $15 per visit Hospice Services No co-payment Inpatient Hospital Services • $50 per stay for mental health and/or substance abuse treatment

• $100 per stay for medical stays Mental Health and Substance Abuse Outpatient Treatment $10 to $15 per visit for all outpatient services, except laboratory test, electroconvulsive therapy, and pharmacological management

Nursing Home Services No co-payment Occupational Therapy $15 per visit Outpatient Hospital Services • $15 per visit (multiple visits to the same provider in the same day will be treated as a single visit)

• $60 for emergency room visits (waived if admitted to hospital) Physical Therapy $15 per visit Physician/Clinic Services (including Nurse Practitioner, Nurse Midwife, Laboratory and Radiology services) $15 per visit , except for clozapine management, preventive medicine, and diagnostic services Podiatry Services $15 per visit

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Service/Item Co-payment Speech Therapy (ST) $15 per visit Vision Care Services $15 per visit

*The Benchmark Plan includes members with incomes over 200% of the federal poverty level, covered under Title XIX or Title XXI.

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Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1 Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42 CFR 457.710(b))

Wisconsin's BadgerCare Plus program will attempt to address four fundamental goals: 1) Increased access to coverage 2) Increased access to services 3) Improved health outcomes and quality of care 4) Improved delivery systems impacts

BadgerCare Plus Goals.

Access to coverage: Some families who join the workforce have access to affordable, employer-sponsored health care. For many others, however, access and affordability is an issue. Through a comprehensive, integrated program, BadgerCare Plus builds a bridge between Medicaid and employer-sponsored health care coverage, just as welfare reform has transformed the ties between welfare and work.

To preserve access to health care for low-income families and children, BadgerCare Plus recognizes that a majority of low-income families work, that current BadgerCare Plus and AFDC income standards required for Medicaid are significantly less than the minimum wage, and that health care is not always accessible or affordable through employment. Through strengthening the ability of both parents to be employed and to care for their children, BadgerCare Plus supports the transition to independence.

In addition, given the different and more generous standards for W-2 and the complexity and intricacies of former AFDC rules, many low-income families are no longer eligible for Medicaid based on prior AFDC standards or no longer understand that they may be eligible under obsolete, confusing AFDC standards.

Just as welfare reform is now experimenting with creative links between cash assistance and employment, BadgerCare Plus is an innovative and progressive model to effectively integrate Medicaid with employment-based health insurance. BadgerCare Plus builds upon the intent of Title XXI to accomplish this integration.

BadgerCare Plus will provide access to health care, without supplanting private insurance by incorporating the following mechanisms:

• Applicants who are covered under a health insurance plan as defined in HIPAA will not be eligible for BadgerCare Plus.

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• Applicants who have access to coverage under family health insurance subsidized by an employer at 80% or more of the premium cost will not be eligible for BadgerCare Plus. • Applicants who were covered during the six months prior to application under employer family health insurance plans meeting HIPPA standards for family coverage will be ineligible for BadgerCare Plus. However, exceptions will be made where prior coverage ended due to reasons unrelated to the availability of BadgerCare Plus. These reasons include, but are not limited to:

 Loss of employment due to factors other than voluntary termination;  Change to a new employer that does not offer family coverage;  Change of address so that the individual is now outside the employer- sponsored insurance plan’s service territory;  Discontinuation of health benefits to all employees by the applicant’s employer; and  Expiration of COBRA coverage period.

• The Department intends to purchase family coverage made available by the employer of members of an eligible family when the employer’s contribution is greater than 40% but less than 80%. This will only occur when the Department determines that purchasing the employer coverage would be more cost-effective than providing the coverage directly under BadgerCare Plus. The cost effectiveness will compare the cost to the State to buy in to the employer's plan versus the cost to directly provide coverage to the recipient. • The Wisconsin Medicaid fiscal agent will notify the applicant, employer, insurance company, if necessary and the involved certifying agency of the cost-effectiveness decision and terms of the agreement. • The Wisconsin Medicaid fiscal agent will establish a communication protocol with each employer regarding notification of the applicant’s employment, coverage levels and premium amounts. • The Wisconsin Medicaid fiscal agent will monitor employers’ health insurance plans for open enrollment periods and will conduct an employer telephone inquiry to obtain the necessary cost-effectiveness information to facilitate insurance buy-in when available. • The Wisconsin Medicaid fiscal agent will gather information regarding the applicant’s access to and/or participation in the employer’s health insurance plan beyond the previous six-month period for informational purposes only. EDS and Department staff will monitor this information for crowd-out impact.

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• The Wisconsin Medicaid fiscal agent will verify health insurance coverage through the existing insurance exchange process with insurance carriers and telephone inquiries. EDS currently electronically exchanges insurance information with 95% of the insurance carriers, by market share in the state.

If the verification shows that BadgerCare Plus family members are currently covered or were covered within the past six months by an insurance plan meeting HIPAA standards, or currently have access to such a plan, subsidized at 80% or more of the premium cost, eligibility for BadgerCare Plus ends.

If the verification shows that BadgerCare Plus family members have access to (but not coverage) employer family health insurance coverage subsidized at less than 80% of the premium cost, they continue to receive BadgerCare Plus benefits on a fee-for-service basis, pending qualification for the HIPP Program

Participating families with incomes at or above 150% FPL will be assessed a premium cost share of 5% of their monthly family income.

• The Department will limit eligibility to those families whose income does not exceed 185% FPL. Employer-subsidized health insurance is not common among families with incomes this low. • A provision of 1995 Wisconsin Act 289 required Wisconsin employers offering employee health insurance to include all employees. This was designed to prevent employers from offering a health insurance plan to only higher-compensated employees. • Wisconsin has legislation pending to create a small employer insurance pool.

While we believe the measures listed above will be sufficient to prevent crowd-out, implementation of BadgerCare Plus will be carefully monitored to assess any adverse impact BadgerCare Plus may create for both employee use of employer- subsidized coverage, and employer reductions in coverage for workers. Monitoring can be done using reports produced by the Department’s Center for Health Statistics. If it appears additional measures are needed, the state will investigate the following mechanisms as additional tools to use in preventing insurance crowd-out:

• Establishing limited entry/enrollment periods for BadgerCare Plus. This will encourage employees to purchase ongoing medical care through employer- subsidized insurance, rather than depending on BadgerCare Plus exclusively for episodes of ill health.

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• Enactment of insurance reforms to encourage coverage of all employees. The Department intends to continue working with employers and the state Office of the Commissioner of Insurance to encourage broad-based health coverage of all employees.

Access to services: Through BadgerCare Plus, the Department will integrate employer health care and Medicaid without supplanting private insurance. This will help to assure access to health care for all low-income families who do not have employer insurance. Access is balanced with personal responsibility through cost- sharing.

Health outcomes and quality of care: The major goal of BadgerCare Plus is to improve the health of Wisconsin’s low-income families with children by providing access to affordable health care for low-income families with children. We expect to improve health outcomes and reduce unnecessary and uncompensated health care costs by establishing a medical “home” for all low-income families and children, thereby strengthening health care prevention in the community.

To measure these health outcomes, we will use the same HEDIS measures as we do for the current AFDC-related/Healthy Start HMO program.

Wisconsin’s AFDC/HMO program currently provides financial incentives to participating HMOs that provide the targeted number of HealthCheck screens to enrolled eligible children. The AFDC/HMO contract and capitation rate provides additional funds to HMOs to meet targeted levels of screening equal to 80 percent of those eligible. Funds are recouped at the close of the contract year if the HMO does not meet the required target. The HMOs have the financial incentive to meet the screening targets and retain the HealthCheck funds. A HealthCheck screening requirement and financial incentive will be a requirement of HMOs serving the BadgerCare Plus population.

In addition, the Department is in the planning stages of establishing a series of performance-based contract measures designed to enhance quality of care and administrative efficiencies. The system will initially be limited to four or five measures that are attainable and consistent with established guidelines and standards. A bonus payment system is being planned for the 1999 contract year for the AFDC/Healthy Start HMO program and possibly for BadgerCare Plus HMO programs. This bonus system will provide financial incentives to HMOs that meet performance targets. HMOs that fall below minimum performance standards will not be eligible for the incentive payments.

We are currently considering linking HMO bonus payments to meeting new performance targets that address the health needs of women and children by

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assuring that HMOs provide PAP and STD screening and childhood immunizations at appropriate rates and intervals. If there is sufficient time to develop initiatives for BadgerCare in 1999, we will consider implementing performance standards in the year 2000.

Delivery systems impacts: As part of the BadgerCare Plus program, Wisconsin will make an effort to further streamline eligibility procedures. The BadgerCare program will build upon the success of the State's program of HMO enrollment for health care. BadgerCare Plus will provide Wisconsin Medicaid’s comprehensive benefits and services through a health care delivery system with strong quality assurance safeguards.

Currently, 14 licensed HMOs in Wisconsin participate in the Wisconsin Medicaid HMO program. Medicaid-certified HMOs will participate in all of the State’s 72 counties (fee-for-service remains in the two small, rural counties). With clear and measurable performance standards, and ongoing, continuous quality improvement activities, the Wisconsin Medicaid HMO program has demonstrated improved health outcomes. The Wisconsin Medicaid HMO contract for low-income families with children is frequently identified as one of the best in the nation.

BadgerCare Plus will prevent crowd-out of private insurance by buying employees into employer-based group health coverage when it is available and it is cost- effective to do so. In these situations, BadgerCare Plus will provide wraparound services to BadgerCare Plus recipients in employer health insurance plans up to the Medicaid benefit level, including any deductibles, coinsurance, and copayments that may be imposed on the employee by the employer's health insurance plan.

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9.2 Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42 CFR 457.710(c))

As described in response to question 9.1, BadgerCare Plus will promote the achievement of the following four goals:

1) Increasing access to coverage 2) Increasing access to services 3) Improved health outcomes and quality of care 4) Improved delivery systems impacts

Access to health care coverage. BadgerCare Plus will increase the number of insured Wisconsin residents, primarily children. BadgerCare Plus will increase the number of children insured by enrolling entire families. BadgerCare Plus will improve the outreach to and increase the enrollment of Medicaid-eligible children and adults.

BadgerCare will not cause crowd out. That is, persons who enroll in BadgerCare Plus will not drop other insurance coverage in order to participate in BadgerCare Plus. Employers will not change the coverage they offer in response to the availability of BadgerCare Plus.

We do not believe adverse selection will be an issue in the implementation of BadgerCare Plus. Disabled children will continue to be eligible for Medicaid through the State's categorical and medically needy provisions for SSI-related recipients. We believe enrollees in BadgerCare Plus will report that they are satisfied with the price they have to pay for coverage and the choice of coverage available to them.

Access to services. Wisconsin predicts that BadgerCare Plus will produce positive results relating to access to services. A greater share of BadgerCare Plus enrollees will have a primary care physician than the general public. Utilization of services patterns for BadgerCare Plus enrollees will be enhanced by linking recipients to a "medical home." BadgerCare Plus and Medicaid enrollees will report satisfaction with the simplified eligibility process. BadgerCare Plus enrollees will report that they are satisfied with their access to services as measured by criteria such as waiting times for appointments. Enrollees in BadgerCare Plus will be satisfied with their ability to get referrals to specialists. Pregnant women enrolled in BadgerCare Plus will have greater access to prenatal care services than a comparison population.

Health outcomes and quality of care. Wisconsin predicts that BadgerCare Plus will produce positive results relating to health outcomes and quality of care. BadgerCare Plus enrollees will self-report improved health status. BadgerCare Plus enrollees will utilize more preventive and primary care services than a comparison population. BadgerCare Plus enrollees will have greater continuity of care than a comparison

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population. BadgerCare Plus enrollees will have fewer preventable hospitalizations than a comparison population. Enrollees in BadgerCare Plus will report they are satisfied with the quality of care they receive.

Delivery system impacts. Wisconsin predicts that BadgerCare Plus will produce positive results relating to delivery system impacts. BadgerCare Plus will not result in employers reducing their health insurance benefit packages. Persons enrolling in BadgerCare Plus will not drop existing coverage to enroll in BadgerCare Plus. Enrollment in BadgerCare Plus will increase the likelihood of obtaining employment. Enrollment in BadgerCare Plus will reduce the likelihood that an enrollee will utilize welfare services. BadgerCare Plus will result in greater HMO capacity in Wisconsin. BadgerCare Plus will result in long-term savings for the Medicaid program.

9.3 Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42 CFR 457.710(d))

A table entitled "Timeframes and Specific Objectives/Goals for Phase 1 of BadgerCare" is included as Appendix B of this document. A summary of how performance under the plan will be measured follows.

Data Sources/Analysis Plan

The analysis plan uses a variety of approaches and multiple data sources. Some aspects of the analysis are much more difficult to quantify than others. While there is considerable existing data available, some analyses will require primary data collection through direct contact via a survey or other means. Some parts of the evaluation will require the development of a control or comparison group to determine program impact.

Baseline Data

The state will measure these types of outcomes and behavior from standard enrollment data available from the CARES system and utilization data reported by BadgerCare HMOs. BadgerCare HMOs will provide the state summary utilization survey data on key indicators (PAP tests, mammograms, immunizations, HealthChecks, mental health and substance abuse evaluations, emergency room visits, etc.) as well as complete utilization history for all BadgerCare recipients. In addition, beginning in the year 2000, BadgerCare HMOs will be required to submit complete encounter data for all their recipients. Access and utilization data for the general population is available in reports and databases produced and maintained by the Department's Office of Health

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Care Information, the Department's Center for Health Statistics, and the Wisconsin Office of the Commissioner of Insurance.

With this comprehensive utilization data available, the State will be able to analyze BadgerCare access and utilization data and compare it to traditional Medicaid populations and general populations. Wisconsin has been in the forefront of states in its ability to report health care utilization and status across Medicaid, commercial, and other public program populations, and to measure utilization rates and health status indicators against defined public goals such as the Wisconsin Public Health Agenda 2000.

