BadgerCare Plus Overview

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.

BadgerCare Plus merges family Medicaid, BadgerCare, and Healthy Start into a single program. BadgerCare Plus will expand enrollment to:

• 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.

All individuals enrolled in BadgerCare Plus and Wisconsin Medicaid will be referred to as “members.”

BadgerCare Plus is comprised of two benefit plans, the Standard Plan and the Benchmark Plan. The services covered under the BadgerCare Plus 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 BadgerCare Plus Benchmark Plan is a more limited plan, modeled after commercial insurance.

New services covered under BadgerCare Plus 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. Future Updates will describe these new benefits in detail.

Refer to the November 2007 Update (2007-79), titled “Introduction to BadgerCare Plus — Wisconsin’s New Health Care Program,” for general information on covered and noncovered services, copayments, and enrollment.

Covered Services

Home health services covered under the Standard Plan and the Benchmark Plan are the same as those covered under the current Wisconsin Medicaid program. Refer to the appropriate publications for covered services, policies, and procedures.

Service Limitations for the Benchmark Plan

Under the Benchmark Plan, home health services are limited to 60 home health visits per member per enrollment year.

Prior Authorization

Standard Plan

Prior authorization (PA) policy and procedures are the same under the Standard Plan as they are under the current Wisconsin Medicaid program.

Home health services provided by nurses who are working independently of a home health agency always require PA.

Benchmark Plan

Prior authorization policy and procedures are the same under the Benchmark Plan as they are under the current Wisconsin Medicaid program except that PA will not be granted for visits that exceed 60 during the member’s enrollment year.

Under the Benchmark Plan, home health agencies do not need PA for home health services up to and including 30 visits during one enrollment year. The 31st visit through the 60th visit requires PA.

Even with PA, the Benchmark Plan will not cover over 60 home health visits per enrollment year.

Enrollment Year Under BadgerCare Plus

An enrollment year is defined as the continuous 12-month period beginning the first day of the calendar month in which a member is enrolled in the Benchmark Plan and ending on the last day of the 12th calendar month.

For example, a member completes their BadgerCare Plus application materials by September 25, 2008. During the month of October, the Department of Health and Family Services (DHFS) reviews the application materials and determines that the member is eligible for the Benchmark Plan effective September 1, 2008, the first day of the calendar month that the application materials were completed; however, the enrollment year for this member will not begin until October 1, 2008, the first day of the calendar month in which the DHFS actively enrolled the member in the Benchmark Plan. The Benchmark Plan enrollment year for this member is defined as October 1, 2008, through September 30, 2009. Services received after eligibility is established and before the enrollment year begins are covered under the Benchmark Plan but do not count toward the service limitations.

Subsequent enrollment years begin on the first day of the calendar month immediately following the end of the previous enrollment year, if there is no coverage gap. If there is a coverage gap for more than one day, the enrollment year will reset to begin on the first day of the month in which the DHFS re-enrolls the member into the Benchmark Plan.

If a member switches from the Benchmark Plan to the Standard Plan, the Benchmark Plan enrollment year does not reset. For example, a member’s enrollment year under the Benchmark Plan begins March 1, 2008. During the third month, the member’s income status changes and she is now eligible for the Standard Plan effective June 1, 2008. During August, the DHFS determines that the member is no longer eligible for the Standard Plan and effective September 1, 2008, the member returns to the Benchmark Plan. Since there is not a gap in coverage, the initial Benchmark Plan enrollment year is still active. The member must adhere to limits for services received while covered under the Benchmark Plan during the enrollment year period March 1, 2008, through February 28, 2009.

The Benchmark Plan enrollment year is the time period used to determine service limitations for members in the Benchmark Plan. Services received while covered under the Standard Plan do not count toward the enrollment year service limitations in the Benchmark Plan and vice versa. If a member switches between the two plans during one enrollment year, service limitations will accumulate separately under each plan.

Reimbursement

Providers will be reimbursed for services provided to members at the current Wisconsin Medicaid rate of reimbursement for covered services.

Copayments

Standard Plan

Under the Standard Plan, home health services do not require a copayment.

Benchmark Plan

The copayment amount for home health services under the Benchmark Plan is $15.00 per visit. A visit is defined as all home health services provided on the same date of service by the same performing provider. A single $15.00 copayment applies regardless of the number or type of procedures administered during the visit.

Copayment amounts collected from members should not be deducted from the charges submitted to BadgerCare Plus. Providers should indicate their usual and customary charges for all services provided. BadgerCare Plus will automatically deduct the appropriate copayment amount from payments allowed by BadgerCare Plus.

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.

No other members are exempt from the copayment requirement under the Benchmark Plan.

Under the Benchmark Plan, a provider has the right to deny services if the member fails to make his or her copayment.

Information Regarding BadgerCare Plus HMOs

BadgerCare Plus HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements. For managed care policy, contact the appropriate managed care organization.