“Did You Know?
Now You Know!”
An Introduction to Health Care and Long Term Supports
for Children and Youth
With Disabilities and/or Special Health Care Needs
Updated Spring 2015
Goals for Today:
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Systems of Support
Private Health Insurance
Health Care Reform
Medicaid/BadgerCare
Medicaid Waiver Programs
More than Health Care…
Systems of Support
How Are Formal Supports Organized?
Federal Government provides Funding and
Requirements to
State Governments who provide Funding and
Requirements to
Local Systems of Services, including Counties
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Examples of Federal Programs
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Centers for Medicaid and Medicare Services (CMS)
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Maternal and Child Health Bureau (MCHB)
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Birth to 3 Programs
Public school based special education services, ages 3-21
Social Security Administration (SSA)
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Provides funding for Wisconsin’s Title V program and its Regional CYSHCN Centers
Provides funding for Family Voices of WI Family to Family Health Information Center
Office of Special Education Programs (OSEP) from the US Department of Education
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Medicaid services (including Title 19)
Home and Community-Based Waiver Services (such as the Children’s Long Term Support Waivers)
Medicare services
Supplemental Security Income (SSI) and Social Security Disability Income (SSDI)
Vocational Rehabilitation
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Examples of State Programs
State of Wisconsin program:
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Family Support Program
State funding added to Federal Programs:
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Birth to 3 Program
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Medicaid/Forward Card Services (BadgerCare, Katie Beckett, SSI, Title 19)
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Home and Community-Based Waivers (e.g. Children’s Long Term Support
Waiver)
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Early Childhood (ages 3-5) through the public schools with IEP
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K-12 special education through the public schools with IEP
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Public education 18 – 21 transition services with IEP
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DVR (Division of Vocational Rehabilitation)
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Examples of County Programs
County money added to state programs:
• Medicaid waiver programs, including Children’s Long Term
Support Waiver
County money for individual county programs:
• Family Support Program (FSP)
• Community mental health “wraparound” services
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The Reality of Waiting Lists
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There is not enough money for services for people with
disabilities to have the help they need to live in the
community.
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They exist throughout the state, even though they may vary
from county to county
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They affect the amount of services received
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They affect the quality of services received
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Children Might Wait For…
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Family Support
Home and Community-Based waivers, including the Children’s Long
Term Support Waiver and In-Home Autism Services
Your child CANNOT be placed on a waiting list for:
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Birth to Three services
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Medicaid card services, including dentists and mental health
professionals who only take a limited number of Medicaid patients
However, there may be a delay in receiving these services
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Did You Know?
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Call to find out where you are on the wait list
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Keep county informed of change of address/phone number
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If you have a critical need it’s important to let someone
know!
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You may be able to get off the wait list sooner or get other help
while you are waiting
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What Other Help is Out There?
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Connect with Independent Living Centers and community
equipment lending closets
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Look at alternative sources of supports – national and
community resources for one time needs; faith
communities; service organizations
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Be creative – not everything needs a formal solution!
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PRIVATE
HEALTH
INSURANCE
The Benefits Plan
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Insurance covers ONLY what is written into the Benefits
Plan.
It is the legally binding contract between you and your
insurance company.
It defines what is and is not covered.
It can sometimes be unclear.
The Affordable Care Act ensures that benefