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Thursday, June 28, 2012
Wednesday, June 20, 2012
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Monday, June 18, 2012
Wisconsin's Insurance Commissioner: Request: DENIED
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In our June 1 Update newsletter,
we covered Wisconsin Commissioner of Insurance Ted Nickel's special
request to the Feds asking to side-step private health insurance rate
review thresholds under the Affordable Care Act.
In his May 7, 2012 request letter,
Commissioner Nickel sought a state specific threshold for rate review.
He said that the Affordable Care Act’s rate review threshold of
reasonableness was “inappropriate” for Wisconsin. Unfortunately for the
Commissioner, his request lacked actuarial data and failed to include
any public input. Additionally, Commissioner Nickel’s letter incorrectly
characterized the current rate review procedures in Wisconsin. ABC for
Health submitted comments to the Feds on Commissioner Nickel's request.In a letter dated June 1, the Feds replied to Commissioner Nickel, denying his request. They actually said the Commissioner didn't follow the directions. Therefore, the 10% rate review threshold will continue to apply in Wisconsin. The Centers for Medicare and Medicaid Services (CMS) writes:
"CMS
has determined that we are unable to accept your proposal because it
does not set forth a proposed State-specific threshold to be used to
determine rate increase filing that would be subject to review in the
State of Wisconsin. Instead, the proposal requested approval for a
methodology and permission for the Office of the Commissioner to use the
methodology to arrive at a State-specific threshold on its own. This proposed approach is not consistent with the instructions presented in the Guidance,
and would not permit the announcement of a State-specific threshold by
June 1, as required under 45 C.F.R. 154.200(b)." (emphasis added.)
CMS posted ABC for Health's public comment on their web page. HealthWatch has been tracking Wisconsin's meager, even hollow attempts at implementing the rate review provision of health reform since spring of 2011 when HHS first announced that the new regulation would take effect on September 1, 2011. Want to learn more? Click here to read a special edition of the HealthWatch Reporter devoted entirely to this issue!
A "Win" For Mental Health Parity
Good
news came out of California this week, signaling that progress is being
made in holding insurers accountable to state mental health parity
laws. A federal appeals court issued a decision that was structured around the state's mental health parity law, finding that even when a private insurance plan excludes mental health treatment, it still must be covered under state law.
Recall that in 2008, the federal government passed the Wellstone and
Domenici Mental Health Parity Act, which requires individual plans and
companies with more than 50 employees to provide the same coverage for
physical ailments and mental health services. States have adopted their
own mental health parity statutes that demand increased coverage, in
addition to existing insurance mandates; the Affordable Care Act also
includes mental health services on its list of essential health
benefits, which state-licensed health insuring organizations are
required to cover in their health insurance plans.
In
the case that went to California's court of appeals, a woman's coverage
at a residential treatment program was denied, and insurer Blue Shield
asserted that residential treatment wasn't "listed" in the Mental Health
Parity Act for the state. The Ninth Circuit ruled the
"law requires insurers to pay for all medically necessary treatment for
severe mental illness." Kenny Goldberg of KPBS public broadcasting in
San Diego reports that the deputy commissioner with the California Department of Insurance
has seen other insurers try to dodge paying for mental health
treatments. He quotes her as saying, "Despite the passage of the mental
health parity law more than a decade ago, insurers have just been
reluctant and resistant to complying." However, it often falls to the
consumer to "know the rules" in order to challenge the insurer! In
California, insurers MUST cover treatments for severe mental illness,
even if the policy excludes it. In Wisconsin, Governor Doyle signed
"mental health parity" legislation into law in April 2010. Wisconsin’s
new law applies to all businesses in the state with at least 10
employees.A Closer Look at Mental Health for Children
Guaranteed Coverage Through EPSDT (HealthCheck)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a comprehensive, preventive well-child screening program for Medicaid-eligible children (under age 21). Congress added the EPSDT component to Medicaid in 1967 in response to documented, widespread, preventable mental and physical illnesses among low-income children and to promote the early detection and treatment of health conditions that could lead to chronic illness or disabilities. Called "HealthCheck" in Wisconsin, the purpose of EPSDT is to assure that all Medicaid-enrolled children receive periodic, comprehensive health screening exams resulting in the identification and provision of medically necessary health care services.Why bother with HealthCheck? Here are just a few of the many reasons:
- Children and families struggle accessing dental care
- Children hit routine limits to mental health care
- EPSDT offers broad coverage
- EPSDT is less expensive than private coverage
- Per Capita, the cost of insuring a low-income child under Medicaid saves money
- Benchmark Plan affects coverage for thousands of Wisconsin children under age 21
- All Benchmark-enrolled children are eligible for Standard Plan benefits
- Coverage limits of Benchmark Plan DO NOT APPLY
- Children get the services they NEED and are entitled to under federal law
Core Plan Law Suit Moves Forward
In the May 18 edition of the HealthWatch Reporter
newsletter, we discussed the continuing dramatic growth the BadgerCare
Plus Core Plan Wait List and plummeting enrollment numbers. Since that
time, much has happened. The enrollment continues to drop and the Wait
List continues to grow, for one. The exchange of letters
among Wisconsin Representative Jon Richards and Representative Tamara
Grigsby and the Feds highlighted the shortcomings of the Wisconsin
Department of Health Services (DHS). CMS said the Walker Administration
MUST submit a plan by August 1 to the federal government that addresses
the large number of individuals falling off the Core Plan. They
continued that Wisconsin "will conduct targeted outreach" to
get people back onto the Core Plan (after the new restrictive
re-enrollment policy begins.) Yet, we would have gone further, and
demanded the Wait List be opened, and the "surplus" be invested in the
health of the people of Wisconsin. Finally, Legal Action of Wisconsin filed suit.
They allege that DHS has violated state and federal law by not
enrolling people in the program. The media is running wild with this
news, citing the HealthWatch Wisconsin Core Plan Counter to demonstrate the size of the Core Plan Wait List. Below are a few news clippings from this week:
- Shephards Express - State sued for not enrolling BadgerCare participants
- Journal Sentinel - Pair sues state over health insurance aid
- Wisconsin State Journal - Lawsuit alleges state is illegally denying BadgerCare coverage
- WCCF Blog - Lawsuit seeks to lift freeze on BadgerCare for childless adults
BadgerCare Plus Changes Take Effect July 1
In two weeks, the new BadgerCare Plus eligibility and enrollment rules will go into effect. Below,
you'll find a summary of the changes, as well as the projected impact
on adults and children on BadgerCare programs. You'll also find a
listing of strategies to help keep families connected to their existing
coverage. If you know of a parent or patient that will LOSE BADGERCARE COVERAGE because of the changed policies, email HealthWatch Wisconsin! We want to hear from the people of Wisconsin!
And don't forget, if you join or renew your HealthWatch membership before July 1, you will receive your own BadgerCare Plus Eligibility Index, a handy reference that will help you make sense of the new premiums and policy information.Summary of Changes to BadgerCare Plus
According to Ops Memo 12-25, the following policy changes will go into effect July 1, 2012:
- New premiums for non-pregnant, non-disabled adults above 133% FPL enrolled in BadgerCare Plus or the Core Plan;
- 12 month restrictive re-enrollment for those who fail to pay premiums;
- Crowd-out for non-pregnant, non-disabled adults (parents or caretakers) above 133% FPL who have access to employer sponsored coverage and contribute less than 9.5% of their household income to the premium payment; and
- Elimination of retroactive eligibility (backdating) for non-pregnant non-disabled parents and caretaker relatives between 133% and 150% FPL.
Strategies for Keeping Wisconsin's Families Covered
In just two weeks, the new BadgerCare Plus rules will be enforced. Families will be subject to new premiums, new reporting requirements, and new penalties for non-compliance. Many adults will lose coverage. Some families won't learn of the rule changes until they are faced with a coverage denial at a hospital, pharmacy or clinic. Below are a few suggestions and strategies of how to help families encountering rule changes.
Applying for Coverage: You should never be told over the phone that you are not eligible for coverage. You can mail or fax an application, you can apply by phone, or you can apply online. You should never be discouraged from applying using any of these options. Contact an advocate as soon as possible if you have problems completing or filing an application.
Renewing Coverage: It is important that you renew your coverage when you receive a “Notice of Review and Reapplication” in the mail. Read this notice carefully. It will tell you how to renew your coverage by mail, telephone, online or by making an appointment.
