BADGERCARE+ Wisconsin Department of Health Services The BadgerCare Plus Core Plan for Childless Adults March 17, 2009
Agenda: The BadgerCare Plus Core Plan for Childless Adults Demographics: Who are the Childless Adults? Program Design Covered Services Implementation The Enrollment Services Center Applying for the Core Plan Questions?
Demographics: Who are the “Childless Adults”? Low-income childless adults are the most chronically uninsured people in Wisconsin. These are individuals and married couples who are: Between the ages of 19 and 64; Not pregnant, disabled, or qualified for any other Medicaid, Medicare or SCHIP program. “Childless adults” may have children, but either their minor children are not currently living with them or those children living with them are 19 years of age or older.
Demographics, continued The most recent Wisconsin Family Health Survey estimates that there were 66,000 uninsured childless adults in Wisconsin with incomes that did not exceed 200% FPL. 41,000 people are expected to sign up for the Core Plan.
Program Design Eligibility Requirements Payment of an annual application processing fee of $60 or $75 (depending on HMO selection) Income up to 200% of the Federal Poverty Level (FPL) $20,800 annual income for single person (~$10/hour) $28,000 annual income for couple (~13.46/hour for both) Reporting requirements Move out of state, turn 65, change living arrangement, death, or become eligible for BC+, Medicaid or Medicare. Federal Requirement: Not covered by private health insurance for the previous 12 months No access to employer-sponsored health insurance for the previous 12 months
Program Design, continued Enrollment Requirements Managed Care Delivery Model (HMO) The BadgerCare Plus Core Plan for Childless Adults will be delivered through HMOs Participants will select a HMO at the time of application (with 90 days to change their choice) Lower application fee for Tier 1 selection (Effective date of tiers TBD) Eligibility and HMO enrollment begin dates are linked – begins after selection on the next 1st or 15th of month Health Survey Physical Exam (first year requirement) Failure to obtain = loss of eligibility for 6 months (with good cause exemptions) HMOs are required to provide access for exams to avoid penalty This requirement is unique among state Medicaid programs
Cost Sharing Application Processing Fee (non-refundable) Co-Payments Program Design, continued • Nominal co-payments range from $0.50 - $3 • Co-payments are waived for preventive services • $20 monthly cost-sharing cap for generic drugs
MONTHLY INCOME LIMITS • 100% FPL • Single = $ 866.67 • Married = Couple $1,166.67 • 200% FPL • Single = $1,733.33 • Married Couple = $2,333.33 • For updated guidelines go to badgercareplus.org/fpl.htm.
Covered Services • The BadgerCare Plus Core Plan will cover these services: • Doctor visits • Hospital services • Emergency room visits • Emergency ambulance rides • Emergency dental services • Some prescription drugs • Physical therapy • Occupational therapy • Speech therapy • Cardiac rehabilitation • Durable medical equipment • Disposable medical supplies • Dialysis/kidney-related services
Covered Services • The BadgerCare Plus Core Plan does not cover these services: • Non-emergency dental services • Chiropractic services • Hearing services • Routine vision exams • Home health care • Hospice • Inpatient mental health and substance abuse treatment services • Non-emergency transportation • Nursing home care • Podiatry • Reproductive health services (these services are covered through BadgerCare Plus Family Planning Waiver Services) • Services for children and pregnant women • See http://dhs.wisconsin.gov/badgercareplus/core/coveredservices.htm
Implementation – Phase 1 • General Assistance Medical and Milwaukee GAMP transition: • Almost 13,000 individuals enrolled in General Assistance medical programs around the state as of December 2008 were transitioned to the Core Plan on January 1, 2009. • As of February 19, 2009, there were 12,950 of these members. 12,399 of these are in Milwaukee County, and the remainder (551) in counties in the balance of the state. • You may hear this population is referred to as “Transitional Childless Adults” (TCLAs).
Implementation – Phase 1 • Enrollment periods for TCLA members were set as 12-14 months based on the member’s month of birth (ending December 2009 – February 2010). • When the initial enrollment period expires, TCLA members must do a renewal of their benefits.
Implementation - Phase 2 • Services will be provided to the entire TCLA population via fee for service from January 1-March 31, 2009. • Effective April 1 (scheduled) Milwaukee TCLA members will be enrolled in HMOs. • Other TCLA members will be enrolled in HMOs during the summer of 2009 (scheduled) along with full program implementation in phase 3.
Implementation – Phase 3 • In June, 2009 (scheduled), new enrollees will be able to apply for the BC+ Core Plan for Childless Adults. • Also at that time, the Childless Adult population will begin to be served via the state’s centralized Enrollment Services Center (ESC) for all relevant programs (the BC+ Core Plan, FoodShare, Family Planning Waiver). • The ESC will also assume management of Well Woman Medicaid cases.
The Enrollment Services Center • Applications and other interactions for the childless adult population will be processed centrally by the Enrollment Services Center (ESC) • Online at access.wisconsin.gov • Via phone at the Enrollment Services Center. • The ESC will be comprised of a combination of state and vendor staff – the vendor involved is Automated Health Services (AHS).
ESC Functions • The Enrollment Services Center will include these functions, managed in conjunction with the vendor: • Mailroom and scanning services • Application and renewal services • Eligibility processing services • HMO Enrollment services • Member services • Fiscal services • Other services, including benefit recovery, fair hearing and grievances, outreach and field representatives.
Programs administered by the ESC will be… • BadgerCare Plus Core Plan for Childless Adults (BC+ CLA), • FoodShare, • Family Planning Waiver, • Well Woman Medicaid, • Other Health Care programs for spouses of a childless adult (excluding Long Term Care/institutions and Medicaid Purchase Plan (MAPP) • HMO enrollment services for BC+ Families. Note: The ESC will not administer W-2 or Child Care cases.
Local IM Agencies • Will continue to serve: • Families • Pregnant Women • Elderly and/or Disabled • For programs: • BadgerCare Plus • Medicaid, including Long Term Care/institutions and MAPP • Medicare Premium Assistance • FoodShare • Caretaker Supplement
Applying for the Core Plan • The BC+ Core Plan has a four step enrollment process: • Application • Health Survey (Health Needs Assessment) • HMO Selection • Payment
ACCESS Application and Core Plan Request • Eligibility for the Core Plan is prospective. • Benefits and HMO enrollment begin on the 1st or 15th of the month, 2 business days after the ESC receives all required information.
Health Survey Objectives Give HMOs information about the health status of enrollees. Includes a basic indication if the enrollee is at “high risk” for a negative health outcome. Help members choose the HMO that will best meet their health needs. Provide DHS with data about the health status and needs of childless adults.
HMO Choice All available HMOs in the applicant’s service area will be presented in a ranked list. HMO rankings are based on: Presence of an identified doctor or hospital / clinic in the network, Performance ratings on asthma and diabetes (with a stronger weight if a person has the condition) HMO customer satisfaction ratings When HMO enrollment is not mandatory (tribal members, migrant workers, applicants with only one HMO in the service area), members will see different versions of the HMO choice pages. Following is a sample of the draft HMO choice cover page. (The data does not reflect actual HMO information and is for illustrative purposes only.)
BC+ Core Plan Fee • The BC+ Core Plan requires payment of a non-refundable annual application fee. • The fee is $60 or $75 depending on the member’s HMO choice: • Lower application fee for Tier 1 selection • Effective date of tiers is to be determined – all fees will be $60 at program implementation. • There will be screening in place as part of the application process, so that individuals can decide whether or not to proceed with paying the fee.