Medical Assistance Quick Explanation
by: Sarah Diedrick-Kasdorf, Senior Legislative Associate, Wisconsin Counties Association
Under the bill, the Department of Health Services is directed to study potential changes to the Medicaid state plan and to waivers Wisconsin has received from the federal government with regard to the state’s MA program.
The goal of the study is to recommend program changes that would:
- Increase the cost-effectiveness and efficiency of care and the care delivery system for MA programs.
- Limit switching from private health insurance to MA programs.
- Ensure the long-term viability and sustainability of MA programs.
- Advance the accuracy and reliability of eligible MA programs and claims determinations and payments.
- Improve the health status of individuals who receive benefits under the MA program.
- Align MA program benefit recipient and service provider incentives with health care outcomes.
- Support responsibility and choice of MA recipients.
If the Department of Health Services determines that revision of existing statutes or rules is necessary to advance one of the study goals, the Department could promulgate rules that do any of the following to the MA program:
- Require cost-sharing from recipients up to the maximum allowed by federal law or a waiver of federal law.
- Authorize providers to deny care or services if a program benefit recipient is unable to share costs, to the extent allowed by federal law or waiver.
- Modify existing benefits or establish various benefit packages for different groups of recipients.
- Revise provider reimbursement models for particular services.
- Mandate that program benefit recipients enroll in managed care.
- Restrict or eliminate presumptive eligibility.
- Impose restrictions on providing benefits to individuals who are not citizens of the United States (to the extent permitted by federal law).
- Set standards for establishing and verifying eligibility.
- Develop standards and methodologies to assure accurate eligibility determinations and redetermine continuing eligibility.
- Reduce income levels for purposes of determining eligibility to the extent allowed by federal waiver or law.
The department may makes these changes through the promulgation of an emergency rule. Do not need to follow the usual procedures.
Rule changes only need to be submitted to the Joint Committee on Finance through a 14-day passive review process. DHS required to submit MA plan amendment or request a waiver, if necessary, to implement the rule change.
DHS also required to request a waiver from federal DHHS to permit DHS to have in effect eligibility standards, methodologies, and procedures under the state MA plan or waivers of federal laws relating to MA that are more restrictive than those in place on March 23, 2010.
If the waiver request is not approved by December 31, 2011, DHS is required to reduce income eligibility standards on July 1, 2012 for non-disabled, non-pregnant adults to 133% of the FPL, to the extent permitted under the Patient Protection and Affordable Care Act (state can request if it certifies to DHHS that it has a budget deficit).
All of these provisions sunset on January 1, 2015.
What MA programs are affected?
Broad range of MA programs including :
- BadgerCare Plus and its subprograms, including Core (childless adults) and the family planning waiver program.
- Medicaid for elderly, blind and disabled populations and its subprograms:
- SSI-related Medicaid
- MA purchase plan
- Institutional and community-based long-term care programs: Family Care, COP, CIP.
- Katie Beckett program
- SeniorCare
Other considerations:
The LRB indicates that such emergency rules could not conflict with current statutory provisions relating to these programs, except those provisions that are referenced in the bill as not applicable if DHS promulgates rules that would conflict with these sections. The sections that impact counties are:
- Payments to counties for IM services
- Payments to ADRCs for conducting functional screens
- Payments to nursing homes
- MA eligibility and benefits
County human services concerns:
Loss of eligibility for clients.
Loss of federal matching dollars for county-matched services.
Changes in payment structure/levels.