Vol. 12, No. 15
August 15, 2016
Welcome to the HealthWatch Wisconsin Update Newsletter, a bi-monthly publication with exclusive features for members of HealthWatch Wisconsin.
"When It's Time to Change, It's Time to Rearrange"
In this issue...
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BadgerCare Plus Enrollment Data: July
The Wisconsin Department of Health Services released the July BadgerCare Plus enrollment data - and the more things change, the more they stay the same! BadgerCare Plus enrollment, overall, is down from June. Over 1,275 children were dropped from the program - a continuing downward trend. Over 1,100 parents were dropped from coverage, as were over 550 childless adults. The category of "income extensions" increased by almost that exact number - 554. That increase would account for a small number of parents and children, but does not compensate for all 2375+ that were dropped.
Enrollment in the states Medicaid program looks a little different. Enrollment in EBD Medicaid (Elderly, Blind, Disabled) made modest gains, which continues an upward enrollment trend. The MAPP program (Medicaid Purchase Plan) also continues to add members, and has been increasing for the past 12 months.
Two-Midnight Payment Cuts Removed Through Finalized Medicare 2017 Payment Rates
Back in 2014, the Centers for Medicare and Medicaid Services (CMS) adjusted payments of compensation for inpatient services falling under the "two-midnight" rule by -0.2%, a $220 million payment cut. The "two-midnight" rule, established for Medicare admissions on or after October 1st, 2013, states that inpatient admissions will be payable under Medicare A if the admitting practitioner expects the patient to require a hospital stay crossing two midnights. All other inpatient stays lasting less than two midnights are classified, and subsequently billed, as outpatient services.
This past April, CMS proposed to drop the payment cut after receiving a multitude of lawsuits filed against them and negative questioning from a federal judge. In late July, CMS finalized the 2017 Medicare payment rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System. These payment rates include an increase of 0.8% for inpatient payment rates in order to offset the accrued damage from the changes to the "two-midnight" rule in the last three years. Additionally, the new Medicare payment rates include a 1.5% payment reduction to help recover $11 billion lost due to coding overpayments since 2008. While facing critique for this reduction, CMS is required to recover the lost funds by 2017 and therefore deems this a necessary reduction.
Changes to "No Wrong Door" Policy May Speed Eligibility Determinations
One of the consumer-friendly provisions of the Affordable Care Act, commonly known as the "no wrong door" policy, requires state Medicaid agencies to coordinate with state or federal health insurance marketplaces to make sure that an application for health coverage gets routed to the appropriate program regardless of which entity receives the initial application. So far, achieving efficiency in the processing and transfer of individual applications has proved a challenge, making for delays that cause gaps in coverage when people choose the wrong program agency as their first application choice. Fortunately, new guidelines from the Centers for Medicare and Medicaid Services (CMS) may help streamline the process and help avoid gaps in health coverage.
Under the ACA, states that chose to rely on the Federally Facilitated Marketplace (FFM) instead of building their own insurance exchanges have the choice of allowing the FFM to make final determinations about an applicant's Medicaid eligibility or limiting FFM involvement to simply making an assessment of the applicant's eligibility and sending potentially eligible applications on to the state Medicaid agency. Wisconsin is one of eight "assessment states" that chose to leave the final determination of Medicaid eligibility to the state Medicaid agency. In Wisconsin, the state Medicaid agency is the Department of Health Services (DHS) represented by the regional Income Maintenance Consortia and county human services offices.
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Medicaid Expansion Reduces Number of Uninsured
Since 1965, Medicaid has provided health care coverage to millions of low income, uninsured Americans. It has provided health care access to many in need who would otherwise go without necessary medical services. Recently, legislation has been proposed that limits the program's effectiveness and reach, which may result in a loss of coverage for millions. Additionally, certain states have actively taken a policy of refusing to accept federal policies and funding related to Medicaid expansion.
Emerging data reflects that rejecting Medicaid expansion funds is very unwise. Medicaid not only helps the uninsured, it also promotes preventive care and more early screening tests, resulting in the identification of medical issues before they become much more complicated and expensive. Medicaid has also lifted many out of poverty.
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ForwardHealth Update "New and Clarified Policy for the Behavioral Treatment Benefit"
Behavioral Treatment providers and parents of children in need of behavioral treatment will want to make a point of reading and discussing the latest ForwardHealth Provider Update. Providers will want to take particular note of new enrollment criteria and billing code instructions. Parents and providers alike will benefit from understanding updated descriptions of certain types of available services; refined definitions of documentation and prior authorization requirements for those services; and, important issues to watch out for in order to avoid a conflict between private insurance and Medicaid or BadgerCare coverage.
