General Program Information

In January 2007, Governor Jim Doyle included in his 2007-09 Biennial Budget proposal an innovative state-sponsored health care program to expand coverage to Wisconsin residents and ensure that all children in Wisconsin have access to affordable health care. This new program is called BadgerCare Plus, and it will start on February 1, 2008.

The following are the key initiatives under BadgerCare Plus:

• Ensure that all Wisconsin children have access to affordable health care.
• Ensure that 98 percent of Wisconsin residents have access to affordable health care.
• Streamline program administration and enrollment rules.
• Expand coverage and provide enhanced benefits for pregnant women.
• Promote prevention and healthy behaviors.

BadgerCare Plus will expand enrollment to the following:

• All uninsured children.
• More pregnant women.
• More parents and caretaker relatives.
• Parents with children in foster care who are working to reunify their families.
• Young adults exiting out-of-home care, such as foster care, because they have turned 18 years of age.
• Certain farmers and other self-employed parents and caretaker relatives.

BadgerCare Plus merges family Medicaid, BadgerCare, and Healthy Start into a single program. All individuals enrolled in BadgerCare Plus are referred to as “members.”

Individuals who are 65 years old or older, elderly, blind or have a disability will remain enrolled in their respective programs — SeniorCare, Family Care, or Wisconsin Medicaid. Individuals enrolled in these programs are also referred to as “members” in future Updates.

As with the current BadgerCare program, certain members will be required to pay premiums and some members will have different copayments for certain services. Future Updates will provide service-specific copayment requirements.

Where available, all BadgerCare Plus members will be enrolled in BadgerCare Plus Standard Plan HMOs (previously referred to as Medicaid HMOs). In those areas of Wisconsin where HMOs are not available, services will be reimbursed on a fee-for-service basis.

Benefit Plans under BadgerCare Plus

BadgerCare Plus is comprised of two benefit plans, the BadgerCare Plus Standard Plan and the BadgerCare Plus Benchmark Plan. The services covered under the Standard Plan are the same as the current Wisconsin Medicaid program; therefore, the term “Standard Plan” will be used in all future Updates to describe the shared policy and billing information. The Benchmark Plan is a more limited plan, modeled after commercial insurance.

New services covered under BadgerCare and Wisconsin Medicaid include over-the-counter tobacco cessation products for all members and mental health and substance abuse screening, preventive mental health counseling, and substance abuse intervention services for pregnant women at risk of mental health or substance abuse problems.

BadgerCare Plus Standard Plan

The Standard Plan covers children, parents and caretaker relatives, young adults aging out of foster care, and pregnant women with incomes at or below 200 percent of the Federal Poverty Level (FPL). There are a few changes to current policy regarding copayment amounts, limits, and exemptions, which will be detailed later in this Update and in future service-specific Updates.

BadgerCare Plus Benchmark Plan

The Benchmark Plan was adapted from Wisconsin’s largest commercial, low-cost health care plan. The Benchmark Plan is for children and pregnant women with incomes above 200 percent of the FPL and certain self-employed parents, such as farmers with incomes above 200 percent of the FPL.

The Benchmark Plan will cover prescription drugs, physician services, immunizations, laboratory services, HealthCheck screenings, mental health and substance abuse services, and preventive and basic dental services. Refer to Attachment 1 of this Update for a summary of the Benchmark Plan by service area. More information on covered services will be available in future service-specific Updates.

Services that will be covered under the Standard Plan but are not covered by the Benchmark Plan include, but are not limited to, the following:

• Specialized medical vehicle and common carrier transportation.
• Case management.
• Crisis intervention.
• Community Support Program services.
• Community Care Support services.
• Private duty nursing.
• Personal care.
• Outpatient mental health and substance abuse in the home and the community for adults.

In addition to services not covered, some services covered under the Benchmark Plan have service limitations. Most service limitations under the Benchmark Plan are calculated per enrollment year or the 12-month period beginning when a member becomes enrolled in the Benchmark Plan. Refer to future service-specific Updates to obtain information on service limitations, enrollment year definition, and billing requirements.

Reimbursement

Providers will be reimbursed for services provided to Wisconsin Medicaid and BadgerCare Plus members at the current Wisconsin Medicaid rate of reimbursement for covered services. Specific information on dental reimbursement will be outlined in a future dental Update.

