BADGERCARE

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BADGERCARE
Health Insurance for Childless Adults
Primary Care Alliance Meeting August 15, 2008
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Path to Comprehensive Health Care Reform
BADGERCARE

• Phase I BadgerCare Plus Health Insurance for
  All Kids (2/1/08)
• Phase II Childless Adults Expansion (1/1/09)
• Phase III BadgerChoice / Small Business Health
  Insurance Reform (under development)
• Result
• 98 of Wisconsin residents will have access to
  affordable insurance
• Lower costs for small businesses and their
  employees

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Phase II Timeline
BADGERCARE
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Uninsured Childless Adults
BADGERCARE

• Chronically uninsured
• High users of uncompensated care
• Gross income at or below 200 of FPL
• Ages 19 64
• 60 are employed, but have no employee sponsored
  health insurance
• Not covered or had access to health insurance for
  previous 12 months
• Approximately 81,000 potential members
• Many served by Milwaukees GAMP program (15,000)

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Core Benefit
BADGERCARE

• Less generous than Medicaid or BC Benchmark Plan
  and focused on preventive care
• Benefits designed as HMO benefit
• Physician Services
• Diagnostic Services
• Inpatient stays limited outpatient visits
• Therapies (limited number)
• Durable medical equipment
• Dental services, limited for emergency services
  only
• Emergency outpatient
• Fee-for-Service components
• County-based mental health and substance abuse
• Family planning
• Generic Drugs (BadgerRx Gold for brand name
  drugs)

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Core Plus Benefit
BADGERCARE

• Employer buy-up option
• Allows employers to contribute to their
  employees healthcare
• In addition to Core Benefits
• Comprehensive dental services
• Chiropractic services
• Vision
• Outpatient mental health and substance abuse
  services (20 per year)

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Use of Evidence-Based Medicine in Benefit
DesignClinical Advisory Committee on Health and
Emerging Technology
BADGERCARE

• Advise DHFS Secretary on
• Inclusion and prioritization of services in Core
  and Core Plus benefit plans
• Integration of evidence-based medicine
• Identification of centers of excellence
• Development of therapy guidelines
• Research new / emerging technologies and
  procedures

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HMO Choice
BADGERCARE

• Consumer-driven HMO choice at enrollment
• Thirteen HMOs to provide benefits
• Establish quality-based 2-tiered HMO rating
  system (cost and quality related)
• Performance based enrollment to encourage high
  quality (Tier 1) HMO selection
• Tier 1 HMOs preferred
• Discounted application fee
• HMO auto-assignment if member does not select an
  HMO

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HMO Enrollment Begin Date
BADGERCARE

• Childless Adults Core Plus Benefit Plan will be
  delivered through managed care plans
• Childless Adults will select HMO at the time of
  application (with 90 days to change their choice)
• Without a Fee-For-Service component, the
  eligibility and HMO enrollment begin dates are
  linked
• Enrollment / dis-enrollment information to HMOs
  can be sent same night as confirmation
• Payments can be prorated (daily, weekly,
  bi-weekly, monthly)

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HMO Enrollment Begin Date
BADGERCARE
(Continued)

• Eligibility / Enrollment date the 1st or 15th
  day of the month after eligibility determination
• Prorated capitation payment to HMO days in
  month left in month / capitation rate / number of
  days in month

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Cost Sharing
BADGERCARE

• Application Fee (non-refundable)
• Co-Payments

• Nominal co-payments range from 0.50 - 3
• Co-payments are waived for preventive services
• 20 monthly cost-sharing cap for generic drugs
• Cost-sharing will be capped consistent with the
  Standard Plan

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Health Status
BADGERCARE

• Health Needs Assessment enrollment requirement
• Physical Exam - first year requirement
• Designed to
• Establish detailed medical status baseline
• Promote medical home
• Identify health issues
• Failure to obtain loss of eligibility for 6
  months (with good cause exemptions)
• HMOs will be required to provide access for exams
  to avoid penalty
• This requirement is unique among state Medicaid
  and SCHIP programs

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BadgerChoice WI Health Care Connector
BADGERCARE
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BadgerChoice WI Health Care Connector
BADGERCARE
Accessible online, by mail or phone

• One-stop shop for enrollment, renewal, and member
  service information
• Apply for BadgerCare Plus
• Apply for benefits or renew online, by phone or
  mail
• BadgerChoice will facilitate benefit buy-up,
  Health Needs Assessment, HMO choice, application
  fee payment
• Centralized BadgerChoice Support Center
• Eligibility, membership, and benefit plans
• HMO choice and technical assistance

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BadgerChoice WI Health Care Connector
BADGERCARE
Accessible online, by mail or phone

• Centrally Process Applications
• Verify data using automated data sources when
  available
• Complete enrollment with BC and HMO
• Facilitate employer buy-up contributions
• Proactive Member Identification Enrollment
• Automated data match
• Other state successes include
• VA Common Human Services Index
• PA Pre-fills application and renewal forms
• LA Distributes ID cards w/ activation
  instructions

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BADGERCARE
Questions, Comments?
Jason A. Helgerson Medicaid Director Division of
Health Care Access and Accountability P.O. Box
309 Madison, WI 53701 [phone]
www.badgercareplus.org