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Vol. 12, No. 17 September 16, 2016

Welcome to the HealthWatch Wisconsin Update Newsletter, a bi-monthly publication with exclusive features for members of HealthWatch Wisconsin.

"Wisconsin Navigators Renewed"

In this issue...

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HealthWatch Member Rita and her husband at Lambeau Field

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Top Story: Affordable Care Act Marketplace Assistance!

Funding Renewed for Wisconsin Navigators

On the cusp of the fourth Open Enrollment season for purchasing health insurance in health reform's Marketplace, the Centers for Medicare and Medicaid Services (CMS) have announced grants to Navigators. This is the second year in a three-year funding cycle for "returning grantees" who "currently provide local in-person assistance." 

Wisconsin's three navigators were all re-funded for this second grant year. Covering Wisconsin, the navigators based in Madison, received the lion's share of the award going to Wisconsin, receiving almost a million dollars to connect individuals to Marketplace plans. Overall, CMS announced $63 million in grant dollars to 98 organizations total.

Navigator Agency: Phone: Website:
Covering Wisconsin
Grant Amount: $998,960
608-261-1455 www.coveringwi.org
Northwest WI CEP, Inc.
Grant Amount: $306,227
888-780-4237 http://nwcep.org
Forest Co. Potawatomi Community
Grant Amount: $33,119
715-478-7200 www.fcpotawatomi.com

CMS outlines that Navigator grants help support "local, in-person assistance to help consumers navigate, shop, and enroll in the wide variety of Marketplace coverage options."

They also adopt a "no wrong door" policy - meaning, there are multiple paths to an individual's enrollment options - and multiple paths to help with those decisions. While navigators have targeted service areas, individuals are free to call ANY navigator to be directed to assistance. Individuals can apply at the Marketplace and still be assessed for Medicaid eligibility, or apply at the state and have an application forwarded to the Marketplace.

Congratulations to the Navigators in Wisconsin - we all look forward to working with you this upcoming Open Enrollment Period, which begins November 1, 2016 and runs through January 31, 2017 and as people assess eligibility for Special Enrollment Periods.

Wisconsin Coverage Connections

Sharing Resources: "3 Steps to Health Care Coverage"

ABC for Health is sharing a new video library and downloadable resources on accessing BadgerCare Plus! Hosted on the HealthWatch Wisconsin website is the "3 Steps Video Library" page.

The materials and videos are part of the "Wisconsin Coverage Connections" project, a collaboration with the Northwest WI CEP, Inc., Workforce Resources, Inc. and Workforce Connections, Inc., the three navigator agencies that will help families with BadgerCare Plus Enrollment. Other collaborators include CESAs 4, 10, 11, & 12, along with ABC for Health, Inc. and ABC for Rural Health, Inc.

This video library is YOUR place to learn or refresh your understanding of health coverage program rules. Enjoy our fun approach to learning the basics of BadgerCare Plus – we call it our "3 Steps to Health Care Coverage!" We discuss how you, and other professionals assisting families, can help families Apply, Use, and Keep BadgerCare Plus – perfect for this "Back to School" time of the year!

The project serves a targeted 27-county service area. Individuals working with families in other parts of the state may call to learn about resources closer to their region. Click below to download your 3 Steps Kit!

3 Steps to Health Care Coverage - Family Version 3 Steps to Health Care Coverage - Assister Version

Note: Editions are currently available in English. Check back to the project website in the future for Spanish language editions!)

The Centers for Medicare & Medicaid Services (CMS) have provided $32 million in awards to help 38 community organizations in 27 states enroll eligible children in Medicaid and the Children’s Health Insurance Program (CHIP) as part of the Connecting Kids to Coverage National Campaign.

The project described is supported by Funding Opportunity number: CMS331500-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Want to learn more but not sure where to begin? Start by watching our introduction to the project. Feel free to ask questions, send suggestions, or refer families our way who need more in depth assistance. This library will remain posted as long as the information is current. Have a question not on the list? Send us an email!

Health Care Costs - Continued

ABC for Health's Bobby Peterson on "Here and Now"

In our last Update Newsletter, we featured the few insurance companies shaking up the Marketplace on the cusp of Open Enrollment for 2017 coverage. These companies cited unprofitable Marketplace plans - and too many sick people in their risk pools - as a main reason for exiting the Marketplace. Kevin Counihan, Director & Marketplace Chief Executive Officer at CMS was reported as saying, "It's no surprise that companies are adapting at different rates to a market where they compete for business on cost and quality, rather than by denying coverage to people with pre-existing conditions."