The reporting and evaluation of BadgerCare will continue that tradition.

Subsequent data collection

The primary sources of data envisioned for this evaluation are as follows:

• Surveys - An enrollee satisfaction survey will be administered to obtain data to test a number of hypotheses. The survey will provide information on enrollees’ satisfaction with their choice of plan, the care they receive, the premium amounts, the accessibility of care and the quality of care. The survey will also be a basis for self-reported health status and health risk behavior data as well as utilization data. A stratified random sample of enrollees will be selected to ensure geographic and demographic representation. Consideration will be given to whether it will be necessary to conduct this survey at least twice, once as a baseline and at least once as follow-up. • Interviews - To obtain information on employers’ response to BadgerCare it will be necessary to contact employers through either a survey or an interview method or both. The favored approach will be to survey a sample of employers and, based on the survey results, select a small number for in-depth interviews. • HMO Histories - Enrollee and service specific data will be generated for all BadgerCare enrollees. These data will form the basis for special studies and auditing individual recipients. Quality of care and access issues will be addressed using these data as a sampling frame. The data received through the ongoing Medicaid Managed Care Quality Improvement Program will serve as the source for such data. • Special reports - Special ad hoc reports will be designed based on claims or aggregate HMO reporting. These reports can be used to monitor BadgerCare performance on various utilization and health status measures. Sentinel indicators will be identified and included in these reports.

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• Some special reports may be developed to monitor service utilization and outcomes for BadgerCare enrollees who have been bought into health insurance plans offered through their employers. In these cases, detailed utilization data may not be available in a feasible and cost-effective manner, so proxy measures may have to be developed. • Medical Records Audits - The current auditing of the Medicaid managed care program, performed by Department staff and contractors, will be expanded to encompass the BadgerCare program.

Control Group

A number of hypotheses suggest an evaluation design that requires a control group or a pre-post design. A suitable control group for many of the hypotheses will be Medicaid recipients either selected randomly or matched by characteristics to better mirror the BadgerCare enrollees. On other occasions a pre-post analysis will dictate that baseline information be collected and then replicated at a later date.

Other control groups may be some subset of the general insured population that may have health insurance with a less generous benefit package than BadgerCare.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1 The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2 The reduction in the percentage of uninsured children. 9.3.3 The increase in the percentage of children with a usual source of care. 9.3.4 The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5 HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6

Other child appropriate measurement set. List or describe the set used.

Please see attached "Addendum IV - Contract-Specified Reporting Requirements," from the January 1998 - December 1999 Contract for Medicaid services Between HMO and Wisconsin Department of Family Services."

The Wisconsin Medicaid Health Maintenance Organization (HMO) Reporting Documentation User Manual, January 1998, provides a correlation between the reports listed in Addendum IV and the strategic objectives and performance goals which we indicate that they address. A copy of the User Manual was included with our responses to HCFA's questions about Wisconsin's Phase 1 application.

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Data from the utilization survey requirement described in Addendum IV will provide indications of health care utilization in key preventive health areas within the HMOs. Important indicators we will use include the following: rates of HealthCheck (EPSDT) services, rates of PAP testing, rates of ambulatory follow-up for recipients discharged from a hospital with mental health or AODA diagnoses, rates of hospitalization for recipients with asthma, rates of primary care provider visits, and rates of preventive dental care.

9.3.7 If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1  Immunizations 9.3.7.2  Well child care 9.3.7.3  Adolescent well visits 9.3.7.4  Satisfaction with care 9.3.7.5  Mental health 9.3.7.6  Dental care 9.3.7.7  Other, please list: Please see response to # 9.3.6.

9.3.8 Performance measures for special targeted populations.

9.4

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42 CFR 457.720)

9.5

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the states plan for these annual assessments and reports. (Section 2107(b)(2)) (42 CFR 457.750)

The data sources and analysis plan described in the response to Question 9.3 will provide the information necessary to prepare these reports.

In addition, to obtain information about children without creditable coverage, we will rely on the Wisconsin Family Health Survey, which was discussed extensively in Section 2.1. As indicated in section 2.1, the survey was started in 1989 to collect information on the health status, health problems, health insurance coverage, and use of health care services among Wisconsin residents. The survey will create the baseline data on children without creditable coverage sufficient to provide the information requested in the table to Section 10.1.

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United States Census data will also be used to create the baseline information needed to evaluate the success of BadgerCare.

Further, the Department is creating a data warehouse. This warehouse will compile data from the CARES system and from Medicaid. This warehouse should be up and running by the year 2000.

9.6

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42 CFR 457.720)

9.7

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42 CFR 457.710(e))

9.8

The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42 CFR 457.135)

9.8.1

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4

Section 1132 (relating to periods within which claims must be filed)

9.9

Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42 CFR 457.120(a) and (b))

Public Process

1. Public Meetings and Hearings

Since the announcement of the BadgerCare Plus initiative in January, the State has worked diligently to inform Wisconsin citizens about the proposal as well as to seek input into its design. We have formed a BadgerCare Plus Advisors Group, conducted focus groups with current and potential members and with providers, and held town hall meetings across the state. This effort is described below in the following sections.

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The BadgerCare Plus Advisors Group is responsible for providing guidance and advice to the State on all policy and program design issues. The group has met eight times during the development of BadgerCare Plus to review and discuss recommendations from the internal Steering Committee and offer suggestions for improvements. Each of these two-hour sessions was a public meeting. The Advisors Group includes representatives from business, health plans, providers, public health, farmers, Native American tribes, the State Legislature, faith-based organizations, county government, children’s advocacy groups, and the University of Wisconsin. The Advisors Group includes:

Bevan Baker, City of Milwaukee Health Department Melissa Duffy, Wisconsin Federation of Cooperatives Donna Friedsam, University of Wisconsin Population Health Institute Sabrina Gentile, Wisconsin Farm Bureau Federation Representative Curt Gielow and Representative Jon Richards, Wisconsin State Assembly Michael Jacob, Covering Kids and Families—Wisconsin Nyree Kedrowski and Lori Pidgeon, Ho-Chunk Nation Ed Kamin, Kenosha County Department of Human Services Dr. John Meurer and Dr. Glenn Flores, Medical College of Wisconsin Senator Mark Miller and Senator Dan Kapanke, Wisconsin State Senate Father Thomas Mueller, St. Cyril and Methodist Orthodox Church, Milwaukee Paul Nannis, Aurora Health Care Jon Peacock, Wisconsin Council on Children and Families Bobby Peterson, Advocacy and Benefits Counseling (ABC) for Health, Inc. David Riemer, Wisconsin Health Project Bill Smith, National Federation of Independent Business Dr. Susan Turney, Wisconsin Medical Society Nancy Wenzel, Wisconsin Association of Health Plans

Wisconsin has also held eight focus group discussions to identify problems with current programs, suggest improvements, and provide feedback on concepts and strategies proposed for BadgerCare Plus. One group was composed of BadgerCare Plus and Medicaid providers from throughout Wisconsin. The remaining seven groups, with representatives from thirteen communities across the state, were composed of low-income families, both individuals currently enrolled in Family Medicaid, BadgerCare and Healthy Start, and parents without current health insurance coverage. Each focus group included 15-20 individuals and lasted an average of one and one-half hours. Each participant received a stipend of $20 to offset transportation and/or child care expenses.

The provider group included representatives from HMOs and physicians. Responses revealed that providers remain concerned about ‘no-shows,’ that

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reimbursement rates are too low, and that Medicaid patients are often difficult to treat due to their chaotic lives. A key theme among the group was the need for patients to have a primary care physician. A second theme was the need to help patients understand the importance of getting and staying healthy, and using incentives as one strategy for achieving this goal. The lack of access to dental care and mental health services was a third theme of the discussion.

Findings from the participant groups indicated a preference for submitting applications by mail or over the telephone; some individuals expressed appreciation for face-to-face appointments because it allows them an opportunity to ask questions and get immediate answers. As expected, key reasons for the lack of health insurance were high premiums and/or employers not offering insurance. When asked about their willingness to participate in smoking cessation or weight management programs, the majority of participants expressed an interest and suggested that State health programs partner with local gyms, the YWCA, or fitness centers to encourage individuals to use these benefits.

As noted earlier, each group acknowledged the importance of dental coverage and the continuing difficulty of finding a dentist who would accept their Medicaid card. One participant noted that in her community, individuals were placed on waiting lists for up to two years for routine dental care. Many participants said that access to dental care would not be an issue if they had private insurance.

Finally, several participants in each group felt that they were treated differently in health care settings than individuals with private insurance. Other findings include: satisfaction with Wisconsin’s existing programs, concern that single adults would not be included in BadgerCare Plus, and concern that increased co- payments would have a negative impact on their family. See Appendix E for specific focus group questions.

Wisconsin Executive Order #39, issued in February 2004, affirms the government-to-government relationship between the State of Wisconsin and the eleven American Indian tribal governments located within the State of Wisconsin. The “Department of Health and Family Services Policy on Consultation with Wisconsin’s Indian Tribes,” developed by consensus with the Wisconsin tribes, formalizes the tribal-state relationship. Wisconsin has sent an invitation to all Wisconsin tribes to participate on the BadgerCare Plus Advisors Group and two tribal representatives are participating.

Governor Doyle, Lieutenant Governor Barbara Lawton, and Secretary Helene Nelson hosted twenty town hall meetings across the state throughout the planning

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process to discuss the new program, gather comments about existing programs, and obtain input from interested parties. Each town hall meeting included current Medicaid/BadgerCare participants, health care providers, county staff, advocates, reporters, and others. BadgerCare Plus cards with the program’s e- mail address were distributed at each meeting and participants were encouraged to send written comments. Two or three e-mails are received daily via this site. The town hall meetings were developed in partnership with the Wisconsin Council on Children and Families and ABC for Health, Inc. The list of sites and presenters follows.

January 18th, 2006 Marshfield

Secretary Nelson January 19th, 2006 Rhinelander

Secretary Nelson January 20th, 2006 Baraboo

Secretary Nelson January 30th, 2006 Beloit

Secretary Nelson May 2nd, 2006 Green Bay

Secretary Nelson and Jason Helgerson June 14th, 2006 Wausau

Governor Doyle and Secretary Nelson June 21st, 2006 Racine

Governor Doyle and Jason Helgerson July 20th, 2006 Eau Claire

Governor Doyle and Secretary Nelson July 20th, 2006 Superior

Governor Doyle and Jason Helgerson July 24th, 2006 Beloit

Governor Doyle and Jason Helgerson July 25th, 2006 Prairie Du Chien

Governor Doyle and Secretary Nelson July 31st, 2006 Shawano

Lt. Governor Lawton August 1st, 2006 Jefferson

Secretary Nelson August 4th, 2006 Portage

Secretary Nelson August 8th, 2006 Oshkosh

Secretary Nelson August 14th, 2006 Milwaukee, Northside

Governor Doyle and Secretary Nelson August 15th, 2006 Madison

Lt. Governor Lawton and Secretary Nelson August 23rd, 2006 Ashland

Secretary Nelson August 24th, 2006 Antigo

Lt. Governor Lawton and Secretary Nelson September 5th, 2006 Milwaukee, Southside

Lt. Governor Lawton and Secretary Nelson

Since September 5th, 2006, Governor Doyle, Lieutenant Governor Lawton,

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Secretaries Nelson and Hayden and Jason Helgerson have conducted eight additional town hall meetings.

January 31st, 2007 Oshkosh March 8th, 2007 Green Bay March 22nd, 2007 Eau Claire April 5th, 2007 Verona April 13th, 2007 Kenosha April 16th, 2007 Wausau April 23rd, 2007 Racine April 23rd, 2007 Polk County May 3rd, 2007 La Crosse May 4th, 2007 Green Bay May 14th, 2007 Stevens Point June 20th, 2007 Waukesha

In addition to legislative participation on the BadgerCare Plus Advisors Group, several legislators participated in the town hall meetings. As development of the proposal continues, the Department will provide briefings for members of the Wisconsin State Legislature.

The Department has also arranged individual briefings for interested legislators and/or their staff and the Legislative leadership. Special outreach has been conducted for legislators on key committees, including the Joint Committee on Finance; Senate Committee on Health, Children, Families, Aging and Long Term Care; the Assembly Committee on Health; the Assembly Committee on Children and Families; and the Assembly Committee on Medicaid Reform.

2. Communication and Feedback Process for Public Meetings, Hearings, and Other Interested Parties, Including Written Comments/Response

The Department has had and will have a comprehensive set of procedures to communicate with various parties on our proposal for BadgerCare and to receive and discuss feedback on BadgerCare received from these parties.

• Feedback Process for Public Meetings, Hearings, and Other Interested Parties, Including Written Comments/Responses

In our meetings with various interested parties, and in our distribution of various written BadgerCare documents, we have solicited written

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questions, ideas, and concerns about BadgerCare from any interested parties.

In addition to input received at Town Hall meetings and at the BadgerCare Plus Advisors Group meetings described above, the Department has received many written questions and concerns about BadgerCare from various individuals and organizations. We have found these questions and concerns fruitful, in that they have helped Department staff focus on addressing various implications, permutations, and impacts of BadgerCare Plus that were not immediately apparent.

Throughout the course of BadgerCare development and implementation, we envision continued verbal and written feedback from interested parties, and will use question and answer documents and/or individual policy statements to respond.

3. Coordination of BadgerCare Plus with Native Americans

The Department has extensive experience working closely with Native Americans in developing and implementing State health programs. Appendix G to the waiver application detailed minutes of four meetings the Department attended with Wisconsin tribes on managed care and BadgerCare Plus during 1997.

For statewide Medicaid HMO implementation, Department staff met with tribal health directors over an 18-month period to coordinate HMO expansion with the needs of the tribes and with Indian Health Service responsibilities. A special disenrollment procedure was developed for tribal members that involves close coordination with Indian Health Clinics, tribal members, and the Medicaid HMO enrollment broker. A special payment system was developed so that non-HMO affiliated Indian Health Clinics could still be reimbursed by Medicaid FFS funds for services provided to tribal members enrolled in HMOs, so that Indian Health Service funds would not be jeopardized by the expansion of the HMO program.

