BadgerCare Plus Basic Plan

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                               BadgerCare Plus Basic Plan
            Access to Health Care for Individuals on the
                                      Core Plan Waitlist
                                               Concept Paper

                                              January 20, 2010
Wisconsin – BadgerCare Plus Basic Plan Concept Paper                                                                                   Page 2 of 28




                                BadgerCare Plus Basic Plan
                                   Health Insurance for Individuals on the
                                        Core Plan Waitlist Proposal
                              Wisconsin Department of Health Services

EXECUTIVE SUMMARY ..................................................................................3

STRATEGIC ALIGNMENT ...............................................................................4

PROJECT APPROACH....................................................................................4

WISCONSIN’S UNINSURED............................................................................5

BADGERCARE PLUS FOR CHILDREN AND FAMILIES ...............................7

BADGERCARE PLUS CORE PLAN................................................................8

BADGERCARE PLUS BASIC PLAN.............................................................10
  ELIGIBILITY .......................................................................................................................................................11
  BENEFIT ...........................................................................................................................................................12
  COST MODEL....................................................................................................................................................12

FUNDING AND BUDGET...............................................................................13

PUBLIC INVOLVEMENT................................................................................13

APPENDIX A – FINANCIAL ANALYSIS STATEMENT.................................17

APPENDIX B – BENEFITS COMPARISON...................................................21




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EXECUTIVE SUMMARY

U    nder the direction of Governor Doyle, Wisconsin has developed a new program to allow
     access to health care to address the needs of low-income adults without dependent children
who are currently on the BadgerCare Plus Core Plan Waitlist. It is designed to assist those people
while they're otherwise waiting to enroll in the Core Plan and offer them some basic primary and
preventative services that can help meet their health care needs and help prevent bankruptcy due
to excessive medical debt. This new program, the BadgerCare Plus Basic Plan, is only available to
those eligible for the Core Plan Waitlist, has higher member cost sharing, and a benefit package that is
not greater than the Core Plan benefit package.

This proposal outlines Wisconsin’s plan to create a self-funded option for health care access for
those low-income adults without dependent children on the BadgerCare Plus Core Plan Waitlist. It
builds upon Wisconsin’s goal to ensure access to affordable health insurance for virtually all
Wisconsin residents.

In his 2006 State of the State address, Wisconsin Governor Doyle announced his goal to provide
access to affordable health care to all children and to streamline the enrollment process through
BadgerCare Plus. In his 2007 State of the State address, the Governor announced the expansion
of the program to low-income adults without dependent children. By implementing these important
reforms, 98% of Wisconsin’s population now has access to high quality, affordable health care.


The expansion to low-income adults without dependent children, in the form of the BadgerCare
Plus Core Plan, provides access to health care services that includes primary and preventive care,
certain generic and over-the-counter drugs, and a limited number of brand name drugs. The
BadgerCare Plus Core Plan is not an entitlement program and is less comprehensive than
traditional Medicaid. It is a federally approved 1115 waiver program and must adhere to strict
budget neutrality requirements.

The expansion to adults without dependent children began implementation on January 1, 2009 to
members enrolled in the Milwaukee General Assistance Medicaid Program (GAMP) and other
general assistance (GA) medical program participants statewide. Applications from the general
public began June 15th, 2009, offering benefits that began July 15th, 2009. The interest in enrolling
in BadgerCare Plus Core Plan has been overwhelming. More than 63,000 residents now have
access to affordable health care through the Core Plan – many for the first time in years. This
tremendous interest, however, has now resulted in the suspension of program enrollment and
enactment of a statewide waitlist to comply with Federal waiver budget neutrality requirements.
Applicants that are determined to be potentially eligible for coverage according to Core Plan
program rules will continue to be added to the Core Plan Waitlist.

The BadgerCare Plus Basic Plan is a self-funded plan that focuses on providing Core Plan
Waitlist members with access to vital, cost-effective primary and preventative care. This option will
allow members to have some minimal form of coverage until space becomes available in the
BadgerCare Plus Core Plan and will help prevent bankruptcy due to excessive medical debt.

Eligibility to enroll in the BadgerCare Plus Basic Plan is limited to those applicants on the Core
Plan Waitlist. Waitlist status may only be obtained if an applicant self-reports and meets Core Plan
program rules and is potentially eligible for Core Plan coverage. An applicant must meet program

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rules to enroll in the BadgerCare Plus Core Plan and thus qualify for the Core Plan Waitlist and
BadgerCare Plus Basic Plan. Basic Plan applicants will also be informed of alternative sources of
health insurance coverage. This will include information about the new Wisconsin law that allows
eligible young adults under the age of 27 to be covered under their parents plan. This will also
include information about Wisconsin’s Health Insurance Risk Sharing Plan (HIRSP).

The BadgerCare Plus Basic Plan benefit package provides cost-effective primary and preventative
care. Basic Plan benefits are designed to be more restrictive than Core Plan benefits and will be
provided on a fee-for-service basis generally set at Medicaid rates by Medicaid Certified Providers.

As a self-funded plan, premium payments and member cost-sharing are required. Premiums will
be established that are sufficient to fund the health care costs of the population served. Efforts
have been made to design a broad-based benefit while keeping premium costs as low as
possible.. Badger Rx Gold membership cards will be provided to members to supplement the
Basic Plan’s drug coverage. Basic Plan members must pre-pay monthly premiums. Grace periods
will be enacted as well as disenrollment penalties for failure to pay.

Administrative functions are closely modeled after the BadgerCare Plus Core Plan. This alignment
will help offset additional overhead costs by building upon the infrastructure already in place, and
enable Wisconsin to meet the implementation timelines set forth.

Wisconsin plans to begin accepting initial Basic Plan applications from Core Plan Waitlist
individuals by March 2010, with enrollment and benefits beginning in April, 2010.

STRATEGIC ALIGNMENT

I n his January 2006 State of the State address, Wisconsin Governor Jim Doyle stated that “no
  child should ever be without health insurance.” To meet this goal, BadgerCare Plus – Health
Insurance for All Kids – was implemented on February 1, 2008. BadgerCare Plus covers all
children and expanded coverage groups of pregnant women, parents and caretaker relatives.

In his 2007 State of the State Address, Governor Doyle expanded this initiative to include low-
income adults without dependent children. Expanding BadgerCare Plus to adults without
dependent children was designed to significantly increase access to affordable quality health care
for 98% of Wisconsin’s citizens currently underinsured or uninsured. BadgerCare Plus Core Plan
for adults without dependent children began implementation on January 1, 2009 to members
enrolled in the Milwaukee General Assistance Medicaid Program (GAMP) and other general
assistance (GA) medical program participants statewide. Applications from the general public
began June 15th, 2009, offering benefits that began July 15th, 2009.

Under the direction of Governor Doyle, Wisconsin has developed a new program to allow access
to health care to address the needs of those on the Core Plan Waitlist. It is designed to assist
those people while they're otherwise waiting for to enroll in the Core Plan and offer them some
basic primary and preventative services that can help meet their health care needs. This new
program, the BadgerCare Plus Basic Plan, follows the Core Plan Waitlist enrollment rules, has
higher member cost sharing, and a more restrictive benefit package.