RENEWAL TIP:
Mark the date on your calendar that is one month before your renewal is
due. This way, you’ll have plenty of time to gather the documents
you’ll need to verify income, insurance, and other information. If you
are an advocate working with a family--calendar renewals for your
patients!
The
renewal process might require you to submit verifications of income and
insurance, among other things. Have this information handy to avoid
delays. Your health coverage will be renewed if you are still eligible.
If you do not reply to the notice, you may lose your coverage and be
restricted from coverage for 12 months. After you renew your
eligibility, call the Managed Care Enrollment Specialists at (800)
291-2002 with questions or concerns about continuing in your current
HMO.Report Changes: You MUST report all changes to your county consortium within 10 days. You can find the phone number for your consortium here. Some examples include:
- Change in income
- Change in address
- Change in family size/birth of a baby
- Change in employment status
It's important to note that the restrictive re-enrollment period only applies as long as the adult’s income remains 133% FPL or higher. If the individual's income drops below 133% FPL during the 12 months, the restriction is lifted and the individual is eligible to apply for benefits. This rule applies to Core Plan enrollees, as well as adults enrolled in BadgerCare Plus.
For more information about the upcoming changes, including what to do if your application is denied and how to work with your HMO, CLICK HERE
Thursday, June 7, 2012
State Sued for Not Enrolling BadgerCare Participants
More than 130,000 childless adults waiting for coverage
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Two
Milwaukee women and Legal Action of Wisconsin are suing the state
Department of Health Services (DHS) for failing to enroll the women in
the BadgerCare Plus Core program.
The Plus Core program, which serves low-income childless adults with no other health insurance options, has an enrollment cap of 48,500 individuals.
Yet in April, only 25,800 people were enrolled.
About five times that number—131,000 individuals—were on the waiting list.
Two of those individuals—Teresa Charles and Susan Wagner, of Milwaukee—are eligible for BadgerCare Plus Core but have been on the waiting list for more than two years.
Charles has a chronic lung condition and no health insurance.
Wagner suffers from a seizure disorder and has no health insurance.
Charles and Wagner contend that DHS is violating state and federal laws by failing to enroll them in the program within 60 days.
In May, state Rep. Jon Richards (D-Milwaukee) and state Rep. Tamara Grigsby (D-Milwaukee) had asked the federal government to look into Wisconsin's potentially illegal waiting list for the BadgerCare Plus Core program.
On Tuesday, Richards agreed with the lawsuit's plaintiffs that the state must enroll qualified individuals within 60 days until it reaches the enrollment cap.
“That's the law,” Richards said. “Unfortunately, the Walker administration has specifically not enrolled people in that program even though there is room available to provide insurance under that program.”
Both Charles and Wagner would have been eligible for the General Assistance Medical Program (GAMP), a precursor to the Plus Core plan in Milwaukee County and elsewhere. GAMP didn't have a waiting list at the time it was folded into BadgerCare in 2009.
“That's the frustrating part,” Richards said. “We eliminated the program that they would have relied on and they [the Walker administration] are not letting them in the program we created to take its place.”
The Plus Core program, which serves low-income childless adults with no other health insurance options, has an enrollment cap of 48,500 individuals.
Yet in April, only 25,800 people were enrolled.
About five times that number—131,000 individuals—were on the waiting list.
Two of those individuals—Teresa Charles and Susan Wagner, of Milwaukee—are eligible for BadgerCare Plus Core but have been on the waiting list for more than two years.
Charles has a chronic lung condition and no health insurance.
Wagner suffers from a seizure disorder and has no health insurance.
Charles and Wagner contend that DHS is violating state and federal laws by failing to enroll them in the program within 60 days.
In May, state Rep. Jon Richards (D-Milwaukee) and state Rep. Tamara Grigsby (D-Milwaukee) had asked the federal government to look into Wisconsin's potentially illegal waiting list for the BadgerCare Plus Core program.
On Tuesday, Richards agreed with the lawsuit's plaintiffs that the state must enroll qualified individuals within 60 days until it reaches the enrollment cap.
“That's the law,” Richards said. “Unfortunately, the Walker administration has specifically not enrolled people in that program even though there is room available to provide insurance under that program.”