The Department Secretary meets with tribal leaders at least every six months to discuss health care related issues. We use these meetings to solicit input and provide information to the tribes on BadgerCare Plus. In particular, tribes may be interested in buying into BadgerCare Plus on behalf of their tribal members who are subject to cost sharing. Department staff is also included in a monthly work group with tribal health directors to focus on health care issues identified by the tribal leaders and the Department Secretary in their semi-annual meetings.

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Department staff attends regular meetings with the Great Lakes Inter-Tribal Council, Inc. (GLITC Inc.) and individual tribal health clinics to discuss various aspects of BadgerCare and its impact on the Indian Health Service. In addition, staff attends regular meetings of the Council on American Indian Health and the soon to be established Wisconsin American Indian Forum. The forum, as its predecessor the Council, will meet monthly to explore a wider range of issues including social service issues.

The Department plans to extend the current special procedures for Native Americans that we have in the Medicaid managed care program to the BadgerCare program. Additional special procedures might also be required for Native Americans in BadgerCare. Our goal is to assure that BadgerCare is coordinated with Indian Health Service benefits and funding sources so that IHS benefits and funds are used most effectively for those Native Americans that do not have alternative sources of health care.

4. BadgerCare Public Notices

Providers and recipients will be informed of the BadgerCare Plus initiative in December 2007 and January 2008 through member updates and provider updates.

The state law language changes were included in Wisconsin’s 2007-2009 Biennial Budget, 2007 Wisconsin Act 20, to authorize the BadgerCare Plus program. Public notice for all laws, as part of enactment, is announced in the state’s largest newspaper, Milwaukee Journal-Sentinel. 2007 Wisconsin Act 20 was published on public notice provided on October 26, 2007.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42 CFR 457.120(c))

Please see paragraph 3. in the previous response, to Question # 9.9.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

The cost sharing changes in this plan amendment were part of the BadgerCare Plus program which was created by 2007 Wisconsin Act 20. Public notice procedures were part of the legislative process. Legislative committee meetings, including those in which bill hearings are conducted,

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must comply with the Wisconsin open meetings law. This law generally requires that notice be given at least 24 hours prior to the meeting of a governmental body. In addition, once a bill is enacted, the secretary of state publishes a notice of enactment in the official state newspaper. The law was enacted on October 26, 2007, and was published that same date.

9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42 CFR 457.140)

• Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.

• Projected sources of non-Federal plan expenditures, including any requirements for cost- sharing by enrollees.

A budget entitled "SCHIP Budget Plan FFY 09” is attached.

Wisconsin's state match for the population identified in the SCHIP State plan is provided through State General Purpose Revenue (state tax dollars). Funds for Federal Fiscal Year 08 were appropriated in the State’s 2007-2009 Biennial Budget Legislation (2007 Wisconsin Act 20) and the 2009-2011 Biennial Budget Legislation (2009 Wisconsin Act 28). These funds are authorized through s. 20.435 (4)(b), Wis. Stats., which allows payment for the recipients who are eligible under s. 49.471(4), Wis. Stats.

In addition, premium revenue is collected from members and offsets state and federal costs for the SCHIP program. Co-pay revenues are not directly collected from members to offset state and federal costs for the SCHIP program. However, rates paid to providers are reduced for co-pay amounts, therefore indirectly reducing costs for SCHIP.

All PMPMs reported are the average statewide capitation rates for these recipient groups and are net of premiums.

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SCHIP Budget for New Populations

Note: Estimated costs are shown for July 2008 - September 2009 since costs before

Oct. 2008 will be claimed as a prior period adjustment in FFY 09.

COST PROJECTIONS FFY09 FFY 2009 Costs

Enhanced FMAP Rate 71.57%

Population #1 (children between 250% to 300% FPL)

Gross Insurance Payments $8,139,620.97

Gross per member/per month rate @ 70,927 member months (July 08 - September 09) $114.76

Gross Benefit Costs Subtotal for Population #1 $8,139,620.97

Net Benefit Costs (net of cost share) Subtotal for Population #1 $7,075,715.97

Population #2 (Unborn Children of Pregnant Immigrants 250% to 300% FPL)

Insurance Payments $25,614.05

per member/per month rate@ 97 member months (July 08 - September 09) $264.06

Benefit Costs Subtotal for Population #2 (no cost share applies) $25,614.05

Total Benefit Costs $8,165,235.02

Net Benefit Costs (Total Benefit Costs - Offsetting Beneficiary Cost Sharing Payments) $7,101,330.02

Administration Costs

Personnel** $11,726.29

General administration - Eligibility Administration** $770,963.12

Contractors/Brokers (e.g., enrollment contractors)

Claims Processing

Outreach/marketing costs** $1,707.84

Other - Prenatal Care Coordination** $4,639.41

Total Administration Costs $789,036.67

10% Administrative Cap (net benefit costs ÷ 9) $789,036.67

Federal Share (multiplied by enh-FMAP rate) $5,647,135

State Share $2,243,231

TOTAL PROGRAM COSTS $7,890,366.69

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Total SCHIP Budget for FFY 09

Notes: 1) Estimated costs for new populations are shown for July 2008 - September 2009 since

costs before Oct. 2008 will be claimed as a prior period adjustment in FFY 09.

2) Population #2 includes a reversal of a prior period adjustment for services provided in

previous federal fiscal years, artificially increasing the PMPM for this population.

COST PROJECTIONS FFY09 FFY 2009 Costs

Enhanced FMAP Rate 71.57%

Population #1 (Separate SCHIP Children)

Gross Insurance Payments $50,084,500

gross per member/per month rate @ 426,228 member months $117.51

Gross Benefit Costs Subtotal for Population #1 $50,084,500

Net Benefit Costs (net of cost share) Subtotal for Population #1 $43,691,048

Population #2 (Unborn Children of Pregnant Immigrants)

Insurance Payments $25,156,665

per member/per month rate@ 28,091 member months $895.54

Benefit Costs Subtotal for Population #2 (no cost share applies) $25,156,665

Population #3 (MCHIP Children)

Insurance Payments $59,214,100

per member/per month rate@ 525,406 member months $112.70

Benefit Costs Subtotal for Population #3 (no cost share applies) $59,214,100

Total Benefit Costs $134,455,265

Net Benefit Costs (Total Benefit Costs - Offsetting Beneficiary Cost Sharing Payments) $128,061,813

Administration Costs

Personnel $211,466

General administration - Eligibility Administration $13,903,171

Contractors/Brokers (e.g., enrollment contractors)

Claims Processing

Outreach/marketing costs $30,798

Other - Prenatal Care Coordination $83,665

Total Administration Costs $14,229,100

10% Administrative Cap (net benefit costs ÷ 9) $14,229,100

Federal Share (multiplied by enh-FMAP rate) $101,837,606

State Share $40,453,307

TOTAL PROGRAM COSTS $142,290,913

WISCONSIN

Effective Date:

Approval Date: 75

Section 10. Annual Reports and Evaluations (Section 2108)

10.1 Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42 CFR 457.750) 10.1.1

The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and 10.2

The state assures it will comply with future reporting requirements as they are developed. (42 CFR 457.710(e)) 10.3

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

WISCONSIN

Effective Date:

Approval Date: 76

Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the states Medicaid plan, and continue to Section 12. 11.1

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42 CFR 457.940(b)) 11.2 The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42 CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2

Section 1124 (relating to disclosure of ownership and related information) 11.2.3

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4

Section 1128A (relating to civil monetary penalties) 11.2.5

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6

Section 1128E (relating to the National health care fraud and abuse data collection program)

WISCONSIN

Effective Date:

Approval Date: 77

Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

The review process for eligibility and enrollment matters is the same as the Medicaid Fair Hearing process.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

The review process for health service matters is the same as the Medicaid Fair Hearing process.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each re-determination of eligibility.

N/A

WISCONSIN

Effective Date:

Approval Date: 78

Attachment 3 Wisconsin Description of the Amount, Duration and Scope of Services Covered Section 6.2

The following chart shows the amount, duration and scope of covered benefits provided to members of the Standard and Benchmark Plans. Members with income at or below 200% of the FPL receive the Standard Plan benefits, and members with income above 200% FPL receive the Benchmark Plan benefits.

BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan

Case Management Services Limited to case management provided by public entities or AIDS service organizations. No coverage.

Chiropractic Services Full coverage Full coverage

Dental Services Full coverage Limited coverage of preventive, diagnostic, simple restorative, periodontics, and extractions for pregnant women and children

Coverage limited to $750 per enrollment year.

Disposable Medical Supplies (DMS) Full coverage Coverage of syringes, diabetic pens and DMS that is required with the use of a durable medical equipment (DME) item.

Drugs Comprehensive drug benefit with coverage of generic and brand name prescription drugs, and some over-the-counter (OTC) drugs Generic drug-only formulary with a few generic OTC drugs

Members will be automatically enrolled in the Badger Rx Gold plan. This is a separate program administered by Navitus, which provides for a discount on the cost of drugs.

Durable Medical Equipment (DME) Full coverage Full coverage up to $2,500 per enrollment year

Health Screenings for Children Full coverage of HealthCheck screenings and other services for individuals under age 21 years Full coverage of HealthCheck screenings

HealthCheck “Other” services and Interperiodic services for individuals under age 21 years are not covered.

WISCONSIN

Effective Date:

Approval Date: 79

BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan

Hearing Services Full coverage Limited coverage of services provided by an audiologist.

Hearing aids, hearing aid batteries, cochlear implants and bone-anchored hearing devices are not covered.

Home Care Services (Home Health, Private Duty Nursing and Personal Care) Full coverage of private duty nursing, home health services, and personal care Full coverage of home health services Coverage limited to 60 visits per enrollment year.

Private duty nursing and personal care are not covered.

Hospice Services Full coverage Full coverage, up to 360 days per lifetime

Inpatient Hospital Services Full coverage Full coverage, with the following dollar amount limits per enrollment year:

- $6,300 for stays in a general acute care hospital for substance abuse - $7,000 for stays in an IMD (Institutes for Mental Disease) for substance abuse treatment

Hospital stays for mental health and substance abuse services have a 30-day limit

Mental Health and Substance Abuse Treatment* Full coverage (not including room and board) Coverage of this service is based on the Wisconsin State Employee Health Plan.

Covered services include outpatient mental health, outpatient substance abuse (including narcotic treatment), mental health day treatment for adults, substance abuse day treatment for adults and children, and child/adolescent mental health day treatment and inpatient hospital stays for mental health and substance abuse.

Services not covered are crisis intervention, community support program (CSP), Comprehensive Community Services

WISCONSIN

Effective Date:

Approval Date: 80

BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan

(CCS), outpatient services in the home and community for adults, and substance abuse residential treatment.

Mental health services have no dollar maximums.

Substance abuse services are limited to $7,000. Costs of mental health services, including inpatient stays, apply to this overall limit. Also, there are separate dollar limits for specific substance abuse services: - $4,500 for outpatient substance abuse services including $2,700 for outpatient services (including narcotic treatment) for substance abuse day treatment. - $6,300 for inpatient hospital stays in a general acute care hospital.

Nursing Home Services Full coverage Full coverage for stays at skilled nursing homes limited to 30 days per enrollment year.

Outpatient Hospital – Emergency Room Full coverage

Full coverage

Outpatient Hospital Services Full coverage Full coverage

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) Full coverage Full coverage, limited to 20 visits per therapy discipline per enrollment year

Also covers up to 36 visits per enrollment year for cardiac rehabilitation provided by a physical therapist. (The cardiac rehabilitation visits do not count towards the 20 PT visits.)

Physician Services Full coverage, including laboratory and radiology Full coverage, including laboratory and radiology

Podiatry Services Full Coverage Full coverage

WISCONSIN

Effective Date:

Approval Date: 81

BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan

Prenatal /Maternity Care Full coverage, including prenatal care coordination, and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems Full coverage, including prenatal care coordination, and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems

Reproductive Health Services Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization

Routine Vision Full coverage including coverage of eyeglasses One eye exam every year, with refraction

Smoking Cessation Services Coverage includes prescription and OTC tobacco cessation products. Coverage includes prescription generic and OTC tobacco cessation products.

Transportation – Ambulance, Specialized Medical Vehicle (SMV), Common Carrier Full coverage of emergency and non-emergency transportation to and from a certified provider for a BadgerCare Plus covered service. Coverage limited to emergency transportation by ambulance.

WISCONSIN

Effective Date:

Approval Date: 82

_____________________________________________________________________________ Table of Contents State/Territory Name: Wisconsin State Plan Amendments (SPA) #: WI-13-0030 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Wisconsin consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES ~

Children and Adults Health Programs Group

Shawn Smith mo

CHIP Director OCT 23 2013 Division of Health Care Access and Accountability

1 Wilson Street, Room 365

P.O. Box 309

Madison, WI 53701-0309

Dear Mr. Smith:

I am pleased to inform you that your Title XX1 Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number WI-13-029, submitted on September 20, 2013, and SPA number WI-13-0030 submitted on September 6, 2013, both of which are related to Modified Adjusted Gross Income (MAGD Eligibility, have been approved with an effective date of January 1, 2014.

Title XXI Medicaid Expansion:

SPA number WI-13-029 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI) equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Establish 2101() Group:

SPA number WI-13-0030 provides coverage in a separate CHIP, as specified in the state's submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached and should be incorporated within a separate subsection under Section 4.1 of Maine's approved CHIP state plan.