But for those companies slow to adapt to the new market realities of covering people of all abilities, ages, and health, cost in the meantime is being passed onto the customers. For a first look at what insurance premium rates may look like for 2017 coverage, the "Wisconsin Rate Review Submissions" are available by the Marketplace. These rates are subject to final review by Wisconsin's Commissioner of Insurance.

In an interview on Wisconsin Public Television's "Here and Now," ABC for Health's Executive Director Bobby Peterson spoke about rising insurance premiums - in some instances increases in premiums of 37% - but also the decreases. Peterson says, "It's important for people to look and identify plans. Some actually have lower costs....It's important to shop around." 

Overall when we look at the Marketplace, when insurers first entered the Marketplace, there were lower prices to "get people in." Now, as federal support to offset loses disappear and those "introductory prices" disappear, the premiums are generally going to increase. Is this the "death spiral" for the Marketplace? No. People largely agree that the insurance landscape is so much better than it was - we don't want to go back to how it was just a few years ago, when we segregated the sick into "high risk pools," discriminated against people with pre-existing conditions, or rescinded coverage. People can also agree that we need to make some tweaks to the Affordable Care Act.

Peterson continues, "Our numbers of uninsured have dropped in Wisconsin...But we have a confusing environment in Wisconsin, making it hard to identify eligibility pathways for coverage." Wisconsin hasn't expanded Medicaid, so while, on paper, there is "no gap" between Medicaid and the Marketplace, there are a lot of people who need help. Peterson says, "this is not easy stuff." How programs interrelate, how to enroll in coverage after losing different coverage is not easy, and the result is people going without coverage, going without care, or watching medical debt accumulate - making care more expensive for everyone else.

WI's Uninsured Rate Drops - But Misses "Goal"

Wisconsin's uninsured rate is down by a third, as report in the Milwaukee Journal Sentinel on September 13. That means that from 2013 to 2015, the number of uninsured dropped from 9.1% to 5.7%. While folks in Wisconsin are celebrating this achievement, they also wonder what might have been.

Wisconsin Governor Scott Walker announced his plan in 2013 to not accept Federal Medicaid Expansion funds, and to instead do a unique, state-funded Wisconsin "expansion" in adding adults without dependent children to BadgerCare Plus. His projection was that an additional 224,600 people would gain health coverage. The state has fallen short of that goal, with 195,000 gaining coverage as reported by the Journal Sentinel. Wisconsin Council on Children and Families' Jon Peacock was interviewed for the article, and said the following, that "the state is forgoing substantial federal aid for its health programs as well as missing out on the chance to likely expand health coverage to tens of thousands more people." The Journal Sentinel reported that opposing federal Medicaid Expansion money in Wisconsin will cost the state nearly $680 million by June 2017. 

But Wisconsin was doing fairly well before. Wisconsin had one of the lowest uninsured rates in the country before the Affordable Care Act. It has maintained its "ranking" as one of the states with the least number of uninsured. So who is "left" as uninsured... and Why?

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Marketplace Enrollment Drops after Tightened SEP Rules

As reported in the June 30 edition of the HealthWatch Wisconsin Update, the Centers for Medicare and Medicaid Services (CMS) responded to select insurance company complaints earlier this year by imposing new restrictions and verification requirements on eligibility for Special Enrollment Periods (SEPs) in the federal Health Insurance Marketplace.

In February, CMS made it more challenging for consumers to qualify for a SEP by imposing new verification requirements on SEP applicants. Despite warnings from policy advocates that making it more difficult to qualify for a Special Enrollment Period would negatively impact enrollment rates, CMS began issuing proposed rules to further limit SEP eligibility this past May. Now, Marketplace statistics seem to be demonstrating exactly the sort of drop in enrollment that drew concern from consumer advocates.

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BadgerCare Plus Enrollment Data - August 2016

This week, Wisconsin's Department of Health Services released August BadgerCare Plus enrollment numbers, and the trends continue. Overall, BadgerCare Plus enrollment was down slightly over July numbers. For the first time since March, there was an increase in the number of children enrolled in BadgerCare Plus. The increase did not offset the number lost in July. We can speculate that as families prepared for "Back to School," more children were connected to coverage. The number of adults without dependent children (Childless Adults) enrolled in BadgerCare Plus has remained somewhat steady. In fact, the trend line over the past 12 months is flat.

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Voices & Views: The Harm of Following "Old Rules"

The Health section of Monday's New York Times told the story of Edwina Kirby, a 75 year old retired civil servant, who after many health issues and complications found herself in a nursing facility in Ann Arbor, Michigan. She received physical therapy for months until her daughter received an email from a therapist saying, "Edwina has reached her highest practical level of independence." This meant she was no longer going to be able to receive coverage and would have to pay out of pocket to continue therapy. 

Unfortunately this happens all too often and a patient that is said to be "not improving" or "reached a plateau" loses coverage.  However this is not a reason for coverage to be denied. 

The results from a class-action lawsuit in 2013 specified maintenance, and not improvement, to be the key factor. As a result it was determined that Medicare must cover skilled care and therapy if they are essential to maintain a patient’s current condition. 

The Centers for Medicare and Medicaid Services does not publish statistics on the reason claims were denied, so no one knows how many people have been incorrectly told they can no longer receive coverage due to lack of improvement by the patient. But as the New York Times reported, Gill Deford, the litigation director of the Center for Medicare Advocacy, says, "most people who have had coverage denied were affected."

This improvement standard, while not a part of Medicare regulations, was written into the CMS manual that providers and claims administrators used, and was a rule that was followed for 30 years.

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Bookmark It! Marketplace Application Checklist

Open enrollment will be here sooner than you know it! November 1, 2016 marks the beginning of open enrollment, which runs until January 31, 2017. The Marketplace Checklist is the perfect resource to prepare you for your Health Insurance Marketplace application.

Both seasoned veterans and eager newcomers can benefit from this checklist covering all the documents and necessary pieces of information anyone could possibly need to successfully place a Marketplace application!

Don't be caught off guard by curveballs. Bookmark the checklist, give it a read, and you'll be ready to file a successful Marketplace application starting November 1st!

Watch This! An Introduction to TEPP and TAP (CC)

Individuals in Wisconsin with disabilities could receive assistance that puts specialized equipment in their home to make basic phone use easier! Think of an amplified headset, a visual display that lets you know when a phone is ringing, or a braille display.

The Telecommunications Equipment Purchase Program (TEPP) is a program available to all Wisconsin residents, regardless of age or income. It simply looks at the disability or impairment an individual would have to determine what accessibility equipment would be appropriate. It operates as a voucher program. For those who cannot afford a cost share, there is the TAP program - the "assistance program" that can help.

To learn more about these programs in Wisconsin, made possible by the Universal Services Fund of the Public Service Commission, watch our featured "Video Case Tip" on "Introduction to TEPP and TAP."

Each informative video from our Video Case Tip Library includes links to resources or more information! You can watch these videos at any time—they're on-demand and available wherever there is an internet connection.

3 C's for CYSHCN! "Competency, Capacity, & Coordination"

Ask a Good Question...

What exactly is the Children's Community Options Program?

Get a Good Answer...

Login to the training portal to read the answer to this week's question!

Family Voices Training Schedule for Fall 2016 Announced:

Family Voices of Wisconsin has released their Training Schedule for Fall of 2016.

These events are an opportunity to expand your knowledge of what resources and services are available for children with disabilities and special health care needs; whether you're a healthcare professional or a parent, the trainings cover care from birth all the way through adulthood. Learn about health insurance and how to best use benefits, Medicaid, as well as long-term supports and community resources!

To view the full schedule of events, starting as early as September 21st and running until November 1st, click here!

Safetyweb Network: Update on Rural Internet Access

In the June 1 HealthWatch Update Newsletter, we covered two, new major initiatives in the past 2 years designed to help remedy the "connection problem" in rural Wisconsin. 

The Connect America Fund and the Connect America Fund II have put millions of dollars in the hands of large providers - AT&T, CenturyLink, and Frontier, to expand rural broadband. But what is this "connection problem" they are trying to remedy with these multi-million dollar grants?

In a recent PEW Internet survey, Rural populations had the lowest rate of internet use, and that usage drops as incomes drop. Overall, rural minorities have the lowest levels of internet use out of the total population. In fact, 31% of African American rural residents have access compared to 54% of white rural residents.

But the issue is more than just slow adoption of home internet connections. There are fewer provider options in rural areas and the largest providers are non-existent. That leaves the more expensive, local company as the only option. There is less broadband coverage, and terrain and open land make it difficult to expand services. Yet, access to the internet is critically important for health. In a PEW Internet Usage study, they determined 73% of rural populations are seeking health information online. Rural residents experience difficulty finding and applying for health services as well when there is a lack of connection.

The Wisconsin Hospital Association, in a September 7 letter to the Members of the Legislative Council Study Committee on Rural Broadband agrees. They write, "On behalf of our more than 140 hospital and health system members...The Wisconsin Hospital Association is submitting this comment to you because affordable, fast, reliable broadband access throughout Wisconsin is critically important for hospitals and the communities they serve, impacting access to rural health care and economic development."

The Wisconsin Hospital Association offers four recommendations, ranging from adding a "medically underserved" criteria when determining who gets state broadband grants to creating a publicly available street level map for broadband utilities. The letter along with recommendations are available here.

More on the Safetyweb Project: ABC for Rural Health, Inc. and a group of community partners and experts secured a federal Rural Health Network grant to support the Safetyweb Health Benefits Counseling Network. This project will expand an existing collaboration to implement a health benefits counseling network that integrates new technology solutions to measurably improve access to health coverage and services for patients in Polk County Wisconsin. For more information contact ABC for Rural Health, Inc.'s COO, Mike Rust.

Covering Wisconsin Enrollment Conference: Save the Date

Covering Wisconsin has announced the Wisconsin Enrollment Conference will take place September 19-20, 2016 at the Kalahari Resort in Wisconsin Dells, Wisconsin.

This two day conference is an opportunity for you to connect and share resources with health insurance enrollment professionals from around the state.

For more information, visit www.coveringwi.org

HealthWatch Wisconsin Corner 

Eau Claire County HealthWatch's September meeting took place September 1 at Mayo Health Systems. Sue Lane, a Programs Manager and ACA Navigator with Workforce Resources, spoke about the Affordable Care Act, Marketplace, and BadgerCare health insurance options for open enrollment. Sue also spoke about SEP eligibility outside of open enrollment. The featured November topic is "Bullying!", and the meeting will take place November 3. For more information about Eau Claire County HealthWatch, send us an email.

On September 12th, The Dane County Healthwatch Coalition met at the Aging and Disability Resource Center, where over 20 attendees discussed the opening of a new dental clinic in Madison--Familia Dental--that accepts Medicaid patients, new policies at the Capitol Consortium affecting FoodShare recipients, among other topics

Health Benefits Advocate, Anna Kaminski of ABC for Health, Inc., also gave a Health Benefits Overview covering general eligibility for BadgerCare Plus, the Marketplace, and Elderly, Blind, & Disabled Medicaid, as well as how to apply for benefits.

The Chippewa County HealthWatch Coalition met earlier this week in Chippewa Falls; an update was provided on the Medical Home Project (through the Western Regional Center for CYSHCN). Planned Parenthood also provided an update; the next meeting is scheduled for November 8. To learn more about Chippewa County HealthWatch, send us an email.

Coalition meetings are held every month and the public is welcome to attend!

CLICK HERE to learn more about meetings of a HealthWatch Coalition in your region of the state.

Coalition Corner

For more information email your local HealthWatch Coalition contact below, or email us

Coalition Next Meeting Contact
Chippewa County Nov. 8 Rose Marsh
Dane County Oct. 3 Anna Kaminski
Eau Claire Nov. 3 Lou Kelsey
Milwaukee Oct. 12 Joanna Woodbury
Pierce County TBD Rebecca Tomasek
Polk County TBD Mike Rust
Tri-County Sept. 27 Connie Raether

Featured Headlines

$63 Million in Navigator Grant Awards for 2017, Enroll America

Wisconsin Makes Gains in Health Coverage, Wisconsin Public Radio

Uninsured Rate Falls in Wisconsin, Milwaukee Wisconsin Journal Sentinel

Annual Wisconsin Birth and Infant Mortality Report 2015, Wisconsin Department of Health Services

The Striking Difference Between States that Expanded Medicaid and the Ones that Didn't, Washington Post

Americans Without Health Care at Record Low. So What's the Problem?, New York Times

Health Insurance Premiums Increase 3 Percent For Working People, Oregon Public Broadcasting

Therapy Coverage and Failure to Improve, New York Times

Why Insurance Denies Your Claim, but Pays Your Neighbor's, New York Times

Additional Links of Interest

Governor Brown Should Sign Strongest In Nation Patient Protections Against Surprise Medical Bills, Health Access Blog

Lack of Medicaid Expansion Hurts Rural Hospitals More Than Urban Facilities, Health Affairs

HHS Awards Over $87 Million for Health Centers' IT Enhancements, CMS Press Release