Both Charles and Wagner would have been eligible for the General Assistance Medical Program (GAMP), a precursor to the Plus Core plan in Milwaukee County and elsewhere. GAMP didn't have a waiting list at the time it was folded into BadgerCare in 2009.
“That's the frustrating part,” Richards said. “We eliminated the program that they would have relied on and they [the Walker administration] are not letting them in the program we created to take its place.”
Paying for BadgerCare
BadgerCare Plus Core, like other Medicaid programs, is funded by both the state and federal government.
The federal government pays 60%, while the state picks up 40% of the cost. The federal share is money that would have been sent to hospitals that provide a substantial share of medical care to uninsured individuals. The state share comes from a fee levied on hospitals as well, although it is not specifically earmarked for BadgerCare. The thought was that instead of paying for uncompensated care at hospitals, the federal and state governments would provide funds for insurance for low-income Wisconsinites.
DHS spokeswoman Stephanie Smiley couldn't comment specifically on the lawsuit. But she wrote in an email to the Shepherd that the federal government requires the program to be “budget neutral” and that the state would exceed the amount budgeted for the program if it took people off the waiting list.
“The department is not in a position to open enrollment to the Core plan because we are currently tasked with finding additional savings to the Medicaid program,” Smiley wrote.
But an analysis by Jon Peacock, research director for the Wisconsin Council on Children and Families (WCCF), indicates that the state likely has enough funds to enroll more people than the 25,800 individuals currently covered.
Peacock found that the budget bill assumed that the enrollment freeze would be lifted and individuals would be taken off the waiting list. At budget time, it was assumed that 43,000 childless adults could be covered per month with a cost to the state of $57.8 million annually. Estimates have fluctuated based on updated data, Peacock wrote, but he calculated that the state could afford to serve an estimated 34,400 individuals—roughly 9,000 more people than are currently enrolled in BadgerCare Plus Core.
“When DHS imposed the moratorium on additional enrollment, state officials said they would start taking people off the waiting list once enrollment fell to the point where average monthly spending had declined to the cap set by the waiver agreement,” Peacock wrote in a paper to be released publicly this week. “The state reached that point more than a year ago, but the Walker administration has yet to lift the moratorium on Core Plan enrollment.”
The federal government pays 60%, while the state picks up 40% of the cost. The federal share is money that would have been sent to hospitals that provide a substantial share of medical care to uninsured individuals. The state share comes from a fee levied on hospitals as well, although it is not specifically earmarked for BadgerCare. The thought was that instead of paying for uncompensated care at hospitals, the federal and state governments would provide funds for insurance for low-income Wisconsinites.
DHS spokeswoman Stephanie Smiley couldn't comment specifically on the lawsuit. But she wrote in an email to the Shepherd that the federal government requires the program to be “budget neutral” and that the state would exceed the amount budgeted for the program if it took people off the waiting list.
“The department is not in a position to open enrollment to the Core plan because we are currently tasked with finding additional savings to the Medicaid program,” Smiley wrote.
But an analysis by Jon Peacock, research director for the Wisconsin Council on Children and Families (WCCF), indicates that the state likely has enough funds to enroll more people than the 25,800 individuals currently covered.
Peacock found that the budget bill assumed that the enrollment freeze would be lifted and individuals would be taken off the waiting list. At budget time, it was assumed that 43,000 childless adults could be covered per month with a cost to the state of $57.8 million annually. Estimates have fluctuated based on updated data, Peacock wrote, but he calculated that the state could afford to serve an estimated 34,400 individuals—roughly 9,000 more people than are currently enrolled in BadgerCare Plus Core.
“When DHS imposed the moratorium on additional enrollment, state officials said they would start taking people off the waiting list once enrollment fell to the point where average monthly spending had declined to the cap set by the waiver agreement,” Peacock wrote in a paper to be released publicly this week. “The state reached that point more than a year ago, but the Walker administration has yet to lift the moratorium on Core Plan enrollment.”
Wisconsin Alliance for Women's Health
PO Box 1726 Madison, WI 53701
[p] 608.251.0139 | 866.399.WAWH | [f] 608.256.3004
Monday, June 4, 2012
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