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment. Ms. Jordan’s contact information is as follows:

Page 2- Mr. Shawn Smith Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-3413 Facsimile: (410) 786-5882 E-mail: Joyce. Jordan@ cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Verlon Johnson, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region V, Division of Medicaid and Children's Health Operations. Ms. Johnson's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations Office of the Regional Administrator 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601 If you have additional questions, please contact Ms. Linda Nablo, Director, Division of Children's Health Insurance Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. Enclosures Sincerely, Eliot Fishman Director cc: Verlon Johnson, ARA, CMS Region V

Children's Health Insurance Program Eligibility

Control Panel

General

Information File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Wisconsin

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and OOOO = a four digit number

with leading zeros. The dashes must also be entered. [13-0030 |

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion ¥ Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date

(n/a yyy)

Federal Statute/ Regulation Citation

[Section 2101(f) of the Social Security Act

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:121 out of 2000

Establishes a new coverage group for children who lose Medicaid eligibility as a result of discontinuation of disregards.

Signature of State Agency Official

Submitted By: Alfred Matano

Last Revision Sep 20, 2013 Date:

Submit Date: Sep 6, 2013

BACK CONTINUE »/

coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[H Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

Cc The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(4) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage ina separate CHIP (expected to be no later than April 1, 2016 ).

@

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods. .

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

@ Other,

The state will identify children protected by Section 2101(f) and enroll such children in a separate CHIP based on the following methodology and procedures as approved by CMS.

Any child who is eligible for Medicaid at the time they are transitioned to a MAGI-based Medicaid determination, and who subsequently loses Medicaid eligibility in the transition due to excess income, will be put into the extension if the household had been paying any amount of child support prior to the transition.

Describe the benefits provided to this population:

OCT 23 2013

SPA # WI-13-0030 Approval Date: Effective Date: January 1, 2014 Page | of 2

cMs. CHIP Eligibility

@ This population will be provided the same benefits as are provided to children in the state's Medicaid program. C This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

C Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

@ Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

Are Premiums required? ho | Are copayments or other cost sharing required?

Describe ather cost sharing:

Copayments will be the same as for children in the Medicaid program.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

OCT 23 2013

SPA # WI-13-0030 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Wisconsin

State Plan Amendment (SPA) #: WI-13-0031

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Wisconsin consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CM 4 7500 Security Boulevard, Mail Stop: S2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 2 6 2014

Shawn Smith, CHIP Director

Division of Health Care Access and Accountability 1 Wilson Street, Room 365

P.O. Box 309

Madison, WI 53701-0309

Dear Ms. Smith:

I am pleased to inform you that Wisconsin’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), WI-13-0031, submitted on September 6, 2013, has been approved.

This SPA incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Wisconsin’s CHIP State Plan, in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. The state allowed the Federally Facilitated Marketplace (FFM) to determine CHIP eligibility from October 1, 2013, to December 31, 2013. Effective January 18, 2014, the state elected to change their status and allow the FFM to assess CHIP eligibility.

Until December 31, 2014, the state is using interim paper and online alternative single streamlined applications; both applications provide the option to apply for multiple human services programs. On or before December 31, 2014, the state will implement revised alternative single streamlined paper and online applications that address CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of Wisconsin’s approved CHIP state plan:

e C824 Attachment 1 — Statement related to coordination of eligibility and enrollment

e Attachment 2— Statement of use with respect to the alternative single, streamlined online application

e Attachment 3 — Statement of use with respect to the alternative single, streamlined paper application

This approval and the attachments supercede the following sections of the current CHIP State Plan:

Page 2 — Ms. Shawn Smith

e Section 4.3: Single, Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Ms. Kathleen Cuneo. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Cuneo’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: $2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

E-mail: Kathleen.Cuneo@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Cuneo and to Ms. Verlon Johnson, Associate Regional Administrator (ARA) in our Chicago Regional Office. Ms. Johnson’s address is:

Ms. Verlon Johnson

Office of the Regional Administrator 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601

If you have additional questions, please contact Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920.

We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure cc:

Ms. Verlon Johnson, ARA, CMS Region V, Chicago

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: S2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAILY & CHIP SERVICES

Children and Adults Health Programs Group

MAR 2 6 2014

Shawn Smith, CHIP Director

Division of Health Care Access and Accountability 1 Wilson Street, Room 365

P.O. Box 309

Madison, WI 53701-0309

RE: CS24 — Eligibility Process State Plan Amendment (SPA), WI-13-0031 Dear Ms. Smith:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of CHIP State Plan Amendment (SPA) Transmittal Number WI-13-0031, which was submitted to CMS on September 6, 2013. Our review of this submission included a review of the alternative single streamlined paper and online applications developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act. Both applications provide the option to apply for health coverage only or to apply for multiple human services programs.

Until December 31, 2014, the state is using interim alternative single streamlined paper and online applications. These interim applications need to be revised to reflect the following changes:

The following questions will not appear on applications for health coverage only where the applicant has not indicated that he or she is aged, blind, or disabled:

© Questions about absent parents, beyond an agreement to cooperate with child support (paper and online applications) December 31, 2014

Page 2 — Ms. Shawn: Smith

Questions about non-MAGI income types such as SSI and Child

Support (Receipt of SSI may be asked about as a non-MAGI May1, 2014 screening question, but as below, that would only be for applicants, unlike other income questions) (paper and online applications)

© Question about “support payments or obligations” (online May 1, 2014 application)

© Question about City/State/Country of birth (paper application) May 1, 2014

e Has paternity been established? (paper application) December 31, 2014

In the online application, the following questions will not appear for household members not seeking any benefits, and in the paper application, these questions will be designated for applicants only:

The non-MAGI screening questions related to disability, blindness and long term care need.

Mayl, 2014

Questions related to residency information.

December 31, 2014

All citizenship and immigration questions, including request for Alien Registration Number.

December 31, 2014

Applicants will have the opportunity to identify themselves as American Indians and Alaska Natives for purposes of cost-sharing protections, and identify American Indian and:Alaska Native income not countable for Medicaid and CHIP income determinations.

May 1, 2014

Page 3 — Ms. Shawn Smith

The state will integrate questions for Medicaid, CHIP and APTC into a December 31, 2014 single application. (This includes questions related to employer sponsored health coverage and annual income. For the online application, the system should use the income and household attestation to trigger additional questions based on the program for which the applicant appears eligible.)

Please submit the revised alternative paper and online applications to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerely,

Barbara K. Richards Acting Director Division of State Coverage Programs

ce: Ms. Verlon Johnson, ARA, CMS Region V, Chicago

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility WI.0290.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Wisconsin State Funds: $ Federal Funds: $ Submitted By: Alfred Matano Last Revision Date: Jun 6, 2014 Submit Date: Sep 6, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. 13-0031 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:77 out of 2000 Describes the eligibility process, including single, streamlined application. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER: STATE:

WI-13-0031 Wisconsin

Notwithstanding the final checked statement on page two, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into amemorandum of agreement with the Federally-facilitated Marketplace before April 1, 2014. At such time the agreement is signed, it will be incorporated by reference into this attachment

FORM HCFA-179 (07-92)

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

[lPaper Application OOnline Application

TRANSMITTAL NUMBER: STATE:

WI-13-0031 Wisconsin

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application [X] Online Application TRANSMITTAL NUMBER: STATE: WI-13-0031 Wisconsin

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

oO The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

wz The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means. The agency accepts applications in the following other electronic means. (C1) Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

a income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

rl Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

a Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

SPA# WI-13-0031 Approval pat MAR 2 6 2014 Effective Date: October 1, 2013

Page 1 of 2

CcmMs. CHIP Eligibility

im Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single stream lined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced INo premium tax credits in accordance with section 1943(b)(2) of the SSA.

Redetermination Processing

Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[Mi Once every 12 months.

a Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

Ifthe agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional

[lf information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering x insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

Check all types of agencies that apply:

K] The Exchange

(1 Medicaid

(C1) Other agency administering insurance affordability programs

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the 4) requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

MAR 26 2014

SPA# WI-13-0031 Approval Date: Effective Date: October 1, 2013

Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Wisconsin State Plan Amendments (SPA) #: WI-13-0032 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Wisconsin consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES ‘CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

NOV 2 2 2016

Ms. Rebecca McAtee

Acting State CHIP Director

Division of Health Care Access and Accountability 1 Wilson Street, Room 365

P.O. Box 309

Madison, WI 53701-0309

Dear Ms. McAtee:

The Centers for Medicare & Medicaid Services (CMS) has approved Wisconsin’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA) WI-13-0032-MC5 submitted on September 6, 2013. This SPA relates to Modified Adjusted Gross Income (MAGI) eligibility. CMS issued a Request for Additional Information (RAI) on November 27, 2013. CMS received additional information from the state on February 8, 2014, July 18, 2015 and September 16, 2016. CMS received Wisconsin’s official response to our RAI on November 22, 2016.

SPA number WI-13-0032-MCS is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; substitution of coverage; non-payment of premiums and other eligibility standards. The CS18 has an effective date of July 1, 2013. The CS17, CS19 and C821 have an effective date of January 1, 2014. The CS20 has an effective date of July 1, 2015. Copies of the approved state plan pages are attached and these approved pages supersede sections of Wisconsin’s current state plan as laid out below:

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1

Number

CS20: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage

CS21: Non-Payment of Premiums Section 8.7

Your title XXI project officer is Mr. Patrick Edwards. He is available to answer questions concerning these amendments and other CHIP-related issues. Mr. Edwards’ contact information is as follows:

Page 2 - Ms. Rebecca McAtee Centers for Medi.care & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-0l -15 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-6643 Facsimile: (410) 786-5882 E-mail: Patrick.Edwards@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Mr. Edwards and to Ms. Ruth Hughes, Associate Regional Administrator (ARA) in our Chicago Regional Office. Ms. Hughes' address is: Centers for Medicare & Medicaid Services Division ofMedicaid and Children's Health Operations 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 If you have additional questions or concerns, please contact Ms. Amy Lutzky, Acting Director, Division of State Coverage Programs, at ( 410) 786-0721. We look forward to continuing to work with you and your staff. Enclosures cc: s{JllJ Arine Marie Costello Director Ms. Ruth Hughes, ARA, CMS Region V, Chicago

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance

Program Eligibility

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Wisconsin

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last twa digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. [13-0032

Type of SPA: “| MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing ¥ Non-Financial Eligibility

Proposed Effective Date

(mm/ 8a yyy)

Federal Statute/ Regulation Citation

[42 CFR 457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count: 99 out of 2000

Incorporates CMS forms relating to Substitution of Coverage and Other Eligibility Standards to CMS.

Signature of State Agency Official

Submitted By: Alfred Matano

Last Revision Nov 23, 2016 Date:

Submit Date: Sep 6, 2013

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

rl A non-institutionalized child, if capable of indicating intent and who is emancipated or married. if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

im An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[m] A child who is a ward of the state regardless of where the child lives, or

im A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [m] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

im An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

rl An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

im A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

NOV 2 2 2016 SPA WI-13-0032-MC5 Approval Date: Effective Date: January 1, 2014 Page | of 2

ATOR ION METAR SAECO

MSs CHIP Eligibility |

One or more interstate agreement(s). No

»

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. [f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA WI-13-0032-MC5 Approval Date:. NOV 2 2 2016 Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility |

OMB Control Number: 0938-1148 Expiration dat 31/2014

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[M] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §$1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. $1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status. during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date Yes earlier than the date the notice is received by the individual. “

The date benefits are furnished is: © The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

@ Other date, as described:

Benefits are furnished to applicants as of the date the agency determines they are otherwise eligible and are only pending for verification of citizenship and identity. This date can be any time within the normal application processing time frame.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19. lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). “s

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

SPA WI-13-0032-MC5 Approval Date: NOV a 2 2016 Effective Date:.July 1, 2013 Page | of 3

CHIP Eligibility

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

a An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

{™] An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)\{17));

3. A non-citizen who has been paroled into the United States in accordance, with 8 U.S.C.1182(d)(5) for less than | year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c):

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President: (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.123 1.or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

NOV 22 2016

SPA WI-13-0032-MC5 Approval Date: Effective Date: July 1, 2013 Page 2 of 3

CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not

be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA WI-13-0032-MC5 Approval Date: NOV 22 2016 Effective Date: July 1, 2013 Page 3 of 3

CHIP Eligibility

. OMB Control Number: 0938-1148 . Expiration date: 10/31/2014

nan arR

42 CFR 457.340(b)

Social Security Number

As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s). with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[M] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their SSN.

When requesting an SSN for non-applicant household members, the state assures that:

es

At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used: and

im

im The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA WI-13-0032-MC5 Approval Date: NOV 2 2 2016 Effective Date: January 1, 2014 Page ! of 2

CHIP Eligibility |

«

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. .

NOV SPA WI-13-0032-MC5 Approval Date: 2 2 2016 Effective Date: January 1, 2014

Page 2 of 2

cms CHIP Eligibility .

AMNION AAEOOCANTE RIOR

State Name:| Wisconsin OMB Control Number: 0938-1148

Transmittal Number: WI - 13 - 0032 Expiration date: 10/31/2014

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[®] Substitution of coverage prevention strategy:

Name of policy Description

are

Access to employer-sponsored health | For unborn children and children to be eligible under Separate CHIP:

May not have access to a State employee’s health benefits plan or to an employer’s group or employer's individual health insurance plan unless exempt.

Exemptions:

-If the available insurance is through a person who is not a member of the child’s household or the employer contributes less than 80 percent of the premium cost (This reason does not apply to State employee’s health benefits plan.),

-The insurance only covers services provided in a service area that is beyond a reasonable driving distance from the individual's residence,

-The individual through whom the insurance was available lost their job with the employer providing that insurance,

-The employer discontinued health plan coverage for all employees, .

-At the time the individual failed to enroll in the employer's health insurance coverage, one or more members of the 'individual’s family were covered through:

e A private health insurance policy or Medicaid, and @ No one in the family was covered through CHIP.

-Any other reason determined by the Wisconsin Department of

Health Services as a good cause reason.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state elects to offer dental only supplemental coverage, the following assurances apply:

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

([] The waiting period does not apply to children eligible for dental only supplemental coverage.