PROJECT APPROACH

W     isconsin Governor Jim Doyle charged the Department of Health Services (DHS) with
      designing a program to allow limited access to health care to address the needs of those on

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the Core Plan Waitlist until space in the Core Plan is available. This new program, BadgerCare
Plus Basic Plan, follows the Core Plan Waitlist enrollment rules, has higher member cost sharing,
and a more restrictive benefit package.

BadgerCare Plus Basic Plan is a self-funded option available to those individuals on the Core Plan
Waitlist. The Department will capitalize on current BadgerCare Plus program infrastructure to
reduce administrative overhead and help ensure the Basic Plan as a no cost option for the State.

Utilizing current program infrastructure will also allow the Basic Plan to be implemented quickly to
respond to the great need and interest of the adults without dependent children population.

An internal Steering Committee coordinated program development. Issues were initiated from the
involvement of numerous workgroups. In addition, Steering Committee recommendations are
presented and discussed with the BadgerCare Plus Advisors Group and the Clinical Advisory
Committee on Health and Emerging Technologies (CACHET) (see Public Involvement—Advisors
Group section). A joint hearing at the Senate and Assembly Health Committees was held to gather
additional input. Their comments and suggestions have been considered in developing the benefit
package and incorporated into this proposal.

The Department is working with the State Legislature to seek statutory authority to offer
BadgerCare Plus Basic Plan to individuals on the Core Plan Waitlist.


WISCONSIN’S UNINSURED

W      isconsin has a proud tradition of offering its residents access to comprehensive health care
       services through employers and public programs. Still, far too many people do not have
access to affordable health insurance, and subsequently, lack access to quality health care. The
inability to access affordable health insurance affects all residents through higher health care costs
over time, higher insurance premiums and cost-sharing, and an increased burden on public
programs.

Statewide public health care programs traditionally provide services to low-income children,
pregnant women, and their families, as well as the elderly and disabled. Historically, low-income
uninsured adults without dependent children have not been covered, even though their income
levels are similar to the family program levels. A 2006 survey of the uninsured found that 57% of
all uninsured people in the United States are adults without dependant children.1 This statistic may
actually be worse given the nature of the current economy nationwide.

According to analysis of the 2006 report on Wisconsin Health Insurance Coverage, young adults
are more likely to be uninsured than any other segment of the State’s population. Residents of the
City of Milwaukee and the self-employed also have higher uninsured rates. Low-income Wisconsin
residents are also more likely to be uninsured than those with higher incomes, according to
national research on the uninsured. State and federal data indicate that the number of people with
employer-sponsored insurance is decreasing, while the number of uninsured is increasing.2



       1
         L. Dubay, J. Holahan. A. Cook, “The Uninsured and the Affordability of Health Insurance Coverage,” Health
       Affairs 26, no. 1 (2007): w22-w30, published online November 30, 2006; 10.1377/hlhaff.26.1.w22.
       2
         Kaiser Commission on Medicaid and the Uninsured. “The Uninsured: A Primer.” October 2006. www.kff.org

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Health insurance coverage affects access to health care and the financial well-being of families.
According to the Kaiser Commission on Medicaid and the Uninsured, over 40% of non-elderly,
uninsured adults have no regular source of health care, and coupled with a fear of high medical
bills, many delay or forgo needed care.3 Delaying or forgoing needed primary care can lead to
more serious illnesses and health problems. Lack of health care coverage not only affects access
to health care and health status, but also job decisions and financial security. In addition, medical
expenses of the uninsured have been shown to be a major contributor to U.S. bankruptcy filings.4

There is also an impact on health care providers and hospitals as they face increasing demands
for care by the uninsured for which there is little or no reimbursement. This uncompensated care
places fiscal demands on these institutions, government bodies, private health insurance
companies and the philanthropies that support them. According to the Wisconsin Hospital
Association, 143 Wisconsin hospitals provided $736.1 million of uncompensated health care
services to their patients in fiscal year 2005, including charity care ($338.6 million) and bad debt
($397.5 million).5

According to the American Journal of Medicine®, illnesses and medical bills contribute to a large
and increasing share of US bankruptcies.6 Illness and medical bills were linked to at least 62.1%
of all personal bankruptcies in 2007. 92% of these medical debtors had medical debts over
$5,000, or 10% of pretax family income. Hospital bills were the largest single out-of-pocket
expense for 48%. Between 2001 and 2007, the share of bankruptcies attributable to medical
problems rose by 50%. Based on the current bankruptcy filing rate, medical bankruptcies are
expected to reach about 1.4 million during 2009.

The aforementioned data was the supporting documentation to drive the development of the
BadgerCare Plus suite of programs. Governor Doyle’s goal is to ensure access to health care for
98% of Wisconsin citizens. This was the goal of BadgerCare Plus Core Plan for Wisconsin low-
income adults without dependent children. The demand for BadgerCare Plus Core Plan
enrollment has been overwhelming. More than 63,000 residents now have access to affordable
health care – many for the first time in years. Due to a variety of influencing factors affecting the
down turn of the national economy and individuals economic / employment status, thousands of
citizens are still in dire need of health care access.

As of January 8th, 2010, BadgerCare Plus Core Plan enrolled 63,644 members. Applications
received reached 88,000 with thousands of applications still pending review and approval/denial.
The Core Plan Waitlist was activated October 9th, 2009. An average of 1,500 application requests
have been received each week since the waitlist began. As of the first part of January we have
18,546 members who are currently on the Waitlist. Waitlist member demographics indicate:
   ƒ 45% 30 years of age or younger
   ƒ 19% greater than age 50
   ƒ 58% male
   ƒ 40% eligible for FoodShare

       3
         Kaiser Commission on Medicaid and the Uninsured. “The Uninsured and Their Access to Health Care,”
       October 2006. www.kff.org. publication #1420-08.
       4
         D.U. Himmelstein, “Illness and Injury as Contributors to Bankruptcy,” Health Affairs 24 (2005): w63-w73,
       published online February 2, 2005, 10.1377/hlhaff.w.5.63.
       5
         Wisconsin Hospital Association. “Uncompensated Health Care Report, Wisconsin Hospitals, Fiscal Year
       2005.” January 2007. www.wha.org
       6
         The American Journal of Medicine, “Medical Bankruptcy in the United States, 2007: Results of a National
       Study” 2009. www.pnhp.org

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BADGERCARE PLUS FOR CHILDREN AND FAMILIES

B   adgerCare Plus provides access to affordable, comprehensive health care coverage for all
    children in Wisconsin and their parents. BadgerCare Plus is a single health care safety net
that merged Family Medicaid, BadgerCare (SCHIP), and Healthy Start and significantly expanded
the Health Insurance Premium Payment (HIPP) program to increase effective use of employer-
sponsored insurance.      In addition, BadgerCare Plus dramatically simplified the eligibility
determination process by eliminating needless complexity that created barriers to enrollment,
increased administrative costs and limited access to services. In short, BadgerCare Plus was the
most sweeping reform of the low-income portion of Medicaid in Wisconsin since its inception in
1967. BadgerCare Plus is simple to understand, simple to enroll in, and simple to administer. It
promotes and supports healthy living for low-income children, families, and pregnant women.

BadgerCare Plus for Children and Families serves:

   1)   All uninsured children (birth through age 18) regardless of income
   2)   Pregnant women with incomes up to 300% of the FPL
   3)   Parents and caretaker relatives with incomes up to 200% of the FPL
   4)   Caretaker relatives with incomes up to 200% of the FPL
   5)   Parents with children in foster care with incomes up to 200% of the FPL
   6)   Youth (ages 18 through 20) aging out of Wisconsin’s foster care system
   7)   Farm families and other self-employed parents with dependent children with incomes up to
        200% of the FPL, contingent upon depreciation calculations

The eligibility determination process for children and families is straight forward, and even provides
an Express Enrollment option for children and pregnant women. The State has taken steps to
reduce crowd out, automate verifications, and simplify reporting procedures and eligibility re-
determinations.

BadgerCare Plus for Children and Families offers two benefit packages to its members.

   x    The Standard Plan covers all mandatory and optional health care services for which federal
        matching funds are available. Covered services include: prescription drugs; physician
        services; inpatient and outpatient hospital services; intermediate care facility services;
        laboratory and x-ray services; medical supplies and equipment; dental and vision services;
        Early, Periodic, Screening, Diagnosis, and Treatment services; Mental Health and Alcohol
        and Other Drug Abuse (MHAODA) services; day treatment services; nursing services;
        personal care services; physical, occupational, and speech therapy; and transportation to
        obtain medical care. The Standard Plan cost-sharing has the same nominal co-payments
        as in the former Family Medicaid, BadgerCare, and Healthy Start programs

   x    The Benchmark Plan is adapted from the largest commercial, low-cost health care plan
        available in Wisconsin. It covers prescription drugs, physician services, inpatient and
        outpatient hospital services, laboratory and x-ray services, early childhood development
        services, dental services, limited therapies, and limited mental health/alcohol and drug
        addiction services. In addition, the plan includes two preventive benefits targeted to
        pregnant women including smoking cessation and mental health and substance abuse
        counseling. Cost-Sharing under the Benchmark Plan requires co-payments for certain
        services. Preventive services such as immunizations, well-child visits, smoking cessation,
        prenatal care, etc., are not subject to cost-sharing in the Benchmark Plan.

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Wisconsin implemented an innovative and aggressive multi-year pay-for-performance (P4P)
strategy for Medicaid managed care to improve HMO performance for BadgerCare Plus members
during 2008. P4P in managed care helps the State implement BadgerCare Plus goals and
Wisconsin public health priorities. Wisconsin’s P4P strategy focuses on results, not just services
provided. The multi-year strategy builds upon and refines the State’s existing P4P incentives that
include both individual and system-level incentives to promote and support healthy behaviors and
improved health outcomes.

Wisconsin’s P4P strategy includes incentives in the following areas: Child Immunization; Asthma
Management; Diabetes Management; Blood Lead Testing; and Tobacco Cessation. Performance
in these areas is largely measured using HEDIS, the Healthcare Effectiveness Data and
Information Set established by the National Committee for Quality Assurance (NCQA).

In addition, the Department has implemented a separate quality initiative to substantially improve
health care outcomes for BadgerCare Plus members in Southeast Wisconsin, as HMO
performance in this part of the state has consistently lagged that of HMOs’ in the rest of the state.
Beginning in CY 2011, HMOs providing services in Southeast Wisconsin will incur financial
penalties for not meeting the Department’s quality performance benchmarks in diabetes testing,
blood lead testing, childhood immunization, asthma management, tobacco cessation, emergency
department utilization management, dental utilization, and healthy birth outcomes. Organizations
that do not perform well could lose up to 3.25% of their capitation rate -- the most funding placed
at-risk for performance of any state.

BADGERCARE PLUS CORE PLAN

S   tarting January 1, 2009, the State implemented the second phase of Wisconsin’s
    comprehensive health care reform: enrolling low-income adults without dependent children in
BadgerCare Plus Core Plan to provide access to health care services that includes primary and
preventive care, certain generic and over-the-counter drugs, and a limited number of brand name
drugs. Adults without dependent children use a centralized Enrollment Services Center that
processes applications, renewals, and changes; answers questions; resolves problems for
members and prospective members; and provides ongoing case management.

Potential members must meet certain requirements to qualify for BadgerCare Plus Core Plan that
includes:

   ƒ   Wisconsin residency;
   ƒ   U.S. citizenship or qualifying immigration status;
   ƒ   Ages 19-64;
   ƒ   No dependent minor children under age 19 living with them;
   ƒ   Income at or below 200% of the FPL ;
   ƒ   Not pregnant, disabled, entitled to Medicare or qualified for a full benefit BadgerCare Plus,
       Medicaid, or CHIP program;
   ƒ   Does not have access to health insurance through a current employer in the month of
       application or subsequent three months;
   ƒ   Did not have access to health insurance through a current employer in the 12 months prior
       to application, unless there is a good cause reason for not signing up;
   ƒ   Is not currently covered by a health insurance policy (through employer or individual policy);
       and



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   ƒ   Has not been covered by a health insurance policy in the 12 months prior to application,
       unless there is a good cause reason for losing the coverage, such as a recent layoff.

   Health insurance coverage is defined as medical care (provided directly, through insurance or
   reimbursement or otherwise) under any hospital or medical service policy or certificate, hospital
   or medical services plan contract, or HMO contract offered by a health insurance issuer.

   Health insurance coverage includes group health insurance coverage, individual health
   insurance coverage and short-term, limited duration insurance. For the purposes of this policy,
   health insurance does not include County General Assistance Medical Programs, Health
   Insurance Risk Sharing Plan (HIRSP), Medicaid, BadgerCare Plus, Indian Health Program or
   other public health care programs for the uninsured.

There is no backdating of eligibility for BadgerCare Plus childless adults. Individuals are enrolled
in the program beginning the first or the fifteenth day of the month, whichever is soonest, after all
eligibility requirements have been met. Eligibility is determined within 30 days of submitting their
application and enrollment fee. Eligibility is based upon gross income without any deductions or
disregards. Adults without dependent children that qualify for BadgerCare Plus will remain eligible
for 12 continuous months unless they become eligible for other Medicaid or SCHIP coverage or no
longer reside in the State of Wisconsin.

Building on Wisconsin’s success in managed care, all members will be enrolled in one of the
seventeen Wisconsin health plans currently providing services to BadgerCare Plus members.
This continues efforts to expand access to health care while controlling costs. HMO selection is
part of the application process.

The Core Plan covers services such as primary and preventive care and generic drugs. The
BadgerCare Plus Core benefit plan is less comprehensive than the BadgerCare Plus Standard and
Benchmark plans available to children and families.

The BadgerCare Plus Core Plan is not an entitlement program and is less comprehensive than
traditional Medicaid. It is a federally approved 1115 waiver program and must adhere to strict
budget neutrality requirements.

All BadgerCare Plus Core Plan members have reasonable cost-sharing. Members will pay an
enrollment fee and are required to pay affordable co-payments for services where applicable. Co-
payments are waived for preventive services.

The Enrollment Services Center (ESC) is Wisconsin’s entry point for adults without dependent
children. Their applications, renewals, and all other case processing are handled centrally by a
partnership that includes both public workers and vendor staff. Public workers are responsible for
determining eligibility for BadgerCare Plus and handling all data exchanges. ACCESS, the current
online tool for applications, self-assessment, case management and reporting changes, has been
modified and expanded to provide this functionality.

The application process for BadgerCare Plus Core Plan can be outlined as four main components
as described below:




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   1. Apply for Benefits collects basic demographic information from applicant and his/her family.
      Based on the information provided, the application will determine if applicant is likely eligible
      for the BadgerCare Plus Core Plan (information to sign up for waitlist provided here).
   2. Health Needs Assessment is the next required component of the application process. This
      captures basic health information and preferences from the applicant.
   3. HMO Selection provides information about the potential HMOs in the applicant’s area and
      encourages the selection of HMO during the application process.
   4. Collection/payment of the non-refundable application processing fee.

The expansion to adults without dependent children began implementation on January 1, 2009 to
members enrolled in the Milwaukee General Assistance Medicaid Program (GAMP) and other
general assistance (GA) medical program participants statewide. Almost 12,000 transitional
members were enrolled in BadgerCare Plus Core Plan. Applications from the general public
began June 15th, 2009, offering benefits that began July 15th, 2009.

The interest in enrolling in BadgerCare Plus Core Plan has been overwhelming. More than 63,000
residents now have access to affordable health care – many for the first time in years. Since
BadgerCare Plus Core Plan a federally approved 1115 waiver program, it must adhere to strict
budget neutrality requirements. The enrollment has reached capacity and surpassed federal
waiver budget neutrality limits. The result is the suspension of program enrollment applications
and the enactment of a statewide Waitlist on October 9th, 2009.

The Core Plan Waitlist is made up of those enrollees that are determined to be potentially eligible
for coverage according to Core Plan program rules. The first step of the Core Plan application
process, Apply for Benefits, is completed to determine potential eligibility. The Health Needs
Assessment and HMO selection aren’t completed, nor is there an enrollment fee to be a member
on the waitlist.

As of January 8th, 2010, BadgerCare Plus Core Plan enrolled 63,644 members. Applications
received reached 88,000 with thousands of applications still pending review and approval/denial.
The Core Plan Waitlist was activated October 9th, 2009. An average of 1,500 application requests
have been received each week since the waitlist began. As of the first part of January, we have
18,546 members who are currently on the Waitlist.

BADGERCARE PLUS BASIC PLAN
Under the direction of Governor Doyle, Wisconsin has developed a new program to allow access
to health care to address the needs of those on the Core Plan Waitlist until space in the Core Plan
is available. In addition, the program is designed to prevent members from going into bankruptcy
due to excessive medical debt. This new program, BadgerCare Plus Basic Plan, follows the Core
Plan Waitlist enrollment rules, has higher member cost sharing, and a offers a more restrictive
benefit package. This option allows some minimal form of coverage until space becomes available
in the Core Plan.

Participation, or non-participation, in the BadgerCare Plus Basic Plan does not affect status on the
Core Plan Waitlist. Application processing will be handled centrally by the Enrollment Services
Center (ESC). Applicants for the Basic Plan will be encouraged to apply online via ACCESS,
although telephone applications will also be accepted.




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Eligibility
Eligibility to enroll in BadgerCare Plus Basic Plan is limited to those applicants on the Core Plan
Waitlist. Waitlist status may only be obtained if an applicant meets Core Plan program rules and is
potentially eligible for Core Plan coverage. Like the Core Plan, there is no eligibility backdating for
the Basic Plan.

An enrollee must meet the following program rules to enroll in the BadgerCare Plus Core Plan and
thus qualify for the Core Plan Waitlist and BadgerCare Plus Basic Plan:

   ƒ   Wisconsin residency;
   ƒ   U.S. citizenship or qualifying immigration status;
   ƒ   Ages 19-64;
   ƒ   No dependent minor children under age 19 living with them;
   ƒ   Income at or below 200% of the FPL (self-reported);
   ƒ   Not pregnant, disabled, entitled to Medicare or qualified for a full benefit BadgerCare Plus,
       Medicaid, or CHIP program;
   ƒ   Does not have access to health insurance through a current employer in the month of
       application or subsequent three months;
   ƒ   Did not have access to health insurance through a current employer in the 12 months prior
       to application, unless there is a good cause reason for not signing up;
   ƒ   Is not currently covered by a health insurance policy (through employer or individual policy);
       and
   ƒ   Has not been covered by a health insurance policy in the 12 months prior to application,
       unless there is a good cause reason for losing the coverage, such as a recent layoff.

   Health insurance coverage is defined as medical care (provided directly, through insurance or
   reimbursement or otherwise) under any hospital or medical service policy or certificate, hospital
   or medical services plan contract, or HMO contract offered by a health insurance issuer.

   Health insurance coverage includes group health insurance coverage, individual health
   insurance coverage and short-term, limited duration insurance. For the purposes of this policy,
   health insurance does not include County General Assistance Medical Programs, Health
   Insurance Risk Sharing Plan (HIRSP), Medicaid, BadgerCare Plus, Indian Health Program or
   other public health care programs for the uninsured.

An information letter shall be mailed to all Core Plan Waitlist members with Basic Plan information
and a premium payment slip that they can use to request Basic Plan enrollment and submit initial
premium payment. Basic Plan enrollment shall begin on the first of the month. Initial premium
payments must be received by 4:30 p.m. on the 15th of the month in order to be enrolled the
following month. If an initial payment is received after the cutoff date of 4:30 p.m. on the 15th, the
benefit will be delayed by one month.

BadgerCare Plus Basic members will not be subjected to annual review requirements. Members
shall continue to stay eligible as long as they continue to pay the monthly premium, meet the basic
ongoing eligibility requirements, and are still on the BadgerCare Plus Core Plan Waitlist. As soon
as a spot opens in BadgerCare Plus Core Plan, Waitlist and Basic Plan members will be required
to complete the Core Plan application (including the HNA, HMO selection) in the order in which
they applied.



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Benefit
The BadgerCare Plus Basic Plan benefit package offers cost-effective primary and preventative
care. Basic Plan benefits are not greater than Core Plan benefits. Services will be provided on a
fee-for-service basis from a Medicaid Certified Provider. Reimbursement rates are generally set at
Medicaid rates. The Basic Plan will provide a separate membership card to differentiate from the
current ForwardHealth card currently used for the other Wisconsin health care programs.

Other programs, such as the Family Planning Waiver Program, will continue to be available to Core
Plan Waitlist and Basic Plan members.

The Basic Plan as a fee-for-service benefit covers the following limited services:
   x Professional physician services including primary and preventative care, specialists,
      surgical and medical services, and chronic disease management limited to 10 visits per
      enrollment year.
   x Diagnostic services including laboratory and radiology
   x One inpatient stay and five non-emergency outpatient visits (excluding inpatient psychiatric
      stays in either an Institute for Mental Disease or the psychiatric ward of an acute care
      hospital). Subsequent stays are covered after enrollment year hospitalization (excluding
      ER) deductible of $7,500 billed at Basic Plan payment rates has been met. No outlier costs
      are covered. Providers must accept Medicaid inpatient reimbursement without outliers as a
      condition of program participation.
   x Physical, occupational, and speech therapy are included but are limited to 10 visits annually
      per discipline
   x Emergency outpatient services limited to 5 per enrollment year
   x Dental services limited to emergency services only.
   x Durable medical equipment limited to $500 and disposable medical supplies limited to basic
      physician and therapeutic services, subject to an annual limit.
   x Generic only drugs and some over-the-counter drugs. Preferred brand insulins, Tamiflu
      and Relenza are the only exception to generic and will be covered. Other brand name
      drugs will be discounted through BadgerRx Gold.