New Data: 49 States plus DC Reduce Avoidable Hospital Readmissions, CMS Blog Post

ACA Developments: Renewals and Discontinuation Notices, Health Affairs Blog

Some Small Businesses Restore Group Health Coverage, Wall Street Journal

Et Cetera: Memos & Updates


NEW! New Policies Effective October 3, 2016 Related to Life Insurance and Exemption from Certain Fees, Wisconsin Funeral and Cemetery Aids Program, published August 2016

NEW! BadgerCare Plus Eligibility Handbook, published August 8, 2016 in Release 16-02

NEW! Medicaid Eligibility Handbook (MEH), published Jun. 24, 2016 in Release 16-02

NEW! ACCESS Handbook, published July 11, 2016 in Release 16-01

NEW! Marketplace Handbook, published July 19

FoodShare Handbook, Release 16-01 published May 31, 2016.

Administrator's Memo 14-04, 2015 IM Consortia Administrative Allocation, has been published to the DHS web

Ops Memos:

16-29: Process and System Changes Related to the FoodShare Work Registration Requirements

16-28: Updates to 1095-B Tax Form Administration

16-27: CARES to Transmit Eligibility Information to InterChange in Real Time for Real-Time Eligibility Determinations

16-26: New Software for Accessing Documents in the Electronic Case File

16-25: Federal FiscalYear 2017 FoodShare Mass Change

16-24: Enhancements to ACCESS for Partners and Providers and to CARES

16-J5: Enhancements to Real-Time Eligibility and Automated Case Processing Functions in CARE Worker Web and ACCESS

Other ForwardHealth Announcements:

The ForwardHealth Provider Portal Prior Authorization User Guide was recently revised and was posted to the ForwardHealth Portal on July 29, 2016. Revisions involved conversion to a new user guide format.

ForwardHealth user guides and instruction sheets provide users with step-by-step instructions on navigating specific Portal functionality; they do not contain policy information. For complete ForwardHealth policies and procedures, please refer to the Online Handbook on the Portal.

Funeral & Cemetery Aids Program Memos:

Required Forms for WFCAP Payments, June 13, 2016

Administrator's Memo:

16-06 "FoodShare FFY 14 Bonus Funds"

16-05 "Enhanced Federal Funding for Qualifying IM Activities"

16-04 "QUEST/Vault Card Process & Procedures"

Provider Memos:

2016-35: Changes to Billing Policy for Chiropractic Services

2016-34: New and Clarified Policy for the Behavioral Treatment Benefit

2016-33: New Coverage and Prior Authorization Policy for Positioning Seats for use in Motor Vehicles and at Home

2016-32: Revised Prior Authorization Forms and Changes to Pharmacy Policies for Hepatitis C Agents Effective August 1, 2016

2016-31: Policy Regarding Submission of Hospital Claims for Births

2016-30: Pharmacy Policy Changes Effective August 1, 2016

2016-29: Ambulatory Surgical Center Access Payments Discontinued for Fiscal Year 2016

2016-28: Prior Authorization No Longer Required for Cochlear Implant and Bone-Anchored Hearing Device Implant Surgeries

2016-27: Managed Care Program Length-of-Stay Policy Change for Institutions for Mental Disease

2016-26: Implementation of the All Patient Refined Diagnosis Related groups Classification

Tell Us What You Think!

HealthWatch Wisconsin Update readers, we want to hear from you! What do you think of our newsletter? The subject matter? The format? How do you find the material on the HealthWatch Wisconsin Training Site? Do you have any topics you'd like to see or questions you want answered? Please email HealthWatch and let us know!

Support Our Efforts!

Thank you, HealthWatch members, for your support! ABC for Health works hard to ensure that thousands of families in Wisconsin receive the health coverage they need and deserve. What we learn from individuals and families informs the teaching and training we share with HealthWatch Wisconsin members! Keep those families in mind this season and work towards a happier 2016 by supporting ABC for Health in our mission of helping people secure access to health care and coverage. A tax-deductible financial contribution will support direct legal, advocacy, and education services to families in Wisconsin.

Copyright © 2016 ABC for Health, Inc. All rights reserved. No reprint without permission.

HealthWatch Wisconsin is a project of ABC for Health, Inc.
Update Staff:

  • Bobby Peterson, Executive Director
  • Brynne McBride, Chief Operating Officer
  • Ryan StasellExecutive Assistant
  • Matt Keller, HWW Membership Coordinator

Special thanks to ABC for Health staff for their contributions to this Update Newsletter