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Date of Implementation

1977 (expansions in 1984 and 1995; and statewide expansion in 1996).

July 1, 1999

April 1, 2005 in Milwaukee Co.

April 1, 2006 in Kenosha, Racine and Waukesha Counties.

April 1993

March 1997

Program Sites

All counties, excluding Door, Florence, Marinette, Kewaunee, Columbia, Iowa, and Lafayette

Beginning in April 2000, counties are the same as the low-income family Medicaid HMO program.

Milwaukee, Kenosha, Racine, and Waukesha Counties.

Dane County

Milwaukee County

Program Description and Approach to Managing Care

Recipients are assigned to and receive all care and services through a contracted HMO. HMOs are responsible for providing directly or contracting for covered services to the enrolled population.

Same as low-income family Medicaid Program.

Care coordinators and a network of providers coordinate medical and social services for SSI and SSI-related Medicaid recipients.

Multi-agency, community-based system of mental health and alcohol and other drug abuse (MH/AODA) services for children with severe emotional disturbances (SED).

Same as CCF

Program Goals

Improve quality of care through better access to and continuity of medical care. Reduce costs through better management and reducing inappropriate care.

Provide a bridge for health care between Medicaid and employer-sponsored health insurance for low-income uninsured families.

Integrate medical and social services and improve quality, access, and coordination of medical services. Improve quality of care through better access to and continuity of medical care.

Keeps children with SED out of institutions. Reallocates resources previously used for institutionalization to community based services for children with SED.

Same as CCF

Authority and Funding Source

State Medicaid agency and a state plan amendment.

State Medicaid agency, 1115 Medicaid and SCHIP waivers, and a Title XXI state plan amendment.

State Medicaid agency and a state plan amendment.

Initially an RWJ Foundation grant. Currently joint funding by DHFS and Dane County Department of Human Services (DCDHS). Authorized by CMS as sole source contract.

Initially a five-year CMHS grant. Now continued through joint funding by DHFS and Milwaukee County DHS. Authorized by CMS as sole source contract.

Type of Enrollment (voluntary or mandatory)

Voluntary for eligible recipients in zip codes with one participating HMO and mandatory for eligible recipients in zip codes with two or more participating HMOs. Recipient may obtain an exemption if criteria are met.

Same Low- Income Family Medicaid HMO program.

Mandatory. Recipients are required to try managed care for 60 days. They have up to 120 days to opt out for Kenosha, Milwaukee, Racine, and Waukesha Counties.

Voluntary

Voluntary

Eligible Population

Low-income family Medicaid HMO recipients residing in zip codes with one or more participating HMO. Dual eligibles are excluded. Exemption criteria exist. Healthy Start is a program for pregnant women and children whose family income is under 185% of the poverty level.

Low-income uninsured families up to 185% of the federal poverty level (FPL). Once enrolled, families may remain in BadgerCare until family income exceeds 200% of the FPL. HMO enrollment criteria for HMOs same as Low- Income Family Medicaid.

SSI and SSI-related Medicaid recipients who reside in Milwaukee, Kenosha, Racine, and Waukesha Counties, are 19 or older, and do not live in an institution or nursing home or participate in other managed care or waiver programs (e.g., CIP, COP, CSP).

Child or adolescent Medicaid recipient and must have SED as defined in HSS 107.32, Wis. Admin. Code, and be at imminent risk of institutional admission to a psychiatric hospital, placement in a child caring institution, or juvenile correction facility.

Same as CCF

Recipient Age Requirement

No age restrictions for parents, but their children must be under age 19.

No age restriction for parents, but their children must be under age 19.

Age 19 and older.

Birth through age 18.

Birth through age 18.

Contracting Entity

HMOs who are licensed by the WI Office of the Commissioner of Insurance. The HMO must also meet Medicaid’s additional standards for quality assurance, cultural sensitivity, enrollment capacity and coordination of care.

Same Low-Income Family Medicaid HMO program.

MCO licensed by the Wisconsin Office of the Commissioner of Insurance. The MCO must also meet Medicaid’s additional standards (for quality assurance, cultural sensitivity, enrollment capacity and coordination of care).

Dane County DHS

Milwaukee County DHS

Risk-Sharing Arrangement and Capitation Rates

No risk sharing. Full capitation for all medical services covered by Medicaid except prenatal care coordination and common carrier transportation. HMOs may provide dental and chiropractic care for additional capitation.

The CY 2006 capitation rates for low-income family Medicaid are based on nine age/gender rate cells. The rates are specific to and vary between nine rate regions and five counties.

A single aggregate capitation rate is paid for Healthy Start Pregnant Women. The CY 2006 rate varies based on the same rate region and county configuration used for the low-income family Medicaid population.

The risk-sharing program was terminated on July 1, 2001. Risk sharing was formerly available to HMOs that chose to participate in a risk-sharing program.

The CY 2006 BadgerCare capitation rates are based on 10 age/gender rate cells. The rates also vary based on the benefit mix (dental and chiropractic services) offered by the HMO. The rates are specific to and vary between the same rate region and county configuration used for low-income family Medicaid enrollees.

No risk sharing. State pays a capitation rate based on the Medicaid fee-for-service costs per member month.

For CY 2006, capitation rates are established based on medical status code groupings (MS 21, other SSI, or MAPP), Medicare coverage (dually eligible or MA only) and eight actuarially determined age/gender cells. This results in 34 individual rates providing continuous case mix adjustment through the monthly claims.

No risk sharing. Dane County DHS also provides payment to cover the non-Medicaid services.

The current Medicaid capitation rate is $1,570.80, which is from July 1, 2006 through June 30, 2007.

No risk sharing. Milwaukee County DHS also provides payment to cover the non-Medicaid services.

The current Medicaid capitation rate is $1,588.30, which is from July 1, 2006 through June 30, 2007.

Payment Arrangements for Other Providers

Fully capitated for all specialty and ancillary medical services covered by the Medicaid program.

Same as low-income family Medicaid HMO program.

Fully capitated for all specialty and ancillary medical services covered by the Medicaid program. Fee-for-service payments for CSP and TCM services.

Through contracted arrangements with Dane County for MH services. Fee-for-service payments for all other necessary medical services.

Through contracted arrangements with Milwaukee County for MH services. Fee-for-service payments for all other necessary medical services.

Case Manager (CM) Responsibility

HMO must have system in place to ensure well managed patient care though assignment of a primary care provider (PCP) or other means, referrals for specialty care, and 24-hour urgent or emergency care.

Same as low-income family Medicaid HMO program.

Care coordinator assigned to each member. Care coordinators conduct needs assessment and develop care plan within 60 days of enrollment and help member select PCP. Care plan includes coordination with social services.

Dane County is responsible for the operational administration of the program and subcontracts for all necessary MH/AODA services at whatever level of intensity required by the recipient, (i.e., inpatient hospital, emergency care, outpatient therapy, residential treatment, therapeutic foster care, and case aide and in-home treatment services). Key service components are clinical case management, crisis services, intensive day treatment and school-based MH services.

Milwaukee County is responsible for the operational administration of the program and subcontracts for all necessary MH/AODA services at whatever level of intensity required by the recipient, (i.e., inpatient hospital, emergency care, outpatient therapy, residential treatment, therapeutic foster care, and case aide and in-home treatment services). Key service components are clinical case management, crisis services, intensive day treatment and school-based MH services.

Enrollee Incentives

No copays. Expansion of services beyond those offered in the fee-for-service system.

Transportation arranged and covered by the HMO (Milwaukee County only)

Same as Low-Income Family Medicaid.

No copays. Care coordinator available 24 hours. Expansion of services beyond those offered in fee-for-service system.

Transportation arranged and paid for directly by the MCO. (Milwaukee County Only)

No copays. Expansion of services beyond those offered in fee-for-service system. Allows client to stay at home.

Same as CCF

Enrollee Participation

Enrollee must obtain services through HMO providers.

Enrollee must obtain services through HMO providers.

For: Kenosha, Milwaukee, Racine, and Waukesha enrollees are assessed and care plan developed within 60 days of enrollment. They must obtain services through MCO's provider network.

Enrollees’ families are part of a child and family treatment team that determines the needed services and supports.

Same as CCF

Covered Services

HMO must cover all services covered under Medicaid fee-for-service, except dental and chiropractic.

HMO must cover all services covered under Medicaid fee-for-service, except dental and chiropractic.

Traditional Medicaid fee-for-service coverage. MCO may cover costs of social and wellness programs.

All necessary MH and AODA services including those not traditionally covered under Medicaid.

Same as CCF

Excluded Services

All services excluded by Medicaid program. HMO may elect not to cover dental and chiropractic services.

Targeted Case Management and Crisis Intervention Services are covered under Medicaid fee-For-Service.

Same as low-income family Medicaid HMO program.

All services excluded by Medicaid program. Services such as TCM, Chiro, Crisis Intervention, and CSP are covered under Medicaid fee-for-service.

Physical Medical Services are covered through fee-for-service.

Same as CCF

Current Status

311,018 enrollees in June 2006. (Link to HMO Monthly Enrollment)

62,349 enrollees in June 2006. (Link to HMO Monthly Enrollment)

17,018 enrollees in June 2006. (Link to HMO Monthly Enrollment)

143 enrollees as of June 30, 2006, funded by Medicaid.

488 enrollees as of June 30, 2006, funded by Medicaid.

Plans for Expansion

N/A

N/A

Expansion of SSI managed care to counties where MCOs meet certification requirements.

No expansion plans at this time.

No expansion plans at this time.

Program Monitoring

HMOs must submit encounter data. Program and medical audits are conducted by DHCF. Annual consumer satisfaction survey.

Same as low-income family Medicaid HMO program.

MCOs must submit encounter data. Program and medical audits are conducted by DHCF. The program conducts an annual consumer satisfaction survey.

Program must submit utilization and outcome data. Quality assurance audits are conducted annually by DHCF.

Program must submit utilization and outcome data. Quality assurance audits are conducted annually by DHCF.