   See Appendix B for full benefit description and comparison.

Brand name drug discounts will be available to BadgerCare Plus Basic Plan members through
Badger Rx Gold. Membership cards will automatically be provided to members to supplement the
Basic Plan’s drug coverage. This is a separate program administered by Navitus, which provides
for a discount on the cost of drugs.

Cost Model
The Basic Plan will be self-funded, meaning that no state general purpose revenue or federal
Medicaid funds will be used to pay for it. Premiums and member cost-sharing will be required.
Premiums will be established that are sufficient to fund the health care costs of the population
served. Efforts have been made to design a broad-based benefit while keeping premium costs as
low as possible. Initial estimates indicate a premium at approximately $130 per month.

Basic Plan members will be required to pay premiums in monthly increments due on the 5th of
each month prior to the month of coverage. A grace period of up to 10 days will be allowed,
receiving payments up until the 15th of the month. Benefits will be terminated for failed payments.


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Failure to pay premium amounts in a timely manner may result in a 12-month restrictive re-
enrollment period before allowing a terminated member to reapply for benefits.

Co-payments are also part of the cost sharing structure. Limitations, deductibles, and caps will be
applied on an enrollment year basis. During the deductible period (after first inpatient / five
outpatient hospital stays), the rates charged to members will be set at the Basic Plan payment rate.
This will help ensure the program is sustainable as a self-funded plan, keep cost-sharing affordable
to members, and limit the risk of medical bankruptcy for members. As with BadgerCare Plus
Benchmark and Core Plans, a provider can refuse to provide services if a member does not pay
the copayment.

Administrative functions are closely modeled after the BadgerCare Plus Core Plan. A small portion
of the premium will cover the administrative functions associated with the BadgerCare Plus Basic
Plan. The web-based ACCESS system will be enhanced to accept Basic Plan enrollments. The
ESC will centrally process applications. The CARES system will be enhanced to provide
capabilities to members and workers to request and manage BadgerCare Plus Basic Plan benefits.

Wisconsin plans to begin accepting initial Basic Plan applications from Core Plan Waitlist
individuals by March 2010, with enrollment and benefits beginning in April, 2010.

FUNDING AND BUDGET

B   adgerCare Plus Basic Plan will be self-funded, meaning that no state general purpose revenue
    or federal Medicaid funds will be used to pay for it. Premiums and member cost-sharing will be
required. Premiums will be established that are sufficient to fund the health care costs of the
population served. Efforts have been made to design a broad-based benefit while keeping
premium costs as low as possible. A small portion of the premium will be used to cover
administrative functions.

The Department is creating a $1 million working capital reserve fund using federal grant dollars for
the Basic Plan to reflect potential cash flow and/or underwriting issues with the implementation of
the program. This type of reserve fund is similar to that of commercial insurance plans, but reflects
the unique features of the state operated Basic Plan.

See Appendix A for a copy of the financial analysis document that provides a detailed description
of the data and assumptions used in the development of the BadgerCare Plus Basic Plan benefit
cost model. A professional actuarial firm provided the independent fiscal analysis. Using their
model, they believe the cost estimates are accurate and reasonable. The methods used for
calculating these costs are consistent with the development of the 2010 BadgerCare Plus
capitation rates.

PUBLIC INVOLVEMENT

B    adgerCare Plus for Children and Families was announced by Wisconsin Governor Doyle in his
     2006 State of the State address. His goal was to provide access to affordable health care to
all children and to streamline the enrollment process. In his 2007 State of the State address, the
Governor announced the expansion of the program to low-income adults without dependent
children leading to quality, affordable health care access for 98% of Wisconsin’s population.
Since the original announcement in 2006, the State has worked diligently to inform Wisconsin
citizens about the programs and to seek input into the design and development of the various
BadgerCare Plus suite of programs.

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BadgerCare Plus Advisors Group
The BadgerCare Plus Advisors Group is responsible for providing guidance and advice to the State
on all policy and program design issues. The group met often during the development and
implementation of BadgerCare Plus for Children and Families to review and discuss
recommendations from the internal Steering Committee and offer suggestions for improvements.
Those meetings continued during the development and implementation of the Core Plan for adults
without dependent children. Each of these sessions was also a public meeting.

The BadgerCare Plus Advisors Group has been critical to the design, development, and
implementation of BadgerCare Plus for Children and Families and the Core Plan expansion to
adults without dependent children. The group was expanded from the original Children and
Families initiative to include more representatives from Milwaukee and advocates for a broader
population when work for the adult population began.               The Advisors Group includes
representatives from business, health plans, providers, public health, farmers, Native American
tribes, the State Legislature, faith-based organizations, county government, advocacy groups, and
the University of Wisconsin.

The Advisors Group will continue to work with the Department through development and
implementation of the BadgerCare Plus Basic Plan. Current members are:

   o   Bevan Baker, City of Milwaukee Health Department
   o   Bill Bazan, Wisconsin Hospital Association, Inc.
   o   John Chianelli, Milwaukee County Department of Health and Human Services
   o   Sheila Clough, Howard Young Health Care; Ministry Health Care
   o   Mike Farrell, Creative Insurance Planning Co.
   o   Donna Friedsam, University of Wisconsin Population Health Institute
   o   Jason Helgerson, Wisconsin Department of Health Services
   o   C.C. Henderson, Milwaukee Health Services, Inc.
   o   Barb Horner-Ibler, Free Clinic Collaborative
   o   Michael Jacob, Covering Kids and Families - Wisconsin
   o   Jim Jones, Wisconsin Department of Health Services
   o   Kathy Kaelin, Automated Health
   o   Bruce Kruger, Medical Society of Milwaukee County
   o   Matt Krumenauer, Wisconsin Federation of Cooperatives
   o   Lisa Lamkins, AARP Wisconsin
   o   Maureen McNally, Froedtert and Community Health
   o   Danyel McNeil, City of Milwaukee Health Department
   o   Dr. John Meurer, Medical College of Wisconsin
   o   Senator Mark Miller, Wisconsin State Senate
   o   Father Thomas Mueller, St. Cyril and Methodist Orthodox Church, Milwaukee
   o   Paul Nannis, Strategic HealthCare Solutions
   o   Lon Newman, Family Planning Health Services, Inc.
   o   Bill Oemichen, Cooperative Network
   o   Jon Peacock, Wisconsin Council on Children and Families
   o   Bobby Peterson, Advocacy & Benefits Counseling (ABC) for Health, Inc
   o   Lori Pidgeon, Ho-Chunk Nation
   o   Representative Jon Richards, Wisconsin State Representative
   o   David Riemer, Community Advocates
   o   Bill Smith, National Federation of Independent Business

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Wisconsin – BadgerCare Plus Basic Plan Concept Paper                                Page 15 of 28


   o   Joy Tapper, Milwaukee Health Care Partnership
   o   Dr. Susan Turney, Wisconsin Medical Society
   o   Nancy Wenzel, Wisconsin Association of Health Plans
   o   Paul Zimmerman, Wisconsin Farm Bureau Federation

Clinical Advisory Committee on Health and Emerging Technologies (CACHET)
The Clinical Advisory Committee on Health and Emerging Technology (CACHET) was created to
advise the DHS Secretary on the inclusion and prioritization of services in the Core benefit, identify
centers of excellence and develop therapy guidelines. The CACHET’s advice is taken into
consideration in how to structure the benefit packages to meet the needs of the population and
control costs.