Copayments

As a reminder, providers are prohibited from collecting copayments from the following Medicaid members:

• Nursing home residents.
• Pregnant women.
• Members under 18 years of age with incomes at or below 100 percent of the FPL.
• Members under 18 years of age who are members of a federally recognized tribe regardless of income.
• Members enrolled in Medicaid SSI HMOs or Medicaid special managed care programs.

Standard Plan

Policy and procedures for collecting copayments are the same under the Standard Plan as they are under the current Wisconsin Medicaid program. Refer to previously-published Wisconsin Medicaid publications for more information about copayment amounts and limits.

Some services do not have copayments under the Standard Plan; providers should consult their service-specific publications for more information about services that require copayments.

Policy regarding Standard Plan members who are subject to copayments and members who are exempt from copayments is different than that of the current Wisconsin Medicaid program.

Providers are prohibited from collecting copayments from the following Standard Plan members:

• Nursing home residents.
• Pregnant women.
• Members under 18 years of age with incomes at or below 100 percent of the FPL.
• Members under 18 years of age who are members of a federally recognized tribe regardless of income.

Providers should note that the following Standard Plan members are subject to copayment for services where copayment applies:

• Members enrolled in BadgerCare Plus Standard Plan HMOs (previously referred to as Medicaid HMOs).
• Members under 18 years of age with incomes above 100 percent of the FPL.

Benchmark Plan

Under the Benchmark Plan, copayment amounts generally will be higher than those of the Standard Plan. The only services exempt from copayment are preventive and family planning services and services to pregnant women. Dental services will be subject to deductibles. Under the Benchmark Plan, a provider has the right to deny services if the member fails to make his or her copayment.

The following members are exempt from copayment requirements under the Benchmark Plan:

• Pregnant women.
• Members under 18 years of age who are members of a federally recognized tribe.

Future Updates will address member copayment and cost-sharing requirements in greater detail.

Enrollment

BadgerCare Plus will simplify the enrollment process by consolidating the number of different coverage groups. Under the current enrollment system, there are over 20 different coverage groups, each with different levels of determination and complex rules. Under BadgerCare Plus, this will be reduced to three primary coverage groups. Medical status codes for most current members will be updated to reflect the change in enrollment.

Application Process

BadgerCare Plus will continue the current application process in which individuals who wish to enroll must submit an application through the income maintenance system. This application may be submitted via the Internet at access.wisconsin.gov/access/, over the telephone, through the mail, or in person.

Express Enrollment

Express Enrollment (previously known as Presumptive Eligibility [PE]) will still be available for pregnant women; however, under BadgerCare Plus, Express Enrollment will be expanded to allow certain low-income children a faster, easier way to get in to BadgerCare Plus. BadgerCare Plus will allow Express Enrollment for children to be completed by qualified providers and other community partners (e.g., Head Start; Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]; faith-based organizations; child care centers; schools) for children under 19 years of age with incomes no greater than 150 percent of the FPL. Express Enrollment will be automated though the use of access.wisconsin.gov/access/. A future Update will further define Express Enrollment for children and pregnant women and explain how providers may become certified for Express Enrollment.

Enrollment Verification

Because the Standard Plan and Benchmark Plan differ in covered services and copayments, it is imperative that providers continue to verify a member’s enrollment at each visit to determine under which plan he or she is covered. Providers are reminded to always verify a member’s enrollment before providing services, both to determine that the individual is enrolled for the current date (since a member’s enrollment status may change) and to discover any limitations to the member’s coverage. Providers have several options to obtain enrollment information through the Medicaid Eligibility Verification System and should refer to their provider handbook for more information.

Identification Cards

Identification cards have been redesigned for BadgerCare Plus. Current Forward cards will still be valid. A new ForwardHealth card will be issued upon request when a card is lost or stolen and to new members. Members of the same family may have cards that look different from one another. Refer to Attachment 2 for a sample of the new card.

Further Information on BadgerCare Plus

Refer to the BadgerCare Plus Web site at dhfs.wisconsin.gov/badgercareplus/ for additional program information.

Further Information and Training

Future Updates will include detailed service-specific information. Training on BadgerCare Plus will also be held. Refer to the Wisconsin Medicaid Web site dhfs.wisconsin.gov/medicaid4/trainings/index.htm for information on training dates and locations.

Attachment 1 — At-a-Glance Summary of BadgerCare Plus Benchmark Plan Covered Services
Attachment 2 — Sample ForwardHealth Identification Card