In terms of provider enrollment, the new update appears to ease some of the enrollment requirements for therapists certified as Behavior Analysts, but imposes new training and supervised experience requirements for providers enrolling under a Registered Behavior Technician certification. The update also identifies several CPT or HCPS codes approved for reimbursement by Medicaid and BadgerCare and provides some guidance about how to coordinate claims when both private insurance and Medicaid may be involved.
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One Last Ride -- Seemeyer Exits Retirement to Serve as DHS Seccretary
Last week, Governor Scott Walker announced that Linda Seemeyer, former director of the Walworth County Department of Health and Human Services, will be the new Secretary of the Department of Health Services (DHS).
Starting August 22, Seemeyer will be filling the vacancy left behind by Kitty Rhodes, whose passing left a void in the leadership at DHS. Tom Engels, who was appointed as an Interim Secretary, will then return to his former position as Deputy.
Seemeyer and Walker worked together in the past, when she served as Milwaukee County Administration Director and Walker as 5th Milwaukee County Executive, starting in 2002. Though in 2007, Seemeyer and Walker parted ways citing "personal and professional differences," but have apparently since reconciled.
Auto Enrollment in Medicare Advantage Plans Leaves Some Seniors with Mixed Feelings
According to Kaiser Health News, a little-known section of the Social Security Act is catching some seniors by surprise. Under § 1851(c)(3)(A)(ii) of the Act, health insurance companies, with approval from Medicare, are able to automatically enroll members of their marketplace or other commercial plans into their own Medicare Advantage plans when these individuals become eligible for Medicare. Under a process called "seamless continuation of coverage," insurance companies are required to send a letter to the member explaining the new coverage. Unless the member opts out within 60 days, the Medicare Advantage Plan coverage takes effect.
Unfortunately, Medicare officials have refused to name the insurance companies that have received approval to automatically enroll their members in Medicare Advantage Plans.
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Voices & Views: Is the ACA Broken?
The Affordable Care Act (ACA) has proven to be somewhat problematic for big health insurance conglomerates. Companies such as Aetna, UnitedHealth Group, Humana, and Anthem have all reported unfavorable profits within their Obamacare Divisions, with healthcare premiums being consistently lower than the medical bills insurers pay to healthcare providers. As a result, many of these companies have halted Obamacare expansion in an attempt to stem the tide of hundreds of millions in losses.
The reason for these losses has primarily to do with the provisions of the Affordable Care Act and how different insurance providers are reacting to it; with varying degrees of success. Two major provisions of the Affordable Care Act do much to explain these companies' circumstances. First, there is the requirement that insurance companies do not deny coverage based on pre-existing medical conditions and second, that a tax penalty is levied against those who do not actively participate in the healthcare system. The expectation of this second requirement being that more people will pay insurance premiums that will ultimately cover the costs of those with chronic medical conditions. Unfortunately, this has not worked out as anticipated and the ratio of those who have chronic medical conditions to new healthy enrollees has become too high to turn a profit, even with the encouragement of enrollment through the tax penalty.
However, not all medical insurance companies are losing money.
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Bookmark It! The ACCESS Handbook
Have a question about applying for benefits like child care, FoodShare, Family Planning Only Services, or Health Care? Eligibility confusion? Look no further than the ACCESS Handbook published by the State of Wisconsin Department of Health Services, available at http://www.emhandbooks.wisconsin.gov/ah/ah.htm.
The handbook provides readers with the chance to interact with detailed visuals of the eligibility screening and application process, as well as links and instructions for applying for benefits online. It's useful to bookmark the handbook to keep track of rule changes and updated information, as things change quickly.
Watch This! Marketplace Change Reporting (CC)
Do you know what types of change requires reporting to the Marketplace? Find out what Marketplace change reporting is, why it matters, when to report, and how you can possibly save you money and yourself a headache later on.
To watch, Click Here or on the image at the right.
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"
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Safetyweb Network: The Family Glitch Revisited
The Affordable Care Act introduced Advance Premium Tax Credits to help keep the cost of health insurance "affordable."
"Affordable" was very specific.
Affordable meant that families with household income below 150% of the federal poverty level should not pay any more than 4% of their income for health insurance. Families with income below 133% should not pay any more than 2%. That’s what Congress meant by Affordable Care Act.
This is achieved by offering these families a monthly "Advance Premium Tax Credit" that the Marketplace sends to your insurance company every month to help pay for your premiums. As household incomes rise closer to 400% of the poverty level, the premium tax credits help a little less; keeping your premium costs down to 9.5% of your household income (9.56% of income in 2015, and 9.66% for 2016.)
However, if your employer offers you affordable coverage, then you cannot also qualify for a Premium Tax Credit. Here's where the problem gets out of hand. The Marketplace says that employer-sponsored insurance is affordable if the premium for coverage for just the employee costs less than 9.66% of household income.
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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
County HealthWatch Coalition Updates:
Milwaukee County HealthWatch Update
August's Milwaukee HealthWatch meeting took place Wednesday, August 10 at Aurora Family Services on West Highland Boulevard. The featured presenters were Captain Michael Wright from the Milwaukee Fire Department, and Jill Rabowitz with the Milwaukee Health Department. Captain Wright presented on the Milwaukee Fire Department's role in the City of Milwaukee's Mobile Integrated Health Program, and also provided detailed information about Community Paramedic efforts. Jill Rabowitz with the Milwaukee Department of Health announced upcoming back to school fairs and health department open house events, more information is available here. For more information about Milwaukee HealthWatch, please click here.
Dane County HealthWatch Update
The Dane County Coalition met Monday, August 1 at the Waisman Community Outreach Center in Madison. The meeting theme was 'back to school' and Kirsten Engelbert (Family Liaison of Madison Metropolitan School District) and Amy Olejniczak (PATCH program) were the featured presenters. Jennifer Fischer provided updates on behalf of the ADRC, Michele Chiuchiolo provided an update from the Capital Consortium, and upcoming meeting topics were briefly discussed. Click here for more information about Dane County HealthWatch.
Interested in Joining a Coalition in Your Area?
CLICK HERE to learn more about meetings of a HealthWatch Coalition in your region of the state.
For more information email your local HealthWatch Coalition contact below, or email us
Participation in FoodShare Falls More than 120,000 in 2 Years, Wisconsin State Journal
CMS Final Rule 'Permanently' Removes Controversial Two-Midnight Payment Cut, HealthcareDive
Obamacare Appears to Be Making People Healthier, New York Times
Revisiting Churn: An Early Understanding of State-Level Health Coverage Transitions Under the ACA, National Academy for State Health Policy
Texas Judge Refused to Dismiss Health Insurance Provider Fees Case, Health Affairs Blog
OCI Unveils Revamped Web Site, Office of the Commissioner of Insurance
Mapping Broadband Health in America, Federal Communications Commission
Proposed Rule: Medicaid Disproportionate Share Hospital Payments, CMS
Additional Links of Interest
How to Regulate Insurance Network Adequacy, HealthcareDive
Solutions to Curb Teen Suicide Gain Support, Post-Crescent
Judy Faulkner Refutes Rivals' Claims About Epic EHR Being Closed, HealthcareITNews
Medicaid Coverage of Social Interventions: A Roadmap for States, Manatt
CMS News: Affordable Care Act Payment Model Continues to Improve Care, Lower Cost, CMS
Revisiting Churn: An Early Understanding of State-Level Health Coverage Transition Under the ACA, NASHP
Et Cetera: Memos & Updates
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
15-22 (Amended): New Way to Access Online Reports from CARES
16-23: FoodShare Employment and Training (FSET) Program as an Approved Activity for Wisconsin Shares Eligibility
16-22: Changes to Administrative Code DCF 202 and Creation of DCF 12
16-21: Updated Wisconsin Shares Special Needs Higher Rate Request Form
16-20: CCBG Phase 1: Elimination of the Six Month Report Form (SMRF) for Child Care
16-19 (Amended): Child Care EBT PP Conversion Process
16-J3: Archiving CARES Worker Web and CARES Data
16-18: Updated Institutional Cost of Care Values
16-17:Reasonable Compatibility for the Medicaid Purchase Plan
16-16: New Policy Regarding a QUEST Card Replacement Fee, June 1, 2016
16-15: Spousal Impoverishment Income Allowance Federal Poverty Level Adjustment, May 26, 2016
16-14: Work Requirement for Basic Education and Technical Education or Course of Study Leading to Employment, May 3, 2016
16-13: Wisconsin Shares Self-Employment Policy, May 2, 2016
16-12: CWW Enhancements for Child Care Interviews, April 27, 2016
16-11: Child Care and School Program Collaboration, April 25, 2016
16-08 (AMENDED): WI Shares Child Care Eligibility Verification
16-07: Enforcing the 40% Rule for Children of Child Care Provider Employees, May 16, 2016
16-06: Policy Clarifications for Able-Bodied Adults Without Dependents Exemption for Members Who Are Unfit for Employment, April 11, 2016
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
16-06 "FoodShare FFY 14 Bonus Funds"
16-05 "Enhanced Federal Funding for Qualifying IM Activities"
16-04 "QUEST/Vault Card Process & Procedures"
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 System
2016-25: Information for Eligible Professionals Regarding Program Year 2016 of the Wisconsin Medicaid Electronic Health Record Incentive Program
2016-24: New Coverage and Prior Authorization Policy for Gait Trainers
Tell Us What You Think!
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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.
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Special thanks to ABC for Health staff for their contributions to this Update Newsletter