Current members are:
   o Michele Bachhuber, MD, Security Health
   o Dr. Jessica Bartell, MD
       Dr. Tim Bartholow, Wisconsin Medical Society
   o Bill Bazan, Wisconsin Hospital Association, Inc.
   o Lon Blaser, Group Health Cooperative
       Richard Brown, UW School of Medicine and Public Health
   o Howard Croft, Milwaukee St. Mary’s ER - Infinity Health
   o Mary Davis,Dean Health Plan
   o Dr. Michael Goldrosen, MD
   o Rita Hallett, Wisconsin Department of Health Services
   o Jason A. Helgerson, Wisconsin Department of Health Services
   o Dr. Tito Izard , MD Milwaukee Health Services
       Tom Jackson, UW-Center for Tobacco Research and Intervention (Aurora Affiliate)
   o Dr. Jonathan Jaffery, Wisconsin Department of Health Services
   o Linda Jovilette, Security Health
   o Trudy Mara, Dean Health Plan
   o Marlia Moore , Wisconsin Department of Health Services
   o Christine Petty, Dean Health
   o Scott Persing, MD
   o Matt Richardson
   o Jean Riquelme, Bellin Health
   o Julie Schuller, FQHCs in Milwaukee
   o Charles Shabino, MD Wisconsin Hospital Association
   o Say Xiong

Legislative Briefings
The BadgerCare Plus Advisors Group membership and meetings have included legislative
participation. A joint hearing at the Senate and Assembly Health Committees was held to gather
additional input. Their comments and suggestions have been considered in developing the benefit
package and incorporated into this proposal. As development of the proposal continues, the
Department will provide briefings for members of the Wisconsin State Legislature.

Web Site
A key component of Wisconsin’s outreach and communication strategy is its web presence.
Wisconsin’s external site, www.badgercareplus.org/, includes BadgerCare Plus member and
provider information. It also contains a link for comments and questions. This web site is


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referenced in all marketing and outreach materials and discussions regarding BadgerCare Plus
programs.

Income Maintenance Advisory Committee (IMAC)
The Department consults regularly with a group of managers from county and tribal governments
who are experts in the determination and certification of benefits for Medicaid, BadgerCare Plus,
FoodShare, and Temporary Assistance for Needy Families (TANF) programs. These managers
are appointed by the Wisconsin County Human Services Association and meet monthly with
Department staff and managers.




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Appendix A – Financial Analysis Statement




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Appendix B – Benefits Comparison

     BadgerCare Plus                BadgerCare Plus                BadgerCare Plus             BadgerCare Plus
      Standard Plan                 Benchmark Plan                    Core Plan                  Basic Plan

Ambulatory Surgery Centers (ASC)
Full coverage               Full coverage                      Full coverage                Full coverage limited to 5
                                                                                            visits per enrollment
                                                                                            year.

$3.00 co-payment per service   $15 per visit                   $3.00 co-payment per         $60 co-payment per visit
                                                               service
Chiropractic Services
Full coverage                  Full coverage                   Full coverage                No Coverage
$.50 to $3.00 co-payment per   $15 co-payment per visit        $.50 to $3.00 co-payment
service                                                        per service
Dental Services
Full coverage                  Limited coverage of             Coverage limited to          Coverage limited to
                               preventive, diagnostic,         emergency services only      emergency services only
                               simple restorative,
                               periodontics, and extractions
                               for pregnant women and
                               children

                               Coverage limited to $750 per
                               enrollment year.
$.50 to $3.00 co-payment per   A $200 deductible applies to    No co-payment                $10 co-payment per visit
service                        all services except
                               preventive and diagnostic.

                             Cost-sharing equal to 50% of
                             allowable fee on all services
Disposable Medical Supplies (DMS)
Full coverage                Coverage of syringes,             Coverage of syringes,        Coverage of syringes,
                             diabetic pens and DMS that        diabetic pens, ostomy        diabetic pens, ostomy
                             is required with the use of a     supplies, and DMS that is    supplies, and DMS that is
                             durable medical equipment         required with the use of a   required with the use of a
                             (DME) item.                       DME item.                    DME item.

$0.50-$3.00 co-payment per     No co-payment                   $0.50-$3.00 co-payment       Up to $5 co-payment per
priced unit                                                    per priced unit              priced unit
Drugs
Comprehensive drug benefit     Generic drug-only formulary     Generic-only formulary       Generic-only formulary
with coverage of generic and   with a few generic OTC          drug benefit with a few      drug benefit with a few
brand name prescription        drugs                           generic OTC drugs            generic OTC drugs,
drugs, and some over-the-                                                                   limited to 10 per calendar
counter (OTC) drugs            Members will be                 Minimal brand drug           month.
                               automatically enrolled in the   coverage
                               Badger Rx Gold plan. This                                    Preferred brand insulins,
                               is a separate program           Members will be              Tamiflu and Relenza are
                               administered by Navitus,        automatically enrolled in    the only exception to
                               which provides for a discount   the Badger Rx Gold plan.     generic and will be
                               on the cost of drugs.           This is a separate program   covered.
                                                               administered by Navitus,
                                                               which provides for a         Members will be


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     BadgerCare Plus                 BadgerCare Plus               BadgerCare Plus             BadgerCare Plus
      Standard Plan                  Benchmark Plan                   Core Plan                  Basic Plan

                                                               discount on the cost of      automatically enrolled in
                                                               drugs.                       the Badger RX Gold plan.
                                                                                            This is a separate
                                                                                            program administered by
                                                                                            Navitus, which provides
                                                                                            for a discount on the cost
                                                                                            of drugs.
Co-payments:                   $5 co-payment with no limits    Up to $4.00 copayment for    Up to $5 copayment
- $0.50 for OTC drugs                                          generic drugs and up to
                                                               $8.00 for brand name
- $1.00 for generic drugs                                      drugs with a $24.00
- $3.00 for brand                                              copayment limit per
                                                               month, per provider.
Co-payments are limited to
$12.00 per member, per
provider, per month. OTCs
are excluded from this $12.00
maximum.
Durable Medical Equipment (DME)
Full coverage                 Full coverage up to $2,500       Full coverage up to $2,500   Full coverage up to $500
                              per enrollment year              per enrollment year          per enrollment year
$0.50 to $3.00 co-payment     $5 co-payment per item           $0.50 to $3.00 co-payment    Up to $10 co-payment
per item                                                       per item                     per item
                              Rental items are not subject
Rental items are not subject  to co-payment but count          Rental items are not         Rental items are not
to co-payment                 toward the $2,500 annual         subject to co-payment but    subject to co-payment but
                              limit.                           count toward the $2,500      count toward the $500
                                                               annual limit.                annual limit (covered at
                                                                                            MA rates).
End Stage Renal Disease (ESRD)
Full coverage                 Full coverage                    Full coverage                Full coverage
No copayment                  No copayment                     No copayment                 $10 copayment per visit
Health Screenings for Children
Full coverage of HealthCheck Full coverage of                  Not applicable               Not applicable
screenings and other services HealthCheck screenings
for individuals under age 21
years                         HealthCheck “Other”
                              services and Interperiodic
                              services for individuals under
                              age 21 years are not
                              covered.
$1 co-payment per screening   No co-payment
for 18, 19, and 20 year olds
only
Hearing Services
Full coverage                 Limited coverage of services     No coverage                  No coverage
                              provided by an audiologist.

                               Hearing aids, hearing aid
                               batteries, cochlear implants
                               and bone-anchored hearing
                               devices are not covered.
$.50 to $3.00 per procedure    $15 per procedure,
                               regardless of the number of
No co-payment for hearing      procedures performed during
aid batteries                  one visit


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     BadgerCare Plus                  BadgerCare Plus                BadgerCare Plus              BadgerCare Plus
      Standard Plan                   Benchmark Plan                    Core Plan                   Basic Plan

Home Care Services (Home Health, Private Duty Nursing and Personal Care)
Full coverage of private duty Full coverage of home health Coverage limited to 100            No coverage
nursing, home health          services                       visits post-hospitalization
services, and personal care   Coverage limited to 60 visits  per 30 day period of
                              per enrollment year.           eligibility. No daily limit on
                                                             number of home care
                              Private duty nursing and       visits.
                              personal care are not
                              covered.
No co-payment                 $15 co-payment per visit       No co-payment.
Hospice Services
Full coverage                 Full coverage, up to 360       Full coverage                    Full coverage
                              days per lifetime
No co-payment                 No co-payment                  No co-payment                    No co-payment
Inpatient Hospital Services
Full coverage                 Full coverage, with the        Full coverage (not               First inpatient stay -full
                              following dollar amount limits including inpatient              coverage with Prior
                              per enrollment year:           psychiatric stays in either      Authorization (but with a
                                                             an IMD or the psychiatric        different PA method). If
                              - $6,300 for stays in a        ward of an acute care            first stay is a transfer,
                                   general acute care        hospital)                        both providers must PA.
                                   hospital for substance
                                   abuse                                                      Coverage does not
                                                                                              include:
                              - $7,000 for stays in an
                                   IMD (Institutes for                                        - inpatient psychiatric
                                   Mental Disease) for                                             stays in either an
                                   substance abuse                                                 IMD or the
                                   treatment                                                       psychiatric ward of
                                                                                                   an acute care
                                Hospital stays for mental                                          hospital
                                health and substance abuse                                    - transplant services
                                services have a 30-day limit
                                                                                              Per diem facility stays will
                                                                                              be capped at the length
                                                                                              of 14 days.

                                                                                              No outlier costs will be
                                                                                              paid for inpatient stays,
                                                                                              including stays that occur
                                                                                              during the deductible
                                                                                              period.

                                                                                              Subsequent stays
                                                                                              covered after first
                                                                                              inpatient stay would be
                                                                                              subject to a $7,500
                                                                                              inpatient & outpatient
                                                                                              hospital (excluding ER)
                                                                                              deductible at MA
                                                                                              payment rates per
                                                                                              enrollment year.

                                                                                              After the deductible is
                                                                                              reached, full coverage
                                                                                              payment will not include
                                                                                              outliers.


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    BadgerCare Plus               BadgerCare Plus               BadgerCare Plus              BadgerCare Plus
     Standard Plan                Benchmark Plan                   Core Plan                   Basic Plan

$3.00 co-payment per day     Co-payment:                    $3.00 co-payment per day     $100 co-payment per
with a $75 cap per stay      - $100 stay for medical        for members with income      covered stay (not
                                 stays                      up to 100% FPL with a        applicable to deductible).
                                                            $75 cap per stay
                             - $50 co-payment per
                                 stay for mental health
                                                            $100 co-payment per stay
                                 and/or substance abuse
                                                            for members with income
                                 treatment
                                                            from 100% to 200% FPL

                                                            There is a $300 total co-
                                                            payment cap per
                                                            enrollment year for
                                                            inpatient and outpatient
                                                            hospital services for all
                                                            income levels.
Mental Health and Substance Abuse Treatment*
Full coverage (not including Coverage of this service is    Coverage limited to mental   No coverage.
room and board)              based on the Wisconsin         health therapy services
                             State Employee Health Plan.    provided by a psychiatrist
                                                            only.
                             Covered services include
                             outpatient mental health,
                             outpatient substance abuse
                             (including narcotic
                             treatment), mental health
                             day treatment for adults,
                             substance abuse day
                             treatment for adults and
                             children, and
                             child/adolescent mental
                             health day treatment and
                             inpatient hospital stays for
                             mental health and substance
                             abuse.

                             Services not covered are
                             crisis intervention,
                             community support program
                             (CSP), Comprehensive
                             Community Services (CCS),
                             outpatient services in the
                             home and community for
                             adults, and substance abuse
                             residential treatment.

                             Mental health services have
                             no dollar maximums.

                             Substance abuse services
                             are limited to $7,000. Costs
                             of mental health services,
                             including inpatient stays,
                             apply to this overall limit.
                             Also, there are separate
                             dollar limits for specific
                             substance abuse services:
                             - $4,500 for outpatient
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     BadgerCare Plus                    BadgerCare Plus                  BadgerCare Plus               BadgerCare Plus
      Standard Plan                     Benchmark Plan                      Core Plan                    Basic Plan

                                         substance abuse
                                         services including
                                         $2,700 for outpatient
                                         services (including
                                         narcotic treatment) for
                                         substance abuse day
                                         treatment.
                                   - $6,300 for inpatient
                                         hospital stays in a
                                         general acute care
                                         hospital.
$.50 to $3.00 co-payment per       $10 to $15 co-payment per         $.50 to $3.00 co-payment
service, limited to the first 15   visit for all outpatient          per service, limited to $30
hours or $500 of services,         services:                         per provider, per
whichever comes first,                                               enrollment year
provided per calendar year.        -    $10 per day for all day
                                        treatment services
Co-payment not required
when services provided in
                                   -    $15 per visit for narcotic
                                        treatment services (no
hospital setting
                                        co-payment for lab
                                        tests)
                                   -    $15 per visit for
                                        outpatient mental health
                                        diagnostic interview
                                        exam, psychotherapy í
                                        individual or group (no
                                        co-payment for
                                        electroconvulsive
                                        therapy and
                                        pharmacological
                                        management)
                                   -    $15 per visit for
                                        outpatient substance
                                        abuse services
Nursing Home Services
Full coverage                Full coverage for stays at              No coverage                   No coverage
                             skilled nursing homes limited
                             to 30 days per enrollment
                             year.
No co-payment                No co-payment
Outpatient Hospital – Emergency Room
Full coverage                Full coverage                           Full coverage                 Full coverage limited to 5
                                                                                                   ER visits per enrollment
                                                                                                   year.

