2009 Provider Office Manual

Transcription

1 2009 Provider Office Manual

2 Table of Contents Description Page Number Welcome...1 Current Contracts...2 IPN Partnerships/Programs/Value Added Services Eligibility Verification...5 Referrals, Prior Authorization & Permitted Providers Overview...6 Abri Health Plan AmeriChoice (UHC) Anthem Blue Cross Blue Shield Today s Health Trilogy Health UnitedHealthcare Telephone Numbers & Contact Lists Abri Health Plan AmeriChoice(UHC) Anthem Blue Cross Blue Shield Today s Health Trilogy Health UnitedHealthcare

3 Table of Contents (Continued) Description Page Number Wisconsin Medicaid, Healthy Start & BadgerCare Programs Overview Who to Call BadgerCare Plus Update Provider BadgerCare Plus Copay Summary Blood Lead Testing Requirements Women s Cancer Screening Health Checks Medicaid Preventive Health Programs HealthCheck Forms HealthCheck Billing Hints...89 Claims Information Abri Health Plan...90 AmeriChoice(UHC)...91 Anthem Blue Cross Blue Shield...92 Today s Health...93 Trilogy Health...94 UnitedHealthcare...95

4 Table of Contents (Continued) Description Page Number Additional Information Grants Available for Families...96 Other Documents Contained on CD Ancillary Providers Listing IPN Policies and Procedures.See CD Contents for Details

5 Welcome This manual is intended for Office Managers and other medical business staff who needs to understand how to recognize, refer and bill for patients who will come to the practice through Independent Physicians Network contracts with various health plans. About Independent Physicians Network Independent Physicians Network is a physician managed and controlled, not for profit corporation established in The Network has over 1,000 member physicians who utilize all hospitals in the Milwaukee and surrounding areas. Independent Physicians Network contracts with health plans and ancillary providers on behalf of its member physicians. Other than these contracts, Independent Physicians Network is not affiliated or associated with any hospital, health plan or any other entity. To assure quality, review utilization and assist physicians and providers, Independent Physicians Network contacts its member physicians on a regular basis via newsletters, telephone calls and office visits. Independent Physicians Network also provides services to member physicians such as a group malpractice plan, online credentialing and Elf (its electronic link feature) which provides access to patient eligibility. Through government by its physician Board and Committees, member physicians manage all medical care for Independent Physicians Network patients including inpatient, outpatient, physician and ancillary services. By placing medical decision making back in the hands of physicians, Independent Physicians Network is able to maximize physician reimbursement and improve patient and physician satisfaction. How It Works For each contract Independent Physicians Network has with health plans, you will receive information about how to identify patients and check for eligibility, how to refer enrollees and prior authorize services, who the participating providers are, and where to send claims. Whenever Independent Physicians Network signs an agreement with a health plan, its member physicians automatically begin participating in the plan. Member physicians are not permitted to participate in some contracts and not others. Member physicians may designate their practice open or closed to new patients, but this designation applies to all Independent Physician Network contracted plans. The Independent Physicians Network Medical and Administrative Services staff is available to advise and assist you with issues and problems. You can reach them at

6 Health Plan Contracts Current Agreements Abri Health Plan AmeriChoice (UHC) Anthem Blue Cross Blue Shield Anthem Blue Cross Blue Shield HealthCare Direct Patient Choice Secure Horizons/Evercare(UHC) Trilogy Health Today s Health(Abri) UnitedHealthcare Medicaid HMO Medicaid HMO All Commercial Products Medicare HMO/PPO Commercial Self Insured All Commercial Products Medicare HMO All Commercial Products Medicare HMO All Commercial Products 2

7 IPN Physicians Partnerships/Programs/Value Added Services Partnerships: Electronic Medical Records IPN has entered into a partnership with ProSperus to increase EMR usage among IPN physicians. IPN s partnership with ProSperus gives IPN providers a substantially discounted price as well as additional services not otherwise available. IPN chose ProSperus based on their ability to offer multiple EMR systems using either internal servers or an ASP model. ProSperus has a commitment to independent physicians and excellent service levels. If you are interested in finding out more about EMR systems, please contact Sarah Zwiefelhofer at IPN at Revenue Cycle Management/Practice Management IPN has entered into a partnership with Prosperus to provide a variety of practice management services for interested IPN physicians. The solutions offered by Prosperus range from implementation of a practice management/electronic medical record system to revenue cycle management to full turnkey practice administration. To find out more about the RCM/Practice Management program available for IPN physicians, contact Sarah Zwiefelhofer at IPN at IPN Health Benefit Purchasing Cooperative Independent Physicians Network (IPN) is pleased to announce the formation of the IPN Healthcare Purchasing Cooperative (Coop). The Coop has been formed to help IPN member physicians purchase affordable healthcare for themselves, their employees and their families. Select an agent/agency from the Participating Agencies List. Contact IPN at for a list. Programs: Group Malpractice Insurance Save 30-50% off your premiums though the Independent Physicians Network Group Malpractice Insurance Program. This program is in its seventh year of offering consistently lower premiums through the group purchasing power of IPN. Want to know how much you can save? Contact Jim Ryan at or Christine Sukkert at for a personal premium indication. Prepaid Legal Services Pay one low flat rate for all your legal needs. The Prepaid Legal Services program includes unlimited business consultations, reviews of business documents such as leases and vendor agreements, debt collection letters, attorney letters and phone calls and trial defense services for your practice. Personal and family coverage are also available.