NOV 2 2 2016

SPA WI-13-0032-MC5 Approval Date: Effective Date:-July 1, 2015 Page | of 2

CHIP Eligibility |

_. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

NOV 22 2016

SPA WI-13-0032-MC5 Approval Date: Effective Date: July 1, 2015

Page 2 of 2

OMB Control Number: 0938-1148 xpiration date: 10/31/2014 =

42 CFR 457.570 ,

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? ° Yes

Please describe the lock-out period:

Once eligibility is terminated due to non-payment of premiums, the person is then locked out for the next 90 days unless all arrears owed during the lock-out period are paid in full.

What is the length of the time premium lock-out period? Select a length of time:

© One month

© Two months

@ 90 days

© Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

EX] Individual's income decreased to a level where no premium is required or within Medicaid standards

(O Other financial hardship (2) Other

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will-be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement

SPA WI-13-0032-MC5 Approval Date:, NOV 2 2 2016 Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility .

«

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA WI-13-0032-MC5 Approval Date: NOV 2 2 2016 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Wisconsin State Plan Amendments (SPA) #: WI-19-0004-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group clt/ts cENffls roß Mt[IcAtf & Mf,IIcAtD SEtVtCt$ cENrEn roR MEOTC¡D & Cfltp SERVtCÉS sEP l 0 20t9 Rebecca McAtee CHIP Director 1 West Wilson Street, Room 365 P.O. Box 309 Madison, WI 53701-0309 Dear Ms. McAtee: Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SpA) number V/I-19-0004-CHIP, submitted on March 26,2019, with an effective date of July l,20lg, has been approved. This SPA permits Wisconsin to implement a health services initiative (HSI) to provide lead abatement services in the homes of low-income children and pregnant women. Section 2105(a)(1)(DXii) of the Social Security Act (the Act) and 42 CFR $457.10 authorize use of title XXI administrative funding for expenditures for health services initiatives (HSI) under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR ç457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding. The state shall ensure that the remaining title XXI funding, within the state's l0 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year. The state shall also report at a minimum quarterly to CMS any metrics regarding the implementation of the HSI as agreed to by the state and CMS. Your title XXI project officer is Ms. Dietrich Graham. She is available to answer questions conceming this amendment and other CHlP-related issues. Ms. Graham's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 233 North Michigan Avenue, Suite 600 Chicago,IL 60601 Telephone : (312) 353-9355 E-mail : Dietrich.Graham@cms.hhs. gov

Page 2 - Ms. Rebecca McAtee Official communications regarding program matters should be sent simultaneously to Ms. Graham and to Ms. Ruth Hughes, Deputy Director in our Medicaid Field Operations North Division. Ms. Hughes' address is: Centers for Medicare & Medicaid Services Medicaid Field Operations North Division 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at ( 410) 786-0721. We look forward to continuing to work with you and your staff. cc: Anne Marie Costello Director Ms. Ruth Hughes, Deputy Director, Medicaid Field Operations North Division /signed Anne Marie Costello/

WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN'S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Wisconsin

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (41 CFR, 457.40(b))

______________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children's Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c))

Name: Andrea Palm

Position/Title: Secretary, Department of Health Services Name: Jim Jones

Position/Title: Wisconsin State Medicaid Director Name: Rebecca McAtee

Position/Title: Wisconsin SCHIP Director

* Disclosure: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938 0707. The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CHIP Plan State: Wisconsin Page 2 WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Table of Contents Table of Contents .............................................................................................................................2 Section 1. General Description and Purpose of the Children's Health Plans and the Requirements ...........................................................................................................2 Section 2. General Background and Description of Approach to Children's Health Insurance Coverage and Coordination .....................................................................5 Section 3. Methods of Delivery and Utilization Controls ...................................................1817 Section 4. Eligibility Standards and Methodology. (Section 2102(b)) .............................1824 Section 5. Outreach and Coordination ................................................................................2935 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103) .........3642 Section 7. Quality and Appropriateness of Care .................................................................6268 Section 8. Cost Sharing and Payment .................................................................................7278 Section 9. Strategic Objectives and Performance Goals and Plan Administration .............8995 Section 10. Annual Reports and Evaluations ....................................................................109115 Section 11. Program Integrity (Section 2101(a)) ..............................................................110116 Section 12. Applicant and Enrollee Protections (Section 2101(a)) ..................................110117 Attachment 2 Wisconsin Description of the Amount, Duration and Scope of Services Covered ..........................................................................................................112118 Section 1. General Description and Purpose of the Children's Health Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101(a)(1); (42 CFR 457.70): Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI. 1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State's Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX); (Section 2101(a)(2)); OR

CHIP Plan State: Wisconsin Page 3 WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1 and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State's Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2)) 1.1-DS The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2. Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3. Check to provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130) Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications). 1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65) A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. Original Plan Effective Date: April 1, 1999 Implementation Date: Amendment #1 Effective date: July 1, 1999 Implementation date: July 1, 1999

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Amendment #2 Effective date: October 18, 2001

Implementation date: November 1, 2001

Amendment #3 Effective date: July 14, 2004

Implementation date: August 1, 2004

Amendment #4 Effective date: November 1, 2005

Implementation date: January 1, 2006

Amendment #5 Effective date: January 14, 2008

Implementation date: February 1, 2008

Amendment #6 Effective date: February 1, 2008

Implementation date: February 1, 2008

Amendment #7 Effective date: July 1, 2008

Implementation date: July 1, 2008

Amendment #8 Effective date: December 18, 2009

Implementation date: January 1, 2010

Amendment #9 Purpose of SPA: End of Benchmark Plan coverage and general updates.

Effective date: July 1, 2014

Implementation date: July 1, 2014

Amendment #10 Purpose of SPA: Initiate Health Service Initiative for a Poison Control Center.

Proposed effective date: July 1, 2015

Proposed implementation date: July 1, 2015

Amendment #11 Purpose of SPA: Implement the Mental Health Parity and Addiction Equity Act (MHPAEA, Pub.L. 110-343)

Proposed effective date: July 1, 2017

Proposed implementation date: July 1, 2017

Amendment #12 Purpose of SPA: Implement Lead Abatement HSI

Proposed effective date: July 1, 2018

Proposed implementation date: July 1, 2018

1.4-TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

A telephone conference call was held between staff from the Department of

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Health Services and the tribal health directors of the tribes located in Wisconsin. This call took place on June 14, 2018. Representatives of the 11 tribes located in Wisconsin were invited to the meeting. Representatives of the urban Indian health center in Wisconsin were also invited. A summary of the planned changes to the CHIP plan were sent out in advance and were discussed on the telephone call.

During the call, department staff promised to send the revised plan to the health directors when completed, and this will be done simultaneously with the submission of the plan to CMS.

Subsequently, the Wisconsin Tribal Health Director Association held its bi- monthly meeting, with a quorum attending, on Thursday, November 8, 2018 in Wausau, WI. Deputy Medicaid Director Casey Himebauch attended the meeting. During the meeting, Deputy Himebauch introduced Associate Director of Programs Pamela Appleby who telephonically presented details on each of the State Plan Amendments (SPAs) that Wisconsin intends to submit to CMS during the fourth quarter of 2018, including 18-013 CHIP Lead HSI.

Each amendment was explained; questions and feedback were solicited. Although some clarifying questions were asked, the Tribal Health Directors expressed no concerns regarding any of the SPAs.

Ultimately, the Tribal Health Directors voted unanimously to recommend that Wisconsin submit WI-19-0004-CHIP as presented.

Section 2. General Background and Description of Approach to Children's Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1 can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description.  Population  Number of insured  Race demographics  Age Demographics  Info per region/Geographic information

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified), identified by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102 (a)(1)); (42 CFR 457.80(a))

The Wisconsin Department of Health Services conducts an annual Family Health Survey managed by the Department’s Division of Public Health. The Wisconsin Family Health Survey was initiated in 1989 to provide reliable estimates of health status, health problems, health insurance coverage, and use of health care services among Wisconsin residents. A random sample of households is telephoned by trained interviewers, who speak with the household member most knowledgeable about the health of all household members. This respondent provides information for all people living in the household at the time of the interview.

The survey provides descriptive information about health insurance coverage among Wisconsin residents. To monitor health status and health care utilization issues, survey questions ask about the current health status, chronic conditions, and physical limitations of all household members, as well as the last visit to a doctor, visit to a dentist, and any use of an emergency room in the past year. Demographic characteristics, such as age, race, poverty status, and education, also are obtained for all persons in the household.

According to the Family Health Survey, in 2012 there were about 1,347,000 children under 19 years of age in Wisconsin. Approximately 1,118,000 (83% of these children) were white (majority) and 229,000 (17%) were minority or multiple race.

The 2012 Family Health Survey estimates that 15% of Wisconsin's population was living in a household below 100% of the Federal Poverty Level (FPL). That is, Wisconsin had an estimated 848,000 people in poverty in 2012.

According to the 2012 Wisconsin Family Health Survey, 6% of Wisconsin household residents had no health insurance during all of the previous 12 months, and 5% of household residents had no health insurance for part of the previous 12 months.

Information from the 2012 Family Health Survey provides estimates of the number of uninsured children by FPL. At any one time, an estimated 32,300 children under age 19 were uninsured in 2012.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently being funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

2.2.1 WI Poison Control Center

Wisconsin will elect to use the health services initiative option as allowed at 42 CFR 457.10. Wisconsin is proposing to cover the efforts of the WI Poison Control Center under this initiative.

The Wisconsin Poison Control Center is located in Milwaukee, WI, and provides 24-hour, toll-free poison information for all individuals in the State of Wisconsin. Anyone who has had direct contact with a known or potential poison can receive immediate recommendations on what steps to take to prevent injury from that exposure.

The Wisconsin Poison Control Center provides immediate access to expert treatment advice and assistance over the telephone in case of exposure to poisonous or hazardous substances. A single toll-free telephone number allows for rapid and direct access to highly specialized care, including demographic populations that are typically underserved or lack access to high-quality health care, such as uninsured, low-income, and immigrant families. From anywhere within Wisconsin, the general public, industry, emergency medical services and health care professionals can contact the center at 1-800-222-1222. During 2013, approximately 64.5% of all those receiving services are age 19 or younger.

An electronic medical record is kept that identifies the demographics, interventions and outcomes of all poison exposure cases reported to the Poison Center. All information regarding patient and call identification is kept discreet, meeting all federal requirements pertaining to patient confidentiality. Across the United States, federal agencies recognize and endorse the importance of poison centers in providing medical consultation and public health surveillance. Consultation with Poison Center staff may assist and expedite medical care without concern of violation of patient privacy.

The WI Poison Center also collaborates with the WI Department of Health

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Services to provide poison surveillance data to public health administrators with specific state-wide monitoring for blue-green algae and weapons of mass destruction.

The Poison Center has been Wisconsin’s only designated poison information service since 2001. It received national certification from the American Association of Poison Control Centers in 2005 and successfully re-accredited in 2009 and 2014.

Registered nurses and pharmacists trained and certified as specialists in poison information directly handle telephone inquiries. Consultation with medical toxicologists is available 24 hours a day for health care providers.

The center’s primary mission is to consistently deliver comprehensive and accurate information to callers faced with any poison or drug-related event. Recommendations are provided to individuals of all age groups who are concerned about an exposure to medications, illegal drugs, household chemicals, botanicals, animal and insect venom, food poisoning, occupational chemicals, environmental pollutants and other hazardous substances.

The center also provides poison prevention education through the public education program and public website. A variety of materials, including a comprehensive, standards-based poison prevention curriculum (K-12), are available at www.wisconsinpoison.org.

The overall cost of the program exceeds $1.9M on an annual basis. It has reduced staff and marketing expenditures over the last few years due to lack of funding.

A portion of these costs are currently being funded via an agreement between Children’s Hospital of WI and the State of WI. These funds are currently unmatched by federal funds and are at a maximum of $425,000 annually from the State General Purpose Revenue (GPR.) An additional requirement is that Children’s matches 50% of the GPR for the total agreement.

The Wisconsin Poison Control Center has been an outstanding example of how a public-private partnership can work in the state. CHIP funding will allow this organization to continue its strong track record of providing the residents of the State of Wisconsin access to valuable, cost-effective, and life- saving services.

For future administrative budget assistance, the WI Department of Health Services intends to use the same dollar amount of the current contract to receive the federal match under CHIP using the Health Services Initiatives (HSI) option.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 2.2.2 Lead Abatement

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the Wisconsin Department of Health Services (the Department) will conduct a health services initiative that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support expanded lead abatement activities in impacted areas of Wisconsin based on prioritization criteria as further described herein. Federal assistance is necessary to minimize and further prevent the long- term adverse health effects associated with lead exposure, in targeted high risk areas and across the State. This health services initiative would complement other federal, state and local efforts to test, educate, and abate lead hazards from the homes and improve the health of Medicaid and CHIP- eligible individuals.

The Department is seeking federal funding pursuant to Section 2105(a)(1)(D)(ii) of the Social Security Act for the development and implementation of a lead abatement program through the use of a CHIP health services initiative. The Department will administer all aspects of the program. The Department will provide coordinated and targeted lead abatement services to eligible properties in the impacted area to mitigate lead hazards as outlined below.

2.2.2.1 Monitoring and Oversight To help ensure a successful program, the Department will contract with regional or local housing agencies to administer and manage all daily aspects of the lead abatement projects. The contracted agencies’ activities will include participant enrollment and income verification, generation of lead abatement specifications, and coordination of the bidding process for lead abatement activities. The contracted agencies have previous experience in operating and managing federal housing assistance programs.

2.2.2.2 Eligibility Criteria Properties considered for enrollment must meet all the following conditions prior to the initiation of lead abatement activities. The property shall be: 1. Constructed prior to 1978; 2. Occupied by tenants or owner-occupants at or below 301% of the FPL; 3. Occupied by tenants or owner-occupants who have at least one Medicaid or CHIP-eligible child under 19 years of age or pregnant woman, or a child under 19 years of age or pregnant woman who visits regularly (e.g. home of a family member, relative or child care where a child spends 3 hours a day on two separate days a week and a total of 60 hours per year); 4. Current on all property taxes or have a tax payment plan in place.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 2.2.2.3 Prioritization of Participants The goal of the program is to assist Wisconsin families and property owners with addressing lead hazards in the home environment by providing the services needed to eliminate or control lead hazards. Property owners and families in all of Wisconsin’s 72 counties are eligible for participation in the program if they meet the qualifications as outlined above.

The Department will initially prioritize services to properties where children with elevated blood lead levels reside that are subject to lead hazard reduction work orders issued by a local health department. There are currently an estimated 400 properties across the state under lead hazard control work orders that may be eligible for lead abatement assistance through the CHIP health services initiative. These properties have undergone a thorough lead investigation which has identified lead hazards contributing to an eligible child’s elevated blood lead level. The majority of these investigations were conducted as required by state law in response to a child with one venous blood lead level >20 µg/dL or two venous blood lead levels >15 µg/dL that were drawn at least 90 days apart.

Secondly, the Department will prioritize properties of children with blood lead levels meeting the Wis. Stat. 254.11(9) definition for lead poisoning (≥5 µg /dL) that are not subject to lead hazard reduction work orders. In 2016, there were more than 4,300 children with a blood lead level ≥5 µg/dL many of whom may be eligible for assistance through the CHIP health services initiative.

For the third level of prioritization the Department will focus on a primary prevention approach. Project units will be identified from specific target areas with high rates of both childhood lead poisoning and pre-1950 housing. The Department or its designee will conduct community outreach efforts to identify properties to enroll in the project and engage affected families in these target communities. These outreach efforts may include direct mailings to families residing in the target area, flyers and postings in community areas, and other effective outreach activities as determined by the Department.

Target communities will be selected based on the following criteria:  Percentage of children under age 6 with a blood lead level of ≥5 µg/dL;  Percentage of population that is low-income;  Percentage of pre-1950 housing stock. (90% of Wisconsin children first identified with lead poisoning from 1996 to 2006 lived in homes that were built before 1950.)

2.2.2.4 Income Verification and Enrollment

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 The purpose of the intake and enrollment process is to ensure the owners, tenants, or owner-occupants meet all qualifications for participation in the program through the collection of required documents and completion of enrollment forms. During intake and enrollment, the program process and expectations will be outlined to the participants.

During the enrollment process, the Department will determine if the occupants of the property include at least one Medicaid or CHIP-eligible child under 19 years of age or a pregnant woman. On a monthly basis, the Department will use the state blood lead database, CHIP enrollment database, and Medicaid enrollment database to generate a list of potential participants to share with the contracted agencies. The Department will inform the agencies to proceed with the program services for those we have agreed are potentially eligible.

If the potential participants are not enrolled in Medicaid or CHIP or covered by any other creditable health care insurance program, the contracted agencies and the Department will take steps to assist the participant’s parent or guardian with completing enrollment materials and obtaining access to health care providers.

2.2.2.5 Lead Hazard Risk Assessment Once a property is enrolled, the Department or contracted agency will arrange for a property assessment and lead hazard risk assessment of the child’s residence or other eligible property to determine the presence of lead hazards. Only a certified lead risk assessor may conduct this assessment. Work specifications for lead abatement of identified hazards will be written by the certified lead risk assessor employed or contracted by the Department, a local health department, or the contracted agency.

2.2.2.6 Rental Property Owner Contribution Rental property owners may be required to pay up to 15% of the cost of the lead abatement work as a requirement for participation in the program. Factors considered in determining the rental-property owner’s payment percentage may include the income of the property owner, the number of units owned, owner and/or property compliance history, and the number of units a property owner has enrolled in the program. To fulfill this requirement, rental property owners will need to provide a receipt to the department showing that they have made a direct payment to a certified lead abatement contractor towards services associated with the lead abatement project; the department will not accept any direct payments from rental property owners. The department will retain records of all rental property owner payments made. The rental property owner payment requirement will not be considered a state match for funds or a contribution to the state, and will not be included in the final project cost reported to CMS. The state will subtract the amount paid by the rental property owner from the total cost of

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 lead abatement and report the resulting amount to CMS as the final project cost. Owner-occupants will not be required to provide an owner contribution.

2.2.2.7 Tenant Relocation Services During the course of the lead abatement activities, it may be necessary for the occupants to relocate to ensure their health and safety. The average time frame for completion of lead abatement activities is projected to be 5 to 10 calendar days. Families will be allowed to return to the property upon completion of a successful clearance investigation.

Relocation will be carried out in accordance with the HUD guidelines. Occupants who must vacate the property while the work is ongoing will be treated fairly and equitably. Alternate housing will be identified for displaced families and efforts will be made to identify friends or family members who may be able to provide temporary housing that takes into consideration their specific needs, using HUD occupancy standards for the size and makeup of the household. Priority will be given to relocate the family in a nearby location, especially to maintain the same school district if applicable. At the time relocation occurs, and for the duration of the work, the Department will provide to the residents a per diem allowance to cover meals, lodging and transportation.

2.2.2.8 Lead Abatement Activities After the scope of work has been determined, the lead abatement activity work will be bid and awarded by the contracted agency to certified lead abatement contractors. The contracted agency will select the lowest, most reasonable bid taking into consideration the location of the project, the capability of the abatement contractor to meet project timelines and any other factor that may impact the flow or successful completion of the project.

Individuals performing abatement work must be properly certified by the Department. Only persons certified as lead abatement workers or supervisors may perform lead abatement activities in accordance with the state lead regulations in administrative code, chapter DHS 163, HUD’s Lead Safe Housing Rule, the HUD Guidelines, and all other federal and state lead regulations and guidance. Project monitors will conduct random site visits to properties undergoing work to ensure that contractors follow proper lead abatement work practices in compliance with the regulations.

A certified lead abatement supervisor is required to be present at the job site while all abatement work is being done. This requirement includes all setup and clean-up work. All certified personnel must work for a certified lead company. The lead company and its employees must use abatement methods in accordance with state laws and regulations and use methods developed or provided by the U.S. Department of Housing and Urban Development (HUD)

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 and/or the EPA.

Abatement activities are defined as measures to permanently eliminate lead- based paint hazards, and may include:  The removal, enclosure, or encapsulation of lead based paint and lead dust hazards from an eligible residence;  The removal of lead-based painted surfaces, components or fixtures from an eligible residence;  The removal or covering of lead-contaminated soil up to the eligible residence property line; and  All worksite preparation, clean up, and disposal, and lead risk assessment and clearance activities, including lab sampling analysis, associated with such measures.

For the purposes of this request, abatement does not include any of the following:  Work that does not prevent or reduce a lead hazard;  Work outside the confines of the property lines that is not the responsibility of the property owner or landlord;  Work on dwellings that do not have a Medicaid- or CHIP-eligible individual under the age of 19, or Medicaid/CHIP-eligible pregnant woman, residing or frequently visiting the structure;  Work to replace lead service lines, including main lines connecting home to city water.

Once work has started on an eligible property, all surfaces, components and fixtures that have been identified as a lead hazard will be remediated. Eligible surfaces for abatement activities include all structural components identified during a risk assessment as hazards including but not limited to: all window components, doors and door frames, stairs, interior walls and ceilings, painted built-in cabinets, interior railings, painted floors, interior trim, exterior porches, exterior painted siding, exterior windows and trim, exterior trim boards on the residence, garages, and other structures, and soil. Services may be rendered to the physical structure and include the surrounding land up to the property line.

2.2.2.9 Limitations on the Use of CHIP Funds Minimal rehabilitation work is permitted under this project if it is necessary to protect the integrity of the lead abatement work. In cases where the Department determines that the lead abatement work will fail without additional minor repairs, and certifies that the repairs are essential to maintain the integrity of the lead abatement work, these repairs will be covered. All services necessary for repair integrity will follow the minimum standards as established by HUD for lead-based paint hazard control and/or

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 healthy homes grants (located at https://www.hud.gov/sites/documents/DOC_38179.PDF) and any subsequent amendments to the HUD guidelines.

The Department will not utilize funds from this health services initiative to replace lead service lines. The vast majority of lead poisoning cases in Wisconsin continue to be related to exposure to lead in paint. In the event that the source of lead exposure is related to water, the Department may utilize the health services initiative funds to install a water filter in the home and will refer the property owner to other resources to abate this problem.

Funds from this health services initiative will not be used to address soil contamination for any home where the federal Environmental Protection Agency (EPA) would handle that responsibility due to the location of a home within a designated superfund zone.

Funds from this health services initiative will not be used for assessments of homes with children covered under the Medicaid state plan. Funds from this health service initiative will not be used to assess or remediate homes that are vacant.

2.2.2.10 Use of CHIP Funds to Support Lead Abatement Activities The Department and its contracted agencies will closely monitor the project and ensure compliance with HUD’s Lead Safe Housing Rule, the HUD Guidelines, and all federal and state regulations and guidance. Project monitors will conduct regular onsite visits to properties undergoing work to ensure that contractors utilize proper lead abatement activity work practices, and that they do not utilize prohibited practices during the lead abatement activities.

For the purposes of this health services initiative, the Department requests funding to increase the available abatement workforce by providing training for individuals in lead risk assessor and lead abatement worker and supervisor disciplines. Training for certification/licensure must be provided by an accredited lead training program. These funds will ensure that sufficient numbers of lead professionals are available to meet the increased demand for lead hazard investigation and abatement work using the CHIP funds.

Lastly, the Department requests funding to supplement the administrative functions necessary to successfully implement this CHIP health services initiative. The funding received for this request will supplement but not supplant other federal funding sources for lead abatement or the training/credentialing process of lead risk assessors, lead workers or lead abatement contractors.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 2.2.2.11 Post Lead Abatement Activities The Department recognizes that abatement activities would only be eligible for federal assistance when performance of these activities can be demonstrated to be effective in remediating all identified lead-paint and soil hazards. State and federal laws dictate that a clearance test must be performed after lead abatement work is finished to verify the work area is safe for the resident(s) to return. At the completion of the lead abatement activities, a certified risk assessor will perform a clearance examination in accordance with Wisconsin regulations and the procedures outlined in this document. Only a certified risk assessor, who is independent of the abatement company, may perform clearance testing after abatement work is completed. Re-examinations will be performed when an initial clearance examination fails. The family will return to the property when the property passes clearance.

After interior lead abatement work is completed, a certified lead risk assessor must perform clearance consisting of a visual inspection of the interior to ensure that all specified work was completed and all lead hazards were properly addressed. The certified lead risk assessor must also perform required dust wipe sampling to determine dust lead levels are below the clearance action levels on sampled surfaces. After exterior paint abatement work is completed, a risk assessor must perform a visual inspection of the exterior to ensure that all specified work was completed and lead hazards were properly addressed. Dust wipe clearance testing on porches will follow HUD policy guidance for abatement on the exterior of a house or rental property, using the clearance action level provided in the table below.

The final clearance report will be maintained by the Department. This report will include the results of the visual and any required sampling analysis results with units of measurement.

For purposes of this lead abatement program, the standards shown in the table below will be utilized when determining hazardous levels and the clearance standards for determining a unit is safe for re-occupancy.

Material and Location Tested Considered hazardous if lead is present at or above these levels*

Bare soil (child play area)

At or above 400 ppm of lead Bare soil (other areas)

At or above 1200 ppm of lead Dust - floor

At or above 10 micrograms of lead per square foot of sampled area (µg/ft2) Dust – porch

At or above 40 µg/ft2 of lead

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Material and Location Tested Considered hazardous if lead is present at or above these levels*

Dust - window sill

At or above 100 µg/ft2 of lead Dust – window trough

At or above 100 µg/ft2 of lead Paint tested by an X-Ray Fluorescence (XRF) analyzer Equal to or more than 1.0 milligrams per square centimeter (mg/cm2) of lead on a deteriorated sampled surface Paint tested by lab analysis

Equal to or more than 0.5% (one half of 1 percent) lead by dry weight, or equal to or more than 5,000 parts per million of lead in paint (ppm)

* All levels indicated in the table above will be utilized until and unless more stringent guidelines are promulgated at the state or federal level.

2.2.2.12 Metrics/Reporting Requirements The Department believes that this health services initiative will remediate identified lead hazards from the homes and improve the health of Medicaid and CHIP eligible children throughout Wisconsin. Providing for development and implementation of the lead hazard abatement program will reduce the potential for ongoing exposure or re-exposure to lead hazards for the eligible population and future populations. The Department will maintain a database of these ameliorated properties.

Key metrics the Department will track and report to CMS monthly or at another approved interval include:  Number of lead risk assessments completed;  Number of houses identified with lead hazards in each of the targeted area(s);  Number of houses in each of the targeted areas scheduled for lead hazard abatement;  Number of houses in each of the targeted areas in which lead hazard abatement has occurred; o Number of houses abated for CHIP or Medicaid children under the age of 19; o Number of houses abated for pregnant women;  Record of actual services provided in each house;  Clearance testing results for each house receiving abatement services;  Percentage of Medicaid-eligible children receiving blood lead testing under EPSDT (HealthCheck) statewide and in the areas targeted by this health services initiative;

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018  Percentage of children with elevated blood lead levels statewide and in this health services initiative.

The Department assures that this health services initiative will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children's Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

Wisconsin's process for consulting with leaders of the 11 tribes located in the State of Wisconsin was enacted as amendment 09-020 to the Medicaid state plan. Amendment 09-020 became effective 09/01/2009 with its approval on 07/29/2010. The amendment added the following language to text page 9 of the state plan:

Wisconsin Department of Health Services staff will meet with tribal Health Directors and designees of Indian Health Service and Urban Indian Organizations during the last month in each quarter to discuss state plan amendments before they are submitted to CMS. A Consultation Implementation Plan is maintained which documents what the State and the tribes have agreed to do for the next period.

In practice, this has led to Department of Health Services staff travel to Wausau each quarter to attend meetings of the Wisconsin Tribal Health Directors Association (WTHDA). Adjustments have been made as needed for

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 the convenience of the health directors. For instance, for the current calendar year, the health directors decided to go to an every other month schedule. As a result, for the current calendar quarter, Department staff met with the health directors the first week in May, and will do so the first week in July. In between those two meetings, updates will be sent to provide more current information about this quarter's submissions.

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee- for-service (FFAS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State's Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

See SPA WI_13-0029, Section CS3

4.1. Separate Program Check all standards that will apply to the State plan. (42 CFR 457.305(a) and 457.320(a))

4.1.0.

Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018

Wisconsin is using the SSA verification option for all applicants declaring U.S. Citizenship

4.1.1.

Geographic area served by the Plan if less than Statewide:

See SPA WI_13-0028, Section CS7

4.1.2.

Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

See SPA WI_13-0028, Section CS7

4.1.2.1-PC Age: _______ through birth (SHO #02-004, issued November 12, 2002)

See SPA WI_13-0028, Section CS9

4.1.3.

Income of each separate eligibility group, (if applicable):

See SPA WI_13-0028, Section CS7

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through _____% of the FPL (SHO #02-004, issued November 12, 2002)

See SPA WI_13-0028, Section CS9

4.1.4.

Resources of each separate eligibility group, (including any standards relating to spend downs and disposition of resources):

There is no resource test.

4.1.5.

Residency (so long as residency requirement is not based on length of time in state):

Be physically present in Wisconsin with the intent to reside in the state.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility):

Not applicable.

4.1.7.

Access to or coverage under other health coverage:

Unborn Children

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 May not be covered under a group health plan or under health insurance coverage, as defined in section 2791 of the Public Health Service Act during the month of application or in the previous three calendar months, unless a good cause exemption is granted.

May not have access to a State employee’s health benefits plan or to an employer’s group or individual health insurance plan in the month of application or in the three calendar months following the month of an application, annual review or the start of new employment, or in the previous 12 months, unless a good cause exemption is granted.

A good cause exemption is granted to those unborn children with past or present coverage or access to a health insurance or a group health plan, if the insurance only covers services provided in a service area that is beyond a reasonable driving distance from the individual’s residence.

A good cause exemption is granted to those individuals who were covered by a group health plan or health insurance coverage in the three months prior to application, if insurance did not pay for pregnancy-related services or if:  The individual through whom the insurance was available involuntarily lost their job with the employer providing that insurance, or voluntarily ended their job because of the incapacitation of the individual or because of an immediate family member’s health condition,  Employment of the individual through whom the insurance was available changed and the new employer does not offer health insurance coverage, or the employer discontinued health plan coverage for all employees  COBRA continuation coverage was exhausted in accordance with federal regulations,  Coverage was lost due to the death or change in marital status of the policy holder, or  The insurance was provided by someone not residing with the unborn child;

A good cause exemption is granted to individuals with current, future or past access to an employer’s group health plan, if the available insurance is through a person who is not a member of the unborn child’s household or the employer contributes less than 80 percent of the premium cost. The percentage of employer contribution is not applicable for the State employee’s health plan.

A good cause exemption is granted to those unborn children who, in

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 the past 12 months, had access to a group health plan or had access to access to a State employee’s health benefits plan if:  Employment of the individual through whom the insurance was available ended, or the employer discontinued health plan coverage for all employees; or  At the time the individual failed to enroll in the employer’s health insurance coverage, one or more members of the individual’s family were covered through: o A private health insurance policy or Medicaid, and o No one in the family was covered through SCHIP.

Children covered under Separate SCHIP May not be covered under a group health plan or under health insurance coverage, as defined in section 2791 of the Public Health Service Act, during the month of application or in the previous three months, unless a good cause exemption is granted.

May not have access to a State employee’s health benefits plan or to an employer’s group health plan at the time of application or within the three calendar months following the month of an application, annual review or the start of new employment, or in the previous 12 months, unless a good cause exemption is granted.

A good cause exemption is granted to those children who are covered by health insurance or a group health plan during the month of application or in the previous three months, if the individual is covered by health insurance:  That only covers services provided in a service area that is beyond a reasonable driving distance from the individual’s residence,  Provided by someone who is not a member of the child’s household, or  Which is not a group health plan, or for which an employer contributes less than 80 percent of the premium cost. This reason does not apply to State employee’s health benefits plan.

A good cause exemption is granted to those children who were covered by a group health plan in the three months prior to application, if:  The individual through whom the insurance was available involuntarily lost their job with the employer providing that insurance, or voluntarily ended their job because of the incapacitation of the individual or because of an immediate family member’s health condition,  Employment of the individual through whom the insurance

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 was available changed and the new employer does not offer health insurance coverage, or the employer discontinued health plan coverage for all employees, or  Coverage was lost due to the death or change in marital status of the policy holder.

A good cause exemption is granted to individuals with current, future or past access to an employer’s group health plan, if the available insurance is through a person who is not a member of the child’s household or the employer contributes less than 80 percent of the premium cost. The percentage of employer contribution is not applicable for the State employee’s health plan.

A good cause exemption is granted to those individuals who, in the past 12 months, had access to a group health plan or a State employee’s health benefits plan, if:  Employment of the individual through whom the insurance was available ended, or the employer discontinued health plan coverage for all employees; or  The individual through whom the insurance was available failed to enroll in the employer’s health insurance coverage because one or more members of the individual’s family were covered through: o A private health insurance policy or Medicaid, and o No one in the family was covered through SCHIP.

Other good cause exemptions, consistent with the above reasons, may be approved by the Department of Health Services on a case by case basis.

4.1.8.

Duration of eligibility, not to exceed 12 months:

Eligibility lasts until the birth of the baby for unborn children covered under SCHIP and for 12 months or until determined ineligible for all other children.

4.1.9.

Other standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing an SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 4.1.9.1.

States should specify whether Social Security Numbers (SSN) are required.

An SSN is not required for unborn children, but is required for all other children requesting assistance.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2.

Continuous eligibility

4.1-PW

Pregnant women option. (Section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1- PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of "lawfully residing" children and/or pregnant women. States may elect to cover (1) "lawfully residing" children described at section 2107(e)(1)(J) of the Act; (2) "lawfully residing" pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1-LR

Lawfully residing option. (Sections 2107(e)(1)(J) and 1903(v)(4)(A); CHIPRA #17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following:

A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 USC §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than one year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women.

Elected for children under age 19 .

4.1.1-LR The state provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual's initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5))- A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State's CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The state assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b)) 4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. This applies to pregnant women included in the State plan as well as targeted low-income children. 4.2.3.

These standards do not deny eligibility based on a child having a pre- existing medical condition. This applies to pregnant women included in the State plan as well as targeted low-income children.

4.2-DS

Supplemental Dental - Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b)) 4.2.1-DS These standards do not discriminate on the basis of diagnosis. 4.2.2-DS Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3-DS These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 2102(b)(2) and 42 CFR 457.350)

See SPA WI-13-0031, Section CS24

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplement coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. ((Section 2102(b)(2) and 42 CFR 457.305(b))

Check here if this section does not apply to your state.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the citizenship status of the child. States electing this option should indicate so in the State plan. (42 CFR 457.355)

4.3.2.

Check if the State elects to provide presumptive eligibility for children that meet the requirements of section 1920A of the Act. (Section 2107(e)(1)(L) and 42 CFR 457.355)

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determination, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening household, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State's ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B); 42 CFR 457.310(b)(2), 42 CFR 457.350(a)(1) and 457.80(c)(3))

4.4.

Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1.

only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B), 42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

See SPA WI-13-0031, Section CS24

4.4.2.

children found through the screening process to be potentially eligible for

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B), 42 CFR 457.350(a)(2))

See SPA WI-13-0031, Section CS24

4.4.3.

children found through the screening process to be ineligible for Medicaid are enrolled in CHIP. (Sections 2102(a)(1) and (2) and 2102(c)(2); (42 CFR 431.636(b)(4))

See SPA WI-13-0031, Section CS24

4.4.4.

the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102)(b)(3)(C), (42 CFR 457.805)

See SPA WI_13-0031, Section CS24

4.4.4.1.

(formerly 4.4.4.4) If the state provides coverage under a premium assistance program, describe: 1) The minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42 CFR 457.810(a)-(c))

1) Six months 2) The minimum employer contribution is 40% of the cost of the premiums. 3) To determine the Premium Assistance cost effectiveness, we first determine the Premium Assistance cost. This is the sum of the premium amount of the employer plan, projected BadgerCare Plus Wrap-around cost and the administration cost associated with premium assistance. In the second step we determine the BadgerCare Plus Cost by adding the BadgerCare Plus HMO monthly Cap amount to a lower Wrap- around amount. If the Premium Assistance cost is less than the BadgerCare Plus Cost, we will proceed to buy in to the employer’s insurance.

4.4.5.

Child health insurance is provided to targeted low-income children in the State who are American Indian and Alaskan Native. (Section 2102)(b)(3)(D), 42 CFR 457.125(a))

Wisconsin has a long-standing working relationship with tribal health directors in the State. From statewide HMO implementation, Medicaid staff met with tribal health directors over an 18-month

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 period to coordinate HMO expansion with the needs of the tribes and with Indian Health Service responsibilities. A special disenrollment procedure was developed for tribal members that involves close coordination with Indian Health Clinics, tribal members, and the Medicaid HMO enrollment broker. A special payment system was developed so that non-HMO affiliated Indian Health Clinics could still be reimbursed by Medicaid for fee-for-service funds for services provided to tribal members enrolled in HMOs, and so that Indian Health Service funds would not be jeopardized by the expansion of the HMO program.

We continue to hold regular meetings with tribal leaders to discuss health care related issues. We intend to use these meetings to solicit input and provide information to the tribes on BadgerCare Plus.

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll requirements.

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening household, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2: (Section 2102(a)(2), (42 CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility and a description of the State's outreach efforts through Medicaid and state-only programs.

5.1.1. (formerly 2.2.1) The steps the state is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State's plan was initially approved. States do not have to rewrite this section but may instead update this section as appropriate.

Wisconsin Medicaid is the State's major public health program for children. Medicaid is a federal/state health care program for low- income families, elderly and disabled individuals. It serves many of the poorest and most vulnerable citizens of Wisconsin.

In the 2013 - 2014 fiscal year, the Medicaid GPR budget is approximately $2.3 billion.

Wisconsin Medicaid offers one of the most comprehensive benefit packages of any state Medicaid program and covers most individuals eligible under federal regulations. At the same time, Wisconsin Medicaid is a very cost-effective program.

The Wisconsin Department of Health Services is the largest single provider of direct as well as support services for uninsured and Medicaid-enrolled children and adolescents. Direct services for this population include: preventive child health services (well-child check- ups), prenatal services, Women Infants and Children Supplemental Nutrition (WIC) program services, preventive health education, immunizations, and family planning program services. Support services include case management services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family Planning program funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 amount of patient fee revenue.

The State of Wisconsin has increased the percentage of low-income families with health insurance through a variety of initiatives:

Prenatal Care for Unborn Children. Provisions of 2005 Wisconsin Act 25 enacted on July 25, 2005, authorized the Department of Health and Family Services to provide BadgerCare benefits to unborn children of women who are not otherwise eligible for Medicaid, such as non-qualifying aliens.

BadgerCare Plus. This program provides a consolidated, streamlined program for all children, pregnant women, parents and caretaker relatives. It also expands coverage for pregnant women to 301% FPL, caretaker relatives and parents to 200% FPL and covers all uninsured children. Under SCHIP we are requesting coverage of those children with incomes that exceed Medicaid income limits, but do not exceed 301% FPL.

Many of the families with children who are currently eligible for Family Medicaid or BadgerCare and have chosen not to enroll, need to be provided with information that shows that the program is easier to understand and easier to access. The State’s employs a Partner Outreach Coordinator who collaboratively with local and statewide groups, including the Robert Wood Johnson-funded Covering Kids and Families Initiative, to identify and enroll children who meet program requirements. The Partner Outreach Coordinator

In addition, BadgerCare Plus simplifies the program rules through Medicaid and SCHIP State Plan amendments and modify the current BadgerCare waiver by removing income disregards and deductions in ways that make the program easier for the average parent to understand and allows them to ascertain on their own that their income meets the limits being proposed.

Wisconsin offers applicants and participants multiple methods to apply for BadgerCare Plus: online, in-person, by phone or by mail. Applicants can complete an application at their convenience whenever they choose to and through any of these methods.

Online: To apply online, applicants go to www.access.wi.gov and complete an assessment if they want to see potential eligibility (Am I Eligible?) or applicants can complete and submit an online application (Apply for Benefits). At any time during the application process, the applicant can choose to save the information and complete the application at a later date. The information will be saved

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 under his or her account for 30 days before it expires.

In-Person: The applicant can choose to go to an agency location and apply. Agency locations are listed at https://www.dhs.wisconsin.gov/forwardhealth/imagency/consortia.ht m

Telephone: An applicant can apply for benefits by telephone by calling his or her Income Maintenance consortia. These phone numbers are listed online at https://www.dhs.wisconsin.gov/forwardhealth/imagency/consortia.ht m. They are also listed on several BadgerCare Plus factsheets and brochures. Income Maintenance staff can collect the applicant’s signature over the phone.

Mail-In: Paper applications are available for order through the Department or printable online.

5.1.2. (formerly 2.2.2.) The steps the state is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership.

Guidance: The State should describe below how its Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid-eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42 CFR 457.80(c))

See . 5.1.1.

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2); 42 CFR 457.80(c)) This item requires a brief overview of how Title XXI efforts - particularly new enrollment outreach efforts - will be coordinated with and improve upon existing State efforts.

Applicants are eligible for BadgerCare Plus if they meet all of the following conditions:

 They are not currently enrolled in any group or individual health insurance plan as defined in HIPAA.  They have not been enrolled in a group or individual health plan

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 meeting HIPAA criteria during the past six months.  They have not had access to a State employee’s health benefits plan in the previous 12 months.  They have not had access to a group or individual health insurance plan in the previous 12 months in which their employer pays at least 80 percent of the premium.

Good cause is granted to family members of those individuals who have been or are currently covered, if the individual, through whom the insurance was available, has involuntarily lost their job with the employer providing that insurance, or the employer providing the health insurance coverage does not pay 80% or more of the premium.

Persons who have access to employer health insurance that meets HIPAA standards and for which the employer pays at least 40 % but no more than 80% of the cost will be eligible for the health insurance premium purchase under BadgerCare Plus to assure that BadgerCare Plus does not substitute for private coverage. These provisions apply to the SCHIP expanded population only.

In families, where the state purchases employer subsidized family group health plan for a household that includes both Medicaid funded and SCHIP funded members, we will prorate the cost of the plan based upon the number of members in the family who are funded through SCHIP and the members funded through Medicaid. For example, if a family with a mother and two children, ages seven and nine, applies for BadgerCare Plus and we determine that their family income is 130% of the FPL, we will check with their employer to determine if we should enroll them in HIPP. If their family premium is $99 per month and that proves to be cost effective, the Department will purchase their employer's group health plan for the family and say that $66 of the premium that is intended for the two children will come from SCHIP and $33 will come from Medicaid funds.

The Department will comply with the applicable SCHIP premium assistance rules when determining whether the Department will pay for the employee portion of an employer-subsidized health insurance plan that covers SCHIP children.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

Guidance: Outreach strategies may include, but are not limited to, community outreach workers, outstationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 to inform families of low income children of the availability of the health insurance program under the plan or other private or public health coverage.

The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

5.3. Strategies. Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program. (Section 2102(c)(1); 42 CFR 457.90)

Community Partner Outreach. The State currently employs a full-time Partner Outreach Coordinator who works directly with the community partners across Wisconsin to inform families about BadgerCare Plus, assist with getting health coverage and advocate on behalf of the member. The Partner Outreach Coordinator provides training on a regular basis to keep the community partners informed on Medicaid regulations and how members could be affected. In return, community partners provide feedback to the State on streamlining enrollment to best serve families and children.

The State also provides regular trainings for partners on how to use the online application tool, ACCESS (www.ACCESS.wi.gov), to assist members in applying for benefits, checking their case information and submitting information online. ACCESS has also been enhanced to allow qualified entities, approved by the State, to complete presumptive eligibility determinations.

In 2013, the State established Regional Enrollment Networks that assist all Wisconsin residents in applying for BadgerCare Plus and health insurance through the Federally-facilitated Marketplace. These networks are composed of community partners, health care providers, income maintenance agencies, managed care entities and other key stakeholders across 11 different regions of Wisconsin. These 11 regions align with the 11 Income Maintenance consortia so that both RENs and IM consortia can work together to address the needs of their region. Regional Enrollment Networks work at the local level directly with applicants to help identify and resolve issues and barriers according to the needs of that region and provide feedback to the State on methods to improve.

Public Information Campaign. With the implementation of the Affordable Care Act in 2014, the Department reviewed all of its BadgerCare Plus and Medicaid related content and materials to provide members with up-to-date information about getting health care coverage whether it is provided through the State or through the Federal Marketplace. Wisconsin promotes

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 a “No Wrong Door” approach, which emphasizes to the applicant that whether he or she applies through the State or through the Federal Marketplace, the applicant will always get the appropriate coverage for his or her family. Factsheets, brochures and web resources include information on where and how to apply in Wisconsin and in the Federal Marketplace.

Limited-English Proficiency. The Department has assessed the population of Wisconsin to determine areas with limited-English Proficiency (LEP) and develop methods to help meet the needs of the LEP population. ACCESS, is entirely translated into Spanish. The BadgerCare Plus paper application is translated into Spanish and Hmong.

Strategies to Promote Public Health. The Department is developing strategies to promote the health of the population through a variety of initiatives. These include the following:

 Assuring that eligible families are enrolled in BadgerCare Plus.

 Establishing a medical home and access to quality preventive services through statewide expansion of managed care.

 Creating incentives for managed care organizations to support healthy living incentives and to pay for quality performance.

In addition, the Department holds public health outreach contracts with seven public health agencies across Wisconsin:

 Chippewa County Health Department  Dunn County Health Department  La Crosse County Health Department  Partnership with Juneau County Health Department  Polk County Health Department  Sauk County Health Department  Washburn County Health Department

These agencies work with the Department to educate and inform the public about health care options for adults and children in Wisconsin and assist families and individuals maintain health care coverage. The public health agencies are required to submit proposals to the Department for the fiscal year and provide quarterly updates on how they are meeting their goals. The goals of these public health outreach contracts include:

 Assisting residents with health care applications or renewals;

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018  Assisting individuals with applications for the Federal Marketplace;  Providing education and targeted outreach to the public;  Providing technical assistance to health care providers and community partners about health care in Wisconsin; and  Increasing access to quality services.

Training. The State is continually providing training to Income Maintenance and tribal agencies and community partners about BadgerCare Plus and Medicaid programs. Ongoing training for health care providers is managed by the state’s Medicaid fiscal agent, Hewlett-Packard (HP).

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c); 42 CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(c))

6.1.1.

Benchmark coverage; (Section 2103(a)(1); 42 CFR 457.420)

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1); 42 CFR 457.420(b))

6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1); 42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3); 42 CFR 457.420(c))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: States choosing Benchmark-equivalent coverage must first check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: o dental services o inpatient and outpatient hospital services o physicians' services o surgical and medical services o laboratory and x-ray services o well-baby and well-child care, including age-appropriate immunizations, and o emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: o coverage of prescription drugs, o mental health services, o vision services and o hearing services. If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2. Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If "existing comprehensive state-based coverage" is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for "existing comprehensive state-based coverage" must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4); 42 CFR 457.450)

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4); 42 CFR 457.450)

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all the services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment.

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only New York, Pennsylvania, or Florida (under 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than coverage under one of the benchmark plans specified in 457.420, through the use of a benefit-by- benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison. (Provide a sample of how the comparison will be done).

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount, and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a); 42 CFR 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a); 42 CFR 457.490))

Coverage for both children and unborn children under CHIP is the same as coverage under the Wisconsin Medicaid State Plan. Children and unborn children covered under CHIP receive all Wisconsin Medicaid covered services including EPSDT.

Details about the amount, duration and scope of the covered services are provided in Attachment 2.

6.2.1.

Inpatient services (Section 2110(a)(1))

6.2.2.

Outpatient services (Section 2110(a)(2))

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

See Physician Services in Attachment 2.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services (Section 2110(a)(5))

See Physician Services in Attachment 2.

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11))

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care,

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 pediatric nurse services, and respiratory care services in a home, school, or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15))

See Physician Services in Attachment 2.

6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16))

6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA #7, SHO #09-012 issued October 7, 2009)

6.2.18.

Vision screening and services (Section 2110(a)(24))

6.2.19.

Hearing screening and services (Section 2110(a)(24))

6.2.20.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

6.2.21.

Outpatient substance abuse treatment services (Section 2110(a)(19))

6.2.22.

Case management services (Section 2110(a)(20))

6.2.23.

Care coordination services (Section 2110(a)(21))

See Case Management services in Attachment 2.

6.2.24.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

6.2.25.

Hospice care (Section 2110(a)(23))

Guidance: See guidance for Section 6.1.4.1 for guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check the box below.

6.2.26.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act.

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the discretion of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

6.2.28.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.29.

Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

See Transportation Services in Attachment 2.

6.2.31.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

6.2-DC Dental coverage (CHIPRA #7, SHO #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100- D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999)

1 Current Dental Terminology, ©2010 American Dental Association. All rights reserved.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000- D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900- D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

Dental coverage under CHIP is the same as dental coverage under Wisconsin’s Medicaid State Plan. Thus, the periodicity schedule under CHIP is the same as Wisconsin Medicaid.

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)); (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this

2 Current Dental Terminology, ©2010 American Dental Association. All rights reserved.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1- DS, 4.2-DS, and 9.10 when electing this option. Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6)

6.2-MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1-MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1-MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If "Other" is selected, please provide a description of that standard. International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: )

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 6.2.1.2-MHPAEA Does the State provide mental health and/or substance use disorder benefits? Yes No

Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1-MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer "yes." Yes No

Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3-MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2-MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan.

Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3-MHPAEA must be completed as well as the required parity analysis for the other children.

6.2.2.3-MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A))

Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3-MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3-MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1-MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

6.2.3.1.1-MHPAEA The State assures that:

The State has classified all benefits covered under the State plan into one of the four classifications.

The same reasonable standards are used for determining the

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits.

6.2.3.1.2-MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1-MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits).

Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub-classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan.

Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan. (42 CFR 457.496(d)(2)(ii)).

Annual and Aggregate Lifetime Dollar Limits

6.2.4-MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1-MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied

Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2-MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: ) No

Guidance: If no aggregate lifetime dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3–MHPAEA States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one-third, at least one- third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable.

Guidance: Please include the state’s methodology to calculate the portion

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1-MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2-MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1-MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following: (42 CFR 457.496(c)(4)(i)(B); (42 CFR 457.496(c)(4)(ii))

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2-MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following: (42 CFR 457.496(c)(2)(i); 42 CFR 457.496(c)(2)(ii))

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or

The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits.

Quantitative Treatment Limitations

6.2.5-MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: )

No

Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6-MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1-MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes

No

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Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non-quantitative treatment limitations.

6.2.5.2-MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E))

Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two- thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes

No

Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

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6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E))

The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i))

Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6-MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 requirements. (42 CFR 457.496(d)(4); 42 CFR 457.496(d)(5))

6.2.6.1–MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification.

Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

6.2.6.2–MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1-MHPAEA Does the State or MCE contracting with the State provide coverage of medical or surgical benefits provided by out-of- network providers?

Yes

No

Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2-MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of- network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out-of- network providers for medical/surgical benefits.

Availability of Plan Information

6.2.7-MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1-MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State

Managed Care entities

Both

Other

Guidance: If other is selected, please specify the entity.

6.2.7.2-MHPAEA Reason for any denial for reimbursement or payment for mental health or substance use disorder benefits must be made available to the enrollee by the health plan or the State. The state attests that the following entities provide denial information:

State

Managed Care entities

Both

Other

Guidance: If other is selected, please specify the entity.

6.3. The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480)

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2., formerly 6.4.2., of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)). Describe:

Guidance: States may request two additional purchase options in Title XXI; cost effective coverage through a community-based health-delivery system and for the purchase of family coverage (Section 2105(c)(2) and (3); 457.1005 and 457.1010)

6.4.

Additional Purchase Options- If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3); 42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10 percent limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42 CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above. Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i); 42 CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above. Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii); 42 CFR 457.1005(b))

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42 CFR 457.1005(a))

6.4.1.3. The coverage must be provided through the use of a community based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii); 42 CFR 457.1005(a))

Guidance: Check 6.4.2. if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary's satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3); 42 CFR 457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage. Payment may be made to a State for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3); 42 CFR 457.1010)

Title XXI, Section 2105 provides CMS with the authority to waive requirements prohibiting the purchase of family coverage under Title

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 XXI. This is possible provided the following two conditions are met: (1) such coverage is cost-effective relative to the amounts that the State would have paid to obtain comparable coverage only of the targeted low-income children involved; and (2) the coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. In order to demonstrate compliance with Section 2105, we are providing the actuarial analysis found in section 6.4.2.1, which follows. The crowd-out provisions for BadgerCare Plus assure that only children who are not now covered would be eligible for health care.

6.4.2.1. Purchase of family coverage is cost-effective. The State's cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

To determine cost effectiveness, the State first determines the Premium Assistance cost. The Premium Assistance cost is the sum of the employer plan’s premium, the projected BadgerCare Plus wrap-around cost, and the administrative expenditures associated with premium assistance. In the second step the State determines the BadgerCare Plus Cost by adding the BadgerCare Plus HMO statewide average monthly capitation rate by age and gender to the estimated wrap-around amount. If the Premium Assistance cost is less than the BadgerCare Plus cost, the State will purchase the employer’s insurance.

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B); 42 CFR 457.1010(b))

BadgerCare Plus coverage of families will provide coverage for children who do not currently have access to affordable health care coverage. It will not substitute for coverage which currently covers the children but does not cover the parents.

6.4.2.3. The state assures that the coverage for the family otherwise meets title

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 XXI requirements. (42 CFR 457.1010(c))

The State provides “wrap-around” benefits that cover any services not provided through the family coverage plan that are part of the regular SCHIP services provided under the plan.

6.4.3-PA Additional State Options for Providing Premium Assistance (CHIPRA #13, SHO #10-002 issued February 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child's parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)) Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children? Yes No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee's employer.

6.4.3.2-PA Supplemental Coverage for Benefits and Cost Sharing Protections Provided Under the Child Health Plan

6.4.3.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA Application of Waiting Period Imposed Upon State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.1-PA Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State's process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child. (Section 2105(c)(10)(G))

6.4.3.4.2-PA Describe the State's outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool. (Section 2105(c)(10)(I) Does the State provide this option?

Yes No

6.4.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.4.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State's CHIP plan.

6.4.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies. (Section 2105(c)(10)(K)

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

Section 7. Quality and Appropriateness of Care

Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members' experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to

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WI-19-0004-CHIP Approval Date __________ Effective Date 7/1/2018 beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

Tools for Evaluating and Monitoring Quality- Tools and types of information available include HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A); 42 CFR 457.495)

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A); 42 CFR 457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

Badger Care Plus has multiple quality assurance mechanisms to evaluate and improve HMO quality of care as a contracting condition prior to the start of the BadgerCare Plus contract and multiple monitoring mechanisms and performance incentives during the duration of the BadgerCare Plus