No co-payment                      $60 co-payment per visit          No co-payment for             $60 co-payment per visit
                                   (waived if member admitted        members with income up        (waived if member
                                   to hospital)                      to 100% FPL                   admitted to hospital)

                                                                     $60 co-payment per visit
                                                                     for members with income
                                                                     from 100% to 200% FPL
                                                                     (waived if member
                                                                     admitted to hospital)
Outpatient Hospital Services


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     BadgerCare Plus                   BadgerCare Plus              BadgerCare Plus                 BadgerCare Plus
      Standard Plan                    Benchmark Plan                  Core Plan                      Basic Plan

Full coverage                     Full coverage                 Full coverage up to 25          First 5 outpatient non-ER
                                                                non-ER outpatient visits        visits - full coverage with
                                                                per enrollment year.            Prior Authorization (but
                                                                                                with a different PA
                                                                                                method)
                                                                Outpatient mental health
                                                                and substance abuse             Subsequent visits
                                                                treatment services are not      covered after first 5
                                                                covered.                        outpatient visits would be
                                                                                                subject to a $7,500
                                                                                                inpatient & outpatient
                                                                                                hospital (excluding ER)
                                                                                                deductible at MA
                                                                                                payment rates per
                                                                                                enrollment year.

                                                                                                After the deductible is
                                                                                                reached, full coverage
                                                                                                payment will not include
                                                                                                outliers.
$3.00 co-payment per visit        $15 co-payment per visit      $3.00 co-payment per visit      $60 co-payment per visit
                                                                for members with income
                                                                up to 100% FPL

                                                                $15 co-payment per visit
                                                                for members with income
                                                                from 100% to 200% FPL

                                                           $300 total co-payment cap
                                                           per enrollment year for
                                                           inpatient and outpatient
                                                           hospital services for all
                                                           income levels.
Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)
Full coverage                Full coverage, limited to 20  Full coverage, limited to 20         Full coverage, limited to
                             visits per therapy discipline visits per therapy discipline        10 visits per therapy
                             per enrollment year           per enrollment year.                 discipline per enrollment
                                                           (Cardiac rehabilitation              year. (Cardiac
                             Also covers up to 36 visits   counts towards the 20 visit          rehabilitation counts
                             per enrollment year for       limit for PT)                        towards the 10 visit limit
                             cardiac rehabilitation                                             for PT)
                             provided by a physical
                             therapist. (The cardiac
                             rehabilitation visits do not
                             count towards the 20 PT
                             visits.)
$.50 to $3.00 co-payment per $15 co-payment per visit, per $.50 to $3.00 co-payment             $10 co-payment per visit
service                      provider.                     per service.

Co-payment obligation limited                                   Co-payment obligation
to the first 30 hours or          There are no monthly or       limited to the first 30 hours
$1,500, whichever occurs          annual co-payment limits.     or $1,500, whichever
first, during one calendar year                                 occurs first, during one
(co-payment limits calculated                                   enrollment year (co-
separately for each discipline)                                 payment limits calculated
                                                                separately for each
                                                                discipline)

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     BadgerCare Plus                BadgerCare Plus               BadgerCare Plus               BadgerCare Plus
      Standard Plan                 Benchmark Plan                   Core Plan                    Basic Plan

Physician Services
Full coverage, including       Full coverage, including       Full coverage, including      Full Coverage limited to
laboratory and radiology       laboratory and radiology       laboratory and radiology      10 physician office visits
                                                                                            (limit does not apply to
                                                              Health education for          laboratory and radiology).
                                                              members with asthma,
                                                              diabetes or hypertension.     Includes services
                                                                                            provided by psychiatrist.

                                                                                            Includes SBIRT billing
                                                                                            (not subject to co-pay)

                                                                                            No transplant services
                                                                                            will be covered.

                                                                                            Generic physician
                                                                                            administered drugs are
                                                                                            covered to the extent
                                                                                            they are billed using NDC
                                                                                            codes under the
                                                                                            pharmacy benefit.
$.50 to $3.00 co-payment per   $15 co-payment per visit       $.50 to $3.00 co-payment      $ 10 co-payment per visit
service limited to $30 per                                    per service, limited to $30   (applies to evaluation and
provider per calendar year.    No co-payment for              per provider per              management codes)
                               emergency services,            enrollment year.
No co-payment for              preventive care, anesthesia
emergency services,            or clozapine management        No co-payment for
anesthesia or clozapine                                       emergency services,
management                                                    preventive care,
                                                              anesthesia or clozapine
                                                              management
Podiatry Services
Full Coverage                  Full coverage                  Full Coverage effective       Payable under physician
                                                                                            services (subject to 10
                                                                                            professional visits above)
$.50 to $3.00 co-payment per   $15 co-payment per visit       $.50 to $3.00 co-payment
service; limited to $30 per                                   per service; limited to $30
provider per calendar year.                                   per provider per calendar
                                                              year.
Prenatal /Maternity Care
Full coverage, including       Full coverage, including       Not Applicable                Not Applicable
prenatal care coordination,    prenatal care coordination,
and preventive mental health   and preventive mental health
and substance abuse            and substance abuse
screening and counseling for   screening and counseling for
women at risk of mental        women at risk of mental
health or substance abuse      health or substance abuse
problems                       problems
No co-payment                  No co-payment
Reproductive Health Services
Full coverage, excluding       Full coverage, excluding       Family planning services      Family planning services
infertility treatments,        infertility treatments,        provided by family            by family planning clinics
surrogate parenting and the    surrogate parenting and the    planning clinics will be      will be covered
reversal of voluntary          reversal of voluntary          covered separately under      separately under the
sterilization                  sterilization                  the Family Planning           Family Planning Waiver
                                                              Waiver program.               program.


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     BadgerCare Plus                BadgerCare Plus                BadgerCare Plus       BadgerCare Plus
      Standard Plan                 Benchmark Plan                    Core Plan            Basic Plan

No co-payment for family       No co-payment for family        Not applicable         Not applicable
planning services              planning services
Routine Vision
Full coverage including        One eye exam every year,        No Coverage            No Coverage
coverage of eyeglasses         with refraction
$0.50 to $3.00 co-payment      $15 co-payment per visit
per service
Smoking Cessation Services
Coverage includes              Coverage includes          Coverage includes           Coverage includes
prescription and OTC tobacco   prescription generic and   prescription generic and    prescription generic and
cessation products.            OTC tobacco cessation      OTC tobacco cessation       OTC tobacco cessation
                               products.                  products.                   products.
Refer to the drug benefit for                             Refer to the drug benefit
                               Refer to the drug benefit for                          Refer to the drug benefit
information on co-payments     information on co-payments for information on co-      for information on co-
                                                          payments                    payments
Transportation – Ambulance, Specialized Medical Vehicle (SMV), Common Carrier
Full coverage of emergency    Coverage limited to         Coverage limited to         Coverage limited to
and non-emergency             emergency transportation by emergency transportation    emergency transportation
transportation to and from a  ambulance.                  by ambulance.               by ambulance.
certified provider for a
BadgerCare Plus covered
service.
- $2 co-payment for non-       $50 co-payment per trip         No co-payment          No co-payment
  emergency ambulance
  trips
- $1 co-payment per trip for
  transportation by SMV
- No co-payment for
  transportation by common
  carrier or emergency
  ambulance

Note: The covered services information in this chart is provided as general information. Providers should
refer to their service-specific publications and the Online Handbook for detailed information on covered and
noncovered services and prior authorization information.




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