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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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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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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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(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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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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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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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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6.2.22

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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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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8.5 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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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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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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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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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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