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Understanding Wisconsins Health Plan Options


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Wisconsin has been a leader in trying to provide low cost health insurance for those individuals who are unable to access or qualify for employer sponsored plans. This presentation was part of a kaizen event for clinic personnel on the prior authorization proccess.

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Understanding Wisconsins Health Plan Options

  1. 1. Understanding Wisconsins Health Plan Options<br />An explanation of the various programs, eligibility and the ramifications for the providers<br />
  2. 2. HIRSP Health Insurance Risk Sharing Plan<br />MAPP Medicaid Purchase Plan<br />Forward Health<br />BadgerCare<br />BadgerCare Plus<br />Badger Care Core Plus<br />Medicaid<br />Medicare<br />Commercial Insurance<br />Listing of Wisconsin Programs<br />
  3. 3. Created in 1979 for people who are unable to find adequate health insurance in the private market due to pre-existing conditions or who have lost employer sponsored group insurance<br />Individuals who have incomes above the federal poverty level<br />HIRSPWhat is it? Who is eligible?<br />
  4. 4. Wisconsin Medicaid Program<br />Offers people with disabilities who are working or interested in working the opportunity to buy health care coverage through the Wisconsin Medicaid Program<br />Depending on the individuals income, a premium payment may be required<br />Medicaid Purchase Plan MAPPWhat is it? Who is eligible?<br />
  5. 5. Forward Health is the name for multiple programs administered by the State of Wisconsin<br />The programs include Health Care, like Badger Care and MAPP, Nutrition Programs like WIC, FoodShare Wisconsin, Other programs like energy assistance, Wisconsin Works (W2), SSI, etc. <br />Go to the Forward Health website for a complete listing<br />Forward HealthWhat is it? <br />
  6. 6. Health care cost reimbursement program created by former Governor Tommy Thompson<br />Went into effect July 1, 1999 and was created to provide health care coverage to Wisconsinites who’s employer didn’t provide it or who made too much money to be covered by Medicaid<br />Program was altered in 2008 to BadgerCare+ so that all children would have access to healthcare who were not otherwise covered <br />Badger CareWhat is it? Who is eligible?<br />
  7. 7. Plan to make sure every child in Wisconsin has access to affordable health insurance<br />Expands health insurance coverage and benefits for pregnant women<br />Provides health insurance to parents and caretaker relatives<br />Goal was to ensure that 98% of Wisconsin residents have access to quality, affordable health care<br />BadgerCare+What is it? <br />
  8. 8. All children under 19, regardless of income<br />Pregnant women with incomes up to 300% of the federal poverty level (FPL)<br />Parents and relatives caring for a child up to 200% of the FPL<br />Young adults in foster care who turn 18 are automatically enrolled until they are 21<br />Farm families and other self employed families if income is under 200% of the FPL<br />Must prove Wisconsin residency & citizenship<br />Badger Care + Who is eligible?<br />
  9. 9. Limited plan that covers basic health care services including primary and preventative care as well as generic drugs<br />For people who are not getting BadgerCare +, Medicaid or Medicare<br />For people who do not have access to employer sponsored insurance, or cannot sign up for employer insurance for three months and who did not have access to employer sponsored insurance for 12 months prior to requesting Core+ coverage<br />Badger Care + Core PlanWhat is it?<br />
  10. 10. Ages 19-64<br />Do not have children or dependant children under 19 living with them<br />Not pregnant<br />Family income at or below 200% of FPL<br />Are Wisconsin residents and are U.S. citizen or legal immigrant<br />Must apply and pay an application fee<br />Have to pay monthly premiums based on income<br />Badger Care Core+Who is eligible?<br />
  11. 11. Joint federal and state program established in 1965 under Title XIX of the federal Social Security Act<br />BadgerCare extends Medicaid coverage through a Medicaid expansion under Titles XIX and XXI<br />Goal of BadgerCare is to extend gap between Medicaid and private insurance without replacing or crowding out private insurance<br />MedicaidWhat is it? <br />
  12. 12. Medicaid used to cover some of the same people as Badger Care plus<br />Now Medicaid applies only to the elderly, blind and disabled<br />BadgerCare + is Wisconsin’s program for families, pregnant women and minors seeking affordable health insurance<br />MedicaidWho is eligible?<br />
  13. 13. Medicaid policies and procedures that are published apply to both the Wisconsin Medicaid and Badger Care Plus<br />Badger Care Plus has two plans within it, the standard plan and the benchmark plan<br />Badger Care Benchmark plan may differ from Badger Care Plus and Medicaid in coverage, prior authorization, cost-sharing and reimbursement<br />On line handbook must be used to research coverage, prior authorization and reimbursement for clarification<br />Program administration<br />
  14. 14. Communicated on line via the handbooks and updates<br />Forward Health is the portal for information on all Badger Care and Medicaid<br />HIRSP has separate guidelines for prior authorization and coverage conditions, the provider section of their website lists the procedures that require prior authorization<br />WPS administers the HIRSP plan, at times you may be redirected to the WPS website<br />Wisconsin Program changes<br />
  15. 15. Wisconsin has been on the forefront of expanding healthcare coverage for all its residents<br />Badger Care Plus was ahead of the national program SCHIP which is the federal program for health care coverage for children<br />The future of these programs remains to be seen as healthcare reform evolves<br />Badger Care may be the format that the state uses to comply with the federal changes<br />Putting it all together<br />
  16. 16. Funding for Medicaid & Badger Care products is 60/40. With the federal government providing 60% of the funding to the state and the state providing another 40%<br />Provider rates are poor, usually less than Medicare<br />FPL determinations used to vary state by state, however new health care reform bill standardizes it to 133% of FPL<br />Putting it all together <br />
  17. 17. HIRSP program in theory could dissolve with the new health care legislation which will require insurance companies to cover pre-existing conditions<br />Look for some standardization of coverage with the new legislation, there may no longer be differences in what programs require prior authorization, and what is a covered service<br />Under the new health care legislation Wisconsin’s state Medicaid cost would actually go down<br />Putting it all together<br />
  18. 18. 3 Plans<br />Part A Automatic benefit with Social Security, provides inpatient hospital coverage, an annual deductible is paid by beneficiary<br />Part B Medical insurance benefit that provides outpatient coverage, there is a monthly premium as well as an annual deductible to be paid by beneficiary<br />Part D Prescription Drug Coverage there is a monthly premium as well as an annual deductible to be paid by beneficiary<br />Medicare <br />
  19. 19. Medicare Part B is paid for using a deduction from Social Security. For 2010 it is $96.40 per month, with a $155 annual deductible and a 20% coinsurance. There is a income adjustment for individuals with over $85,000 per year of income<br />Medicare Part D is also paid for using a deduction, however the formula for premiums is specific to the individual and individuals need to go on line or call to enroll<br />Medicare Supplements<br />
  20. 20. Why purchase?<br />Covers the 20% coinsurance for Medicare Part B, which can add up for patients that frequently use health care<br />Covers the Part A inpatient deductible<br />Can get coverage for prescription drugs depending on the plan<br />Can get additional coverage for home health care, durable medical equipment, nursing home, etc.<br />Medicare Supplemental Insurance<br />
  21. 21. HMO Health Maintenance Organization<br />PPO Preferred Provider Organization<br />POS Point of Service<br />Indemnity<br />Medicare Advantage<br />Insurance plans<br />
  22. 22. Prepaid medical care<br />HMO pays a particular contracted provider for care<br />Usually operates on a closed panel basis which means individuals are required to seek care from a particular provider who is contracted with the HMO in order for the care to be paid<br />Limit care to a specific geographic region<br />HMO<br />
  23. 23. Providers agree to provide care on a reduced fee to this organization or plan<br />Insured persons are incentivized to use providers in the plan or network because they have less out of pocket cost to use the contracted providers<br />Use of websites and provider handbooks by the insurance plan is common as people can search for an in network provider<br />Less restrictive than an HMO<br />PPO<br />
  24. 24. Usually offered by HMOs as it allows individuals enrolled in the HMO some ability to choose providers that are not on the HMO panel<br />Out of pocket costs are less for using a point of service contracted provider<br />Benefits are that it is less restrictive than a pure HMO plan, but it is not as open as PPO plan<br />Use of a non POS provider requires higher copayments and deductibles be paid <br />POS<br />
  25. 25. Fee for service plan<br />Monthly premium paid by employer and employee or individual<br />Contract between policyholder and insurance company<br />Least restrictive option as individuals can go more freely to providers that take the insurance product purchased<br />Indemnity<br />
  26. 26. Federal program whereby individual can obtain Medicare coverage through private insurance<br />Insurance companies handle all the claims for care and federal government pays the insurance company a defined amount for the insured person<br />Insurance company’s incentive is to negotiate good prices with providers so that they are able to maintain a profit margin<br />Medicare Advantage Plan<br />
  27. 27. In 1995 50.1% of commercial insured Wisconsinites had HMO coverage. In 2009 it was down to 41.7%<br />In 1995 8.4% of commercial insured Wisconsinites had POS coverage. In 2009 it was up to 38.6%<br />In 1995 14.4% of commercial insured Wisconsinites had PPO coverage. In 2009 it was up to 18.2%<br />In 1995 27.1 % of commercial insured Wisconsinites had indemnity coverage. In 2009 it was down to 1.4%<br />Wisconsin Trends in Insurance<br />
  28. 28. Not just in Wisconsin but through out the nation administrative headaches <br />A January 2010 article “The High Cost of Dealing with Insurance” put the staffing cost per physician of dealing with insurance at $68,274 per year. Of that $21,796 was nursing and $25,040 was clerical (MGMA Connexion January, 2010)<br />It is likely not to get better in the near future<br />Trends in dealing with insurance and health care payers<br />
  29. 29. Wisconsin has been a leader in expanding health insurance coverage to its citizens<br />Wisconsin health care providers are experiencing the same administrative headaches related to insurance as the rest of the nation<br />Wisconsin’s variety of state run programs makes things more challenging administratively to provide care to the individuals covered<br />In summary<br />
  30. 30. Questions?<br />