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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

WISCONSIN

Effective Date:

Approval Date: 12