8 Partnerships/Programs/Value Added Services Cont. Group Personal Excess Liability Umbrella Save up to 50% on premiums on this group pricing option. Safeguard your assets and reputation from personal liability lawsuits. This program offers higher limits than what is typically offered by an individual policy. Contact IPN at for an Enrollment Form and Rates. Value Added Services: ELF (Electronic Link Feature) Online Eligibility and Recredentialing. ELF services are available only to IPN member physicians. ELF allows your office to check eligibility for all Wisconsin Medicaid members regardless of plan. Each look up costs only $0.05 per transaction for IPN members. ELF will free up your staff from having to make calls to the plans to verify eligibility. ELF requires internet access and Windows XP. You may also complete your recredentialing application through ELF. If you are interested in seeing a demonstration of the ELF system, please contact IPN through the contact section of IPN s website at or via phone at , select option 1. Collections Service With the increase in accounts receivable due to higher deductible health plans, IPN has made arrangements through Felt and Lukes, LLC (in Hartland) to provide collection services for interested IPN physicians at a discounted rate. To find out more about the collection services program for IPN physicians, contact Tim Felt, from Felt & Lukes, LLC at , ext 229. Network Security IPN has partnered with Tushaus Computer Systems to utilize the Fortinet system for network security. The Network Security Solution offered by Fortinet provides protection from hackers, viruses, spam and spyware and provides advanced intrusion prevention and detection 24 hours a day, 7 days a week. Additionally, the technology will improve your risk management program and sufficiently reduce risks that could lead to potential HIPAA issues. IPN has negotiated a substantial discount with Tushaus. Please contact Ned Smirl, IPN Account Representative, Tushaus, at or via at neds@tushaus.comwww.tushaus.com

9 Eligibility Verification Abri Health Plan Medicaid (414) IVR (414) Website Today s Health (Abri) Medicare 1-(866) Select Option 2 Website Anthem Blue Cross Blue Shield Commercial 1-(888) Trilogy Health Insurance Commercial (262) (866) IVR 1-(866) Website AmeriChoice (UHC) Medicaid Website Secure Horizons/Evercare (UHC) Website UnitedHealthCare Commercial Website 5

10 Referrals, Prior Authorization & Permitted Providers The services that require a referral or prior authorization and the in-network ancillary providers may vary from plan to plan and product to product. Independent Physicians Network(IPN) has developed provider information sheets with pertinent phone numbers, innetwork providers, referral/authorization requirements, and other information for each health plan product. These sheets can be found on the following pages of this manual and on IPN s website at Referrals and prior authorization information is submitted directly to the plan. They will be administered by the plan and reviewed by Independent Physicians Network staff using Independent Physicians Network policies. All referrals must be initiated by the enrollee's Primary Care Physician and must be made to Independent Physicians Network member specialists. The IPN website at will always contain the most current information regarding IPN member physicians. If the desired specialty is not located within the Independent Physicians Network, contact the Independent Physicians Network Medical Services staff at for assistance. Back dated referrals are not permitted. Primary Care Physicians must submit referral information in a timely fashion to allow for processing time. Specialists may not see enrollees without an Independent Physicians Network approved referral. In addition, there are certain providers permitted for ancillary medical services. The use of these providers enables the provision of quality, cost effective care. For example, the designated free standing diagnostic imaging centers have been inspected by member radiologists and the quality of imaging and interpretations reviewed. Typically the plans and their enrollees pay significantly less for services at these high quality, free standing sites than they would in a hospital setting. For Abri Medicaid and AmeriChoice members, Independent Physicians Network uses Dynacare Laboratories exclusively for laboratory services. Except for allowed In- Office lab tests, all Abri and Americhoice enrollees must be sent to Dynacare for laboratory services. Member physicians are reimbursed for lab handling and venipunctures based on the enrollees benefits. To find network laboratories for commercial members, please see the Other Medical Services section of our website at For more information, see applicable Independent Physicians Network Policies & Procedures. 6

11 Abri Health Plan Referrals and Prior Authorizations Referrals (Voice Response) (414) or Inpatient Hospitalization Authorizations (414) Therapy (PT, OT, ST) Authorizations (414) Cardiac Rehabilitation Authorizations (414)

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13 AmeriChoice (UHC T-19) Prior Authorizations MEDICAID Inpatient Hospitalization Authorizations Fax (414) Therapy (PT, OT, ST) Authorizations PCP/Specialist Obtains 9

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17 Anthem Blue Cross & Blue Shield Referrals and Prior Authorizations Cardiac Rehabilitation Authorizations Innovative Resource Group Inpatient Hospitalization Authorizations Fax (262) Radiology Preauthorization Fax (888) (Radiology/Preauthorization Login) Referrals (Voice Response) Referrals not required for HMO members for in network specialty services only (Effective 7/1/2004) Therapy (PT, OT, ST) Authorizations None required for first 6 visits unless the facility is Non-par. (414)

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20 Today s Health Referrals and Prior Authorizations Inpatient Authorizations Select Option 3 Outpatient Authorizations/Referrals Select Option 4 Website 16

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22 Trilogy Health Insurance Prior Notification Fully Insured Group Products Self Funded Group Products

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24 UnitedHealthcare Prior Authorizations COMMERCIAL Inpatient Hospitalization Authorizations

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33 Abri Health Plan Telephone Directory Main Number (414) Fax (414) Provider Relations (414) Transportation (414) Or Interpretive Services (414) Or hour After Hours Help Line Hearing Impaired (414) TTY/TDD Customer Service (Providers and Members) (414) or 29

34 Contact Information Customer Service can assist both Members and Providers Business Hours: 8:00 AM to 5:00 PM Monday through Friday Phone: or Member Services After Hours: Emergency Help Line: Fax: TTY: Web site: Abri Health Plan provides an Interactive Voice Response (IVR) System, which can be used to verify eligibility, to submit or check the status of a referral or authorization, or to check the status of a submitted claim. The IVR line is available 24 hours a day and can be accessed at If you don t have an IVR access code or don t know what your code is, please call Customer Service and we will be able to help you obtain the number. Customer Service provides help and information on eligibility, referrals or authorizations, claims, service locations, transportation, interpretation services, PCP assignment or changes, benefits or other areas. NUMBERS AND ACCESS INFORMATION Corporate Office Address: 2400 S. 102 nd St, West Allis, WI Member Advocate: Care Management: or Behavioral Health Provider Relations Eligibility Verification or Related Information Phone: or IVR: customerservice@abrihealthplan.com Claim Status or Information Phone: or IVR: customerservice@abrihealthplan.com

35 Claim Submission: Paper: P.O. Box , West Allis, WI Electronic: Call Abri at TBD APS claims should be submitted to APS Healthcare Inc., P.O. Box 99, Linthicum, MD Herslof claims should be submitted to Herslof, W Carmen Ave, Milwaukee, WI SEDA claims should be submitted to SEDA, 3520 W Oklahoma Ave, Milwaukee, WI Provider Appeals Address: P.O. Box , West Allis, WI ATTN: Appeals Department Fax: appeals@abrihealthplan.com Provider Relations and Contracting Phone: Fax: Referrals or Pre-Authorizations Phone: or IVR: Pharmacy Prior Authorization: (Fax) Behavioral Health Prior Authorization: Transportation during normal business hours Phone: Emergency Transportation after hours Interpretation/Translation Phone: or Web Site:

36 AmeriChoice (UHC T-19) Telephone Directory MEDICAID Main Number Provider Relations or Ext Customer Service/ Interpretive Services or American Hmong Connection or Hearing Impaired (TTY) 32

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39 Anthem Blue Cross & Blue Shield Telephone Directory Main Number Customer Service/ Interpretive Services none available Hearing Impaired

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42 Today s Health Telephone Directory Main Number (414) Provider Relations Website 40

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44 Trilogy Health Insurance Telephone Directory FULLY INSURED GROUP PRODUCTS SELF FUNDED GROUP PRODUCTS Provider Services (262) Provider Services Website Website 42

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47 UnitedHealthcare Telephone Directory COMMERCIAL Main Number Provider Relations or Ext Customer Service/ InterpretiveServices or Self-Funded Hearing Impaired (TTY) 45

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52 Wisconsin Medicaid, Healthy Start & BadgerCare Programs In 1984, the State of Wisconsin mandated that Milwaukee County Medicaid recipients must obtain their medical care through contracted managed care plans under the states Medicaid HMO initiative. Today six health plans participate in Milwaukee County. Independent Physicians Network contracts with two of them, Abri Health Plan and AmeriChoice, and manages all medical care for these enrollees. The Medicaid initiative is a traditional HMO program under which enrollees must obtain all medical care from or on referral from their primary care physician. There are a number of unique features about this program. Of particular note are the following: Eligibility OB-Gyn's may act as Primary Care Physicians. The state has established preventative health services requirements for HealthChecks and Immunizations which physicians must meet. Eligibility for Medicaid, Healthy Start, and BadgerCare is determined by the state on a month to month basis. In addition, the state issued cards do not list the enrollee's primary care physician. There are specific state rules and requirements for Hysterectomies, Sterilizations and Abortions. There are a number of HMO and community sponsored programs that assist providers in educating and monitoring enrollees. Primary Care Physicians are able to view monthly eligibility reports on These reports list enrollee demographic information for assigned enrollees. The State of Wisconsin Medicaid, Healthy Start and BadgerCare Programs issue identification cards. The eligibility status and selected HMO can only be obtained through vendor provided swipe readers, electronic access through IPN s ELF system, or by calling directly to the state. 50

53 Medicaid Programs, continued Eligibility should be verified before every visit. Instructions on how to verify eligibility are included in this manual. Referrals and Prior Notification Back dated referrals are not allowed. Referrals must be timely to allow for processing time. Instructions on how to submit referrals is included in this manual. For Out-of-Network referrals, call the Independent Physicians Network - Medical Services Department at , select option 2. Enrollees have direct access to the following Ancillary providers: ~ Routine eye exams from participating providers ~ Mental health & AODA services from participating providers ~ Dental services from participating providers Participating providers may differ from plan to plan. Always refer to the IPN website at for the most recent provider listings for referrals. When referrals are approved, a copy is sent to the specialist. Claims and Reimbursement Claims must be submitted and received by the plan within 60 days of the date of service. Approved claims will be paid according to the Independent Physicians Network Medicaid Fee Schedule in effect at the time of service. When there are savings they are distributed to member physicians at year end through its year end distribution process. Coordination of Benefits The health plan will deny Medicaid claims if it is determined that the patient has another insurance as their primary carrier. The plans require a copy of the EOB (Explanation of Benefits) showing a denial from that primary insurance before payment will be considered. 51

54 Who to Call for the Wisconsin Medicaid and BadgerCare HMO Program HMO Enrollment Specialist: (800) HMO Contract Monitors: (800) HMO Ombudsmen: (800) Medicaid and BadgerCare HMOs: Telephone Numbers Are Located Below Recipient Services: (800) or (608) Provider Services: (800) or (608) Automated Voice Response System: (800) or (608) For Questions About: Please Call: Bills and Billing HMO Enrollees Medicaid and BadgerCare HMO Other Recipients Recipient Services (800) or (608) Providers HMO Related Medicaid and BadgerCare HMO, or HMO Contract Monitors (800) Providers Non-HMO Related Provider Services (800) or (608) Change of Address All Recipients County/Tribal Social or Human Services Agency Commercial Insurance or Primary Insurance Problems HMO Enrollees Enrollment Specialist (800) Other Recipients Recipient Services (800) or (608) Providers HMO Related Medicaid and BadgerCare HMO, or HMO Contract Monitors (800) Providers Non-HMO Related Provider Services (800) or (608)

55 Complaints and Grievances HMO Enrollees Medicaid and BadgerCare HMO, Enrollment Specialist (800) , or HMO Ombudsmen (800) Providers Medicaid and BadgerCare HMO Eligibility Grievances County/Tribal Social or Human Services Agency, or Recipient Services (800) or (608) Eligibility Questions Providers Automated Voice Response System (800) or (608) or Provider Services (800) or (608) Medicaid and BadgerCare Recipients.... County/Tribal Social or Human Services Agency, or Recipient Services (800) or (608) Emergency Care HMO Enrollees Medicaid and BadgerCare HMO Enrollment in HMOs Recipients HMO Enrollment Specialist (800) Exemption From HMO Enrollment Recipients HMO Enrollment Specialist (800) HMO Extraordinary Provider Claims Providers HMO Contract Monitors (800) Lost Medicaid and BadgerCare Forward Cards All Recipients Recipient Services (800) or (608) Provider Appeals Providers HMO Contract Monitors (800) Transportation Common Carrier HMO Enrollees Medicaid and BadgerCare HMO, or County/Tribal Social or Human Services Agency Other Recipients County/Tribal Social or Human Services Agency 53

56 What Services Are Covered Under HMOs HMO Enrollees Medicaid and BadgerCare HMO, or Enrollment Specialist (800) Providers Medicaid and BadgerCare HMO, or HMO Contract Monitors (800) Where to Go for Services HMO Enrollees Medicaid and BadgerCare HMO Other Recipients Recipient Services (800) or (608) Medicaid and BadgerCare HMO Customer or Member Services General Information Abri Health Plan (262) (262) Atrium Health Plan (888) (888) Children's Community Health Plan (800) (414) Compcare (888) (888) Dean Health Plan (800) or (608) (608) Group Health Cooperative of Eau Claire Group Health Cooperative of South Central Wisconsin (888) (888) (608) (608) Health Tradition Health Plan (800) or (608) (608) Managed Health Services (888) or (414) (414) MercyCare Insurance Company (800) (800) Network Health Plan (888) or (414) (414) Security Health Plan (800) or (715) (800) UnitedHealthcare of Wisconsin (800) (414) Unity Health Insurance (800) (608) PHC (Rev. 1/06) Department of Health and Family Services Division of Health Care Financing 54

57 January 2008 PHC 1400 To: All Medicaid Recipients English Spanish Russian Hmong For help to translate or understand this, please call (TTY). Si necesita ayuda para traducir o entender este texto, por favor llame al teléfono (TTY)., (TTY). Yog xav tau kev pab txhais cov ntaub ntawv no kom koj totaub, hu rau (TTY). Introducing BadgerCare Plus In 2007, Governor Jim Doyle announced his plan to provide access to health insurance to more people in Wisconsin (including all uninsured children) through the BadgerCare Plus program. BadgerCare Plus is scheduled to begin February 1, It is a new state-sponsored health care program that will replace family Medicaid, BadgerCare, and Healthy Start. BadgerCare Plus was included in the Wisconsin biennial budget (2007 Wisconsin Act 20). The following are the goals of BadgerCare Plus: Ensure that all Wisconsin children have access to affordable health care. Ensure that 98 percent of Wisconsin residents have access to affordable health care. Streamline program administration and enrollment rules. Expand coverage and provide enhanced benefits for pregnant women. Promote ways that you can prevent serious health problems. BadgerCare Plus will expand availability of health care coverage to the following: All uninsured children. More pregnant women. More parents and caretaker relatives. Parents with children in foster care who are working to reunify their families. Young adults exiting out-of-home care, such as foster care, because they have turned 18 years of age. Certain farmers and other self-employed parents and caretaker relatives. People Enrolled in Family Medicaid, BadgerCare, or Healthy Start If you are currently enrolled in family Medicaid, BadgerCare, or Healthy Start, you do not have to do anything to enroll in BadgerCare Plus. We will check to see which BadgerCare Plus plan you are eligible for, and we will enroll you automatically. If you are in an HMO now, you will not have to change your HMO when BadgerCare Plus starts. People Enrolled in Medicaid for the Elderly, Blind, or Disabled If you are enrolled in Wisconsin Medicaid for the elderly, blind, or disabled or are getting long-term care services through Wisconsin Medicaid, BadgerCare Plus will not change your health care coverage in any way. You will continue to receive Medicaid services as you do now. Continued on next page. Questions? Please call Recipient Services at Department of Health and Family Services

58 Continued from previous page. BadgerCare Plus Plans BadgerCare Plus has two different plans the BadgerCare Plus Standard Plan and the BadgerCare Plus Benchmark Plan. The plan you are enrolled in will depend on your income and the people in your household. Most people will be enrolled in the Standard Plan, and you will have the same coverage as you do right now. If you are enrolled in the Benchmark Plan, some of your benefits may change. Below are brief descriptions of the different plans under BadgerCare Plus. BadgerCare Plus Standard Plan In the Standard Plan, the following are true: Your benefits will be the same as they were under Family Medicaid, BadgerCare, or Healthy Start. Your copayments for services will continue to be between $0.50 and $3.00. However, some people who did not have copayments for services will now have copayments after February 1, See Copayment Changes Under BadgerCare Plus Standard Plan for more information. You may continue to see your current doctor and other heath care providers. BadgerCare Plus Benchmark Plan In the Benchmark Plan, the following are true: Doctor visits and hospital stays are covered. Other services are covered but in a more limited way than Wisconsin Medicaid or the Standard Plan. Copayments are higher than in the Standard Plan. Providers may refuse to provide services if the copayment is not paid. You will receive a notice at the end of January 2008 if any of the following changes are made to your case: You or your family cannot enroll in BadgerCare Plus because you have or can get insurance through an employer. You or anyone in your household is automatically enrolled in the Benchmark Plan. There is any change in your premium amount. You need to give proof of your income or bills. In January 2008, we will also be changing the look of the notice letters that you get about your benefits. See New Notices for more information about the new look of the notices. How to Apply You do not have to do anything if you are currently enrolled in Family Medicaid, BadgerCare, or Healthy Start. However, if you know someone who needs health care coverage, applications for BadgerCare Plus will start being accepted in February People can apply for BadgerCare Plus online at access.wisconsin.gov/, over the telephone, through the mail, or at their local county or tribal office. In addition, beginning in mid-january 2008, some community organizations will be able to use Express Enrollment to temporarily enroll certain children in BadgerCare Plus for up to 60 days. This helps children to get health care coverage while they are applying for BadgerCare Plus. To find an organization, call Notice Letters for BadgerCare Plus Enrollment If we can automatically enroll you in the Standard Plan and there are no other changes to your case, you will not receive any further notice. Questions? Please call Recipient Services at Wisconsin Medicaid and BadgerCare Update January

59 Copayment Changes Under BadgerCare Plus Standard Plan Copayments will be different under the BadgerCare Plus Standard Plan. This change is due to the Wisconsin biennial budget (2007 Wisconsin Act 20). Because this change is a result of a change in state law, people affected by this change will not have a right to a hearing to contest this change. Copayments are part of the cost for certain services that you will be responsible for paying. Copayments for the Standard Plan range from $0.50 to $3.00 per service. You must pay your copayment. If you cannot pay it right away, the provider cannot refuse to see you at your appointment. Providers can ask you for copayments at the time of service, or they can bill you for them later. You may be asked for more than one copayment if you get more than one service at an appointment. The following are some people enrolled in the Standard Plan who do not have copayments: People in nursing homes. Pregnant women. Children under age 18 whose family income is at or below 100 percent of the Federal Poverty Level. (This is $17,170 for a family of three.) Children who are enrolled in a federally recognized tribe. The following are people enrolled in the Standard Plan who will have copayments for some services starting February 1, 2008: Children under age 18 with a family income over 100 percent of the Federal Poverty Level. People enrolled in HMOs. New Identification Cards Wisconsin has several health care programs that help over 800,000 people. Wisconsin s name for all of these health care programs is ForwardHealth. ForwardHealth includes BadgerCare Plus; Medicaid for the elderly, blind, and disabled; and Family Care. Beginning February 1, 2008, identification cards for Wisconsin Medicaid and BadgerCare Plus will have a new look. You will continue to use your Forward card but people who are new to Wisconsin Medicaid and BadgerCare Plus will get a ForwardHealth card. The current Forward card and the new ForwardHealth card are valid, and providers should accept either card. After February 1, 2008, if you ask for a new card because your current card is lost or stolen, you will get a ForwardHealth card. Remember to show your ForwardHealth card or Forward card each time you see your doctor or other health care providers. See Attachment 1 of this Update for examples of the new ForwardHealth card and the current Forward ID card. New Notices Changes are being made to the notices you get about your BadgerCare Plus, Medicaid, FoodShare, and Caretaker Supplement benefits. We asked people who get benefits, advocates, and others how to make the notices easier to read and understand. We used their ideas to create new and improved notices. Starting in January 2008, your notices will look different. You will also receive fewer notices each month. See Attachment 2 for a sample notice and information about what is included in the new notices. Questions? Please call Recipient Services at Wisconsin Medicaid and BadgerCare Update January

60 ATTACHMENT 1 Identification Cards Below is an example of the new ForwardHealth card. Below is an example of the old Forward card. 4 Wisconsin Medicaid and BadgerCare Update January

61 ATTACHMENT 2 New Notice Sample (A sample letter and what is included in the new notices is located on the following pages.) Wisconsin Medicaid and BadgerCare Update January

62 MILWAUKEE DSS 1220 W. VLIET ST MILWAUKEE, WI Date: 1/23/2008 JANE SMITH 123 MAIN ST APT 321 MILWAUKEE WI State of Case # Wisconsin Milwaukee County Change Center (414) How to contact your local county/tribal office. Enrollment Status. <Translated> For help with getting this letter explained in your language, please call <Translated> About Your Benefits This letter tells you about your benefits. If you have a question, please call the local agency listed above. If you need help because of a disability, please see the Key Contacts on the last page of this letter. Which benefit? Status of your benefits? Forward Health Wisconsin You applied on January 22, Your application was approved for some of the people in your home. To find out who was approved and who was denied, see page 2. FoodShare Wisconsin You applied on January 22, Your application was approved. For January 2008, you will get $114 and for February 2008, you will get $354. To keep getting benefits after February 2008, you will need to give us proof of items like your address, income and bills. Please see page 3 to learn more. Caretaker Supplement You applied on January22, Your application was denied. Please see the Your Caretaker Supplement Benefits page to learn more. If you don't agree with this decision, you have the right to a Fair Hearing. Please see the last page of this letter to learn more. You may also talk with the local agency listed above. 6 Wisconsin Medicaid and BadgerCare Update January

63 Your Forward Health Benefits Who is enrolled in health care benefits? When? Who is eligible? Which plan? As of Dec. 1, 2007 JANE S JOHN S Who is enrolled, which plan and the dates of coverage. Do you have to pay a premium? MARY S BadgerCare+ Standard Yes see below JANE S, JOHN S, MARY S: You will get the health care benefits shown above until there is a change in your case. Who has to pay a premium? Who will have a premium and how much it will be. When? Monthly amount? Who does it cover? As of Dec. 1, 2007 $125 JANE S JOHN S MARY S JANE S: Your premium is a fee you must pay each month to keep getting benefits. You will get a premium payment notice in the mail each month. More Information BadgerCare+ Standard This is a full-benefit health care plan. It will pay for most services you get from BadgerCare+ health care providers. It will also pay for prescriptions (unless you are also getting Medicare). You may have a small copayment for some services and prescriptions. Forward Card If you are getting health care benefits for the first time, you will get a Forward Health Card and a BadgerCare+ Enrollment & Benefits handbook by mail. Be sure to tell your health care providers that you now have these benefits. In some cases, a provider may be able to give you a refund for bills you paid after your health care benefits started. Which health care benefits have ended or been denied? Who is not enrolled and why. When? Which plan? Who and why? As of BadgerCare+ JAMES S: The person who applied asked that you not get this Dec. 1, 2007 Standard benefit. JAMES S: You are not a U.S. citizen or an immigrant who is able to get this benefit. Supporting Laws: HSS102.02WAC, STS, 49.45(24r) STS Wisconsin Medicaid and BadgerCare Update January

64 Your FoodShare Wisconsin Benefits Monthly FoodShare amount and other information. Who is eligible for FoodShare and how much? When? How much? Who is eligible? Jan. 22, Jan. 31, 2008 $114/month JANE S JOHN S MARYS Feb. 01, Feb. 28, 2008 $354/month JANE S JOHN S MARYS You applied for FoodShare on January 22, Because you applied after the first day of the month, you will get a lower FoodShare benefit in January. Because you needed FoodShare right away, you did not have to give us proof of items like your address, income, and bills when you applied. To keep getting FoodShare after February 28, 2008, you will need to give the proof that your local agency asks for. More Information FoodShare This is a monthly benefit that helps you buy nutritious food for good health. FoodShare benefits come on a plastic card, called the Wisconsin QUEST Card (also called an EBT card), which you can use just like a bank card at most food stores. If you are getting FoodShare for the first time, you will get a QUEST Card and a FoodShare Enrollment & Benefits handbook by mail. Your benefits for January and February will be in your account by January 23, To learn more about using your benefits, please see your FoodShare Enrollment & Benefits handbook. Who is NOT eligible for FoodShare and why? When? As of Jan. 22, 2008 Who and why? JAMES S: You are not a U.S. citizen or an immigrant who is able to get this benefit. Who is not getting FoodShare and why. 8 Wisconsin Medicaid and BadgerCare Update January

65 Your Household's Reported Income and Bills Income you reported. Here is a list of the income and bills that we have on file for your household. Income When and how much? Who has income? Dec Jan As of Feb JANE S Job: ABC COMPANY JOHN S Child Support Received $ every other week $ every other week $0.00 $ each month $ each month $ each month Type of bill Rent Medical Bills Child Support Paid Utilities Bills you reported. Bills As of Dec $ each month $ each month $ each month Yes* * We have on file that you had utility bills for these months. How We Calculated Your Income When and how much? Here are the amounts and limits that were used to decide whether you could get benefits. To learn more, please see your Enrollment & Benefits handbook(s). BadgerCare+ Standard This was used for: JANE S, JOHN S, MARY S How your income and bills were counted. Dec Jan As of Feb Your Gross Income $1, $1, $ Your Counted Income $1, $1, $ Counted Income Limit $1, $1, $1, Your counted income is lower than your gross income because you get some credit for these items: child support payments. Wisconsin Medicaid and BadgerCare Update January

66 FoodShare Jan Feb Your Gross Income $1, $ Your Counted Income $1, $ Counted Income Limit $2, $2, Your counted income is lower than your gross income because of a standard credit that everyone gets. You also get some credit for these items: housing/utility bills, medical bills, child support payments. You also get a credit for working. Your Reporting Rules Based on the benefits you are getting, you must tell your local agency within 10 days if you have a change in where you live or where you are staying, or if someone moves in or out of your home. You must also report if someone gets married or divorced, or if your household s total gross monthly income (before taxes) goes over $1,581. Keep in mind that if your benefits change, your reporting rules may also change. Key Contacts Reporting rules for changes you must report. Contacts for questions or help. Disability Services: If you have a disability and need this letter in another format, call Translation and TTY services are available at no cost to you. Online Help: ACCESS is an Internet tool that lets you apply for other benefits, check your benefits or report changes. Visit access.wisconsin.gov. General Questions about FoodShare or Health Care Benefits or your Forward Card: See your Eligibility & Benefits handbook or go to dhfs.wisconsin.gov/customers/ or call (TTY and translation services are available). QUEST Card: Call (voice) or (TTY) if your QUEST card is damaged, stolen, or lost; if you get an error message while using your card; to check your account balance; or if you have other questions about your QUEST card. Any Other Questions: See the contact information for your local agency on page Wisconsin Medicaid and BadgerCare Update January

67 YOU HAVE THE RIGHT TO A FAIR HEARING ABOUT YOUR BENEFITS What is a Fair Hearing and why should I ask for one? How long do I have to ask for a hearing? Can I keep my benefits while I wait for my hearing? How do I ask for a hearing? A Fair Hearing gives you the chance to tell why you think there has been a wrong decision about your application or benefits. At the hearing, a hearing officer will hear from you and the local agency to find out if the decision was right or wrong. You may bring a friend or family member with you to the hearing. You may also be able to get free legal help. To learn more about free legal help, call The Division of Hearings & Appeals must get your request for a hearing about the decision in this letter by the date below: FoodShare March 20, 2008 Health Care February 5, 2008 If you are getting FoodShare benefits, keep in mind that you can ask for a hearing at any time if you don t agree with the benefit amount. Yes, if you are already getting benefits and if you ask for a hearing before your benefits change, you can keep getting the same benefits until the hearing officer makes a decision. If the hearing officer decides that the local agency was right, you may need to return the extra benefits that you got after your benefits were supposed to change. You can ask for a hearing and/or a hearing request form at the agency shown on the first page of this notice, or you can get a request form at dha.state.wi.us/home/. You can send the form or a letter asking for a hearing to the Division of Hearings & Appeals, PO Box 7875, Madison, WI , or fax it to If you need help with asking for a hearing, please call Fair hearing information and the deadline for requesting a hearing. Wisconsin Medicaid and BadgerCare Update January

68 Abri Health Plan Copay Sheet (as of February 1, 2008) BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan Medicaid SSI Abri is waiving all copays for the Standard Plan for all members. NOTE: Pregnant women and Members under 18 who are members of a federally recognized tribe are exempt from all copays. Per visit means one charge for the whole office call regardless of what is done. OFFICE VISITS no copay (Chiro is only covered through Abri in Milwaukee and Chiropractic Services Waukesha Counties) $15 copay per visit Podiatry Services no copay $15 copay per visit Office Visit - PCP no copay $15 copay per visit Office Visit - Specialist no copay $15 copay per visit Office Surgery no copay $15 copay per visit Urgent Care Services no copay $15 copay per visit Nurse Midwife Services no copay $15 copay per visit Nurse Practitioner Services no copay $15 copay per visit Diagnostic XRay & Lab (office location) no copay no copay Immunizations no copay no copay HealthChecks and Routine Care (any age) no copay no copay SSI members are all in the Standard Plan no copay (Chiro is only covered through Abri in Milwaukee and Waukesha Counties) HOSPITAL SERVICES Emergency Room Services - Facility bill no copay $60 per visit only if not admitted Emergency Room Services - Professional bill no copay no copay Outpatient Hospital Services - Facilty bill no copay $15 copay per visit Outpatient Hospital Services - Professional bill no copay no copay Inpatient Hospital Services - Facility bill no copay $100 copay per stay Inpatient Hospital Services - Professional bill no copay $15 copay per visit TRANSPORTATION Ambulance no copay $50 copay per trip Cab no copay not covered SMV no copay not covered MISCELLANEOUS SERVICES Ambulatory Surgery Services - facility bill no copay $15 copay per visit Ambulatory Surgery Services - professional bill no copay no copay Anesthesia no copay no copay Cardiac Rehab no copay $15 copay per visit, 36 visits maximum per enrollment year Chemo or Radiation Therapy no copay $15 copay per visit Hearing Services & Supplies no copay not covered Diagnostic XRay & Lab (independent lab or professional component) no copay no copay Dialysis Facility no copay $3 copay per day Disposable Medical Supplies Some DMS items are not covered by HMOs after 2/1/08 so copays may apply for certain people and/or for certain services if paid under FFS. Some DMS items are not covered by HMOs after 2/1/08 so copays may apply for certain people and/or for certain services if paid under FFS. The Benchmark Plan only covers limited DMS items and copays may apply. Some DMS items are not covered by HMOs after 2/1/08 so copays may apply for certain people and/or for certain services if paid under FFS. Durable Medical Equipment, Orthotics, Prosthesis no copay $5 copay per item, $2500 maximum per enrollment year. V5336 is not covered unless it is for an adaptive hearing aid. $15 copay per visit, 60 visits per enrollment year no copay Home Health Services no copay no copay Personal Care Worker (PCW) Services no copay not covered no copay $2 copay per visit, 360 visits Hospice Services no copay lifetime max no copay IV Therapy no copay see Home Health Services no copay Abri Health Plan, Inc

69 Abri Health Plan Copay Sheet (as of February 1, 2008) BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan Medicaid SSI Not covered by HMOs as of Not covered by HMOs as of Not covered by HMOs as of 2/1/08, so copays may apply for 2/1/08, so copays may apply for 2/1/08, so copays may apply for certain people and/or for certain certain people and/or for certain certain people and/or for certain Pharmacy Prescription Drugs services when paid under FFS. services when paid under FFS. services when paid under FFS. Prenatal Services including PNCC no copay no copay no copay Private Duty Nursing no copay not covered no copay PT, OT, ST Therapy Services - facility bill from home health agency or outpatient hospital PT, OT, ST Therapy Services - professional bill no copay no copay $15 copay per visit, 20 visit (each type limit) per enrollment year $15 copay per visit, 20 visits (each type) per enrollment year no copay no copay Rehabilitation Inpatient or Outpatient no copay see Hospital Services, Inpatient and Outpatient copays no copay Respiratory Therapy no copay $15 copay per visit no copay Skilled Nursing Facility (SNF) no copay no copay, 30 days maximum per enrollment year no copay Urgent Care Services no copay $15 copay per visit no copay Dental Services no copay (Dental is only covered through Abri in Milwaukee, Waukesha, Racine and Kenosha Counties) Only pregnant women and children up to 18 have dental coverage.there are no copays. Children under 18 must meet $200 deductible per enrollment year and have coverage of 50% of the maximum allowable for each service after that. Preventive and diagnostic services are not subject to the deductible but do have the 50% benefit. All pregnant women are exempt from deductible or coinsurance. Total benefits limited to $750 per enrollment year. no copay (Dental is only covered through Abri in Milwaukee, Waukesha, Racine and Kenosha Counties) MH AODA Services no copay Service limits: $7000 for all services, $4500 for non hospital substance abuse services. Substance abuse day treatment limit is $2700. $6300 for inpatient hospital acute care for substance abuse. Inpatient limit 30 days per enrollment year (in hospital or IMD). Copayment amounts: $10 per day for day treatment, $50 per day for inpatient, $15 per visit for narcotic treatment, $15 per visit for outpatient mental health services, $15 per visit for mental health services. no copay Vision Routine & Hardware no copay $15 copay per visit, one eye exam every 2 years, eyeglasses and contact lenses not covered no copay Abri Health Plan, Inc

70 May 2007 No To: County Departments of Community Programs, Human Services, Social Services HealthCheck Providers Nurse Midwives Nurse Practitioners Physician Assistants Physicians HMOs and Other Managed Care Programs Blood Lead Testing Requirements The Centers for Medicare and Medicaid Services, through Early and Periodic Screening, Diagnosis, and Treatment guidelines, requires that all children who are enrolled in Wisconsin Medicaid receive a blood lead test at about 12 months and again at about 24 months. In addition, children between the ages of three and five must receive a blood lead test if they have never been tested before. This requires the testing of all children enrolled in Wisconsin Medicaid regardless of the presence or absence of recognized lead exposure risks. Medicaid Requirements for Blood Lead Testing According to the Centers for Medicare and Medicaid Services, all Medicaid children are considered at high risk for lead poisoning. Therefore, all children who are enrolled in Wisconsin Medicaid must receive a blood lead test at about the following ages: 12 months and 24 months. Three to five years, if not previously tested. Providers are responsible for assuring that children receive blood lead tests at the required ages. Testing of all children enrolled in Wisconsin Medicaid applies regardless of the presence or absence of recognized lead exposure risks. According to the American Academy of Pediatrics, a low blood lead concentration in a one-year-old does not preclude elevation later. Therefore, providers are required to repeat blood lead testing at about two years of age, regardless of the results of the one-year test. A capillary fingerstick can be done for a blood lead screening test. A confirmatory venous blood test is required only if the capillary blood lead level is 10 mcg/dl or greater. Wisconsin s Blood Lead Testing Results In 2006, 2,117 children in Wisconsin were found to be lead poisoned. From 1997 through 2006, 34,730 children in Wisconsin were found to be lead poisoned 1 and 78 percent of these children were enrolled in Wisconsin Medicaid. Unfortunately, only about one third of all Medicaid children entering school have received the required testing for lead poisoning. Refer to the Attachment of this Wisconsin Medicaid and BadgerCare Update for locations of Wisconsin Lead Poisoned Children from 1997 through Medicaid Blood Lead Testing Summary Report Providers who annually see 25 or more Medicaid-eligible children that fall within the required testing age range recently received a Medicaid Blood Lead Testing Report from the Department of Health and Family Services through the Division of Health Care Financing and the Division of Public Health. The report allows the provider to evaluate his or her Department of Health and Family Services

71 compliance with Medicaid lead testing requirements. Providers who did not receive a report and are interested in receiving one may contact the Wisconsin Childhood Lead Poisoning Prevention Program at (608) Blood Testing at WIC Clinics Approximately 75 percent of all children seen in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics in Wisconsin are Wisconsin Medicaid recipients. The WIC clinics do some blood lead testing of Medicaid-enrolled children when performing routine blood tests for hemoglobin or hematocrit. Confusion often exists when a fingerstick is performed at the WIC clinic for hemoglobin or hematocrit as parents may assume that their child was also tested for lead. To validate that a blood lead test was performed on a particular child and to obtain the result of the test, providers may contact the Wisconsin Childhood Lead Poisoning Prevention Program at (608) or the Milwaukee Childhood Lead Poisoning Prevention Program at (414) Office-Based Blood Lead Testing Wisconsin Medicaid encourages providers to draw capillary (fingerstick) blood lead samples within their office or clinic. Performing the fingerstick in the clinic ensures the test is completed. If the child is referred to an outside area, the test may not be done. Providers wanting to provide blood lead testing in their office should refer to provider handbooks for information on the Clinical Laboratory Improvement Amendment. The Clinical Laboratory Improvement Amendment requires laboratories and providers performing tests for health assessment or for the diagnosis, prevention, or treatment of disease or health impairment to comply with specific federal quality standards. Online Resources for Information on the Treatment and Prevention of Lead Poisoning The following information regarding lead poisoning is available online. The American Academy of Pediatrics delivered a policy statement in 2005 that reiterates the Medicaid blood lead testing mandate because most children with lead poisoning are Medicaid recipients and most have not been tested (pediatrics. aappublications.org/cgi/content/full/ 116/4/1036#SEC6). The Centers for Disease Control and Prevention s (CDC) August 2005 statement titled Preventing Lead Poisoning in Young Children, includes a review of scientific evidence for adverse effects in children at blood lead levels below 10 mcg/dl ( PrevLeadPoisoning.pdf). Information on medical assessment and interventions for lead poisoning, including chelation treatment protocols include the following: The CDC s March 2002 report titled Managing Elevated Blood Lead Levels in Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention ( nceh/lead/casemanagement/ casemanage_main.htm). Protocols for Clinical Management of Lead Poisoned Children, Margaret Layde, M.D., Medical College of Wisconsin (dhfs.wisconsin.gov/lead/ doc/laydeprotocol.pdf). A pproximately 75 percent of all children seen in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics in Wisconsin are Wisconsin Medicaid recipients. 2 Wisconsin Medicaid and BadgerCare Service-Specific Information May 2007 No

72 Lead poisoning risk factors in Wisconsin, such as Medicaid versus non-medicaid status, racial and ethnic disparities, age of child, and age of housing (dhfs.wisconsin.gov/lead/ lpsurveillance/index.htm). Early and Periodic Screening, Diagnosis, and Treatment program requirements, including the blood lead testing requirement ( MedicaidEarlyPeriodicScrn/ 02_Benefits.asp#TopOfPage). Information that can be provided to families include the following: The brochure titled, Look Out for Lead (dhfs.wi.gov/lead/doc/ ParentsLeadEng.pdf). Lead Paint Safety: A Field Guide for Painting, Home Maintenance and Renovation Work ( offices/lead/training/lbpguide.pdf). A list of consumer products that contain dangerous levels of lead (dhfs.wi.gov/lead/ LSources_Products.HTM). Requirements Apply to All Medicaid Children The requirements discussed in this Update apply to all Medicaid children, regardless of whether they are in fee-for-service or an HMO. 1 Defined as a blood lead level equal to or greater than 10 mcg/dl, which the Centers for Disease Control and Prevention (CDC) considers a blood lead level of concern. The Wisconsin Medicaid and BadgerCare Update is the first source of program policy and billing information for providers. Although the Update refers to Medicaid recipients, all information applies to BadgerCare recipients also. Wisconsin Medicaid and BadgerCare are administered by the Division of Health Care Financing, Wisconsin Department of Health and Family Services, P.O. Box 309, Madison, WI For questions, call Provider Services at (800) or (608) or visit our Web site at dhfs.wisconsin.gov/medicaid/. PHC 1250 For more information on educational materials for preventing lead poisoning, providers may contact the Wisconsin Childhood Lead Poisoning Prevention Program at (608) Wisconsin Medicaid and BadgerCare Service-Specific Information May 2007 No

73 ATTACHMENT Locations of Wisconsin Lead Poisoned Children* 1997 Through 2006 * According to statistics provided by the Division of Public Health, a total of 34,730 Wisconsin children less than six years old were found to be lead poisoned during that time period. 4 Wisconsin Medicaid and BadgerCare Service-Specific Information May 2007 No

74 New partnership formed between MHSI and the Milwaukee Affiliate of Susan G. Komen for the Cure MILWAUKEE HEALTH SERVICES, INC. HAS A NEW PROGRAM IN PLACE. IT IS CALLED SCREEN OUT CANCER IN TIME (SOC-IT). THE SOC-IT PROGRAM OFFERS FREE MAMMOGRAMS TO YOUNG WOMEN BETWEEN THE AGES OF 35 AND 44. TO PARTICIPATE IN THIS PROGRAM, YOUR PATIENT: Must be between the ages of 35 and 44. Must have income within the program s guideline limits. The guidelines reflect income that is at or below 250% of the Federal Poverty Level. Must be uninsured; or Have insurance that does not cover screening mammograms. Does not have to have documentation that she is a U.S. citizen. Income Eligibility Guidelines 250% of Federal Poverty Level Effective 04/01/ /31/2009 Size of Family Annual Gross Income 1 $26,000 2 $35,000 3 $44,000 4 $53,000 5 $62,000 6 $71,000 7 $80,000 8 $89,000 For each additional family member add: $9,000 The Martin Luther King Heritage Health Center, offers mammograms by appointment only on Tuesday and Thursday between the hours of 9 am-4 pm. Phone: (414) ext 1121 The Isaac Coggs Heritage Health Center offers mammograms on a walk-in basis or by appointment. Mammograms are done Monday through Friday, 9 am to 4:30 pm. Phone: (414)

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76 Medicaid Preventive Health Programs HealthCheck Screenings HealthCheck is Wisconsin's name for the federally mandated Early and Periodic Screening Diagnosis and Treatment (EPSDT) program. It provides for comprehensive screenings (Well Visits) for Medicaid recipients under the age of 21 with established standards for required components and frequency. Components Health, Nutritional and Developmental Assessment Physical Assessment Age Appropriate Visual Screening Age Appropriate Hearing Screening Oral Health Examination Immunization History Review Blood Lead Test Other Testing, as appropriate to age, sex, race and clinical indicators Frequency birth to 1 year: 6 screenings age 1 to 2 years : 3 screenings age 2 to 3 years: 2 screenings age 3 to 21: 1 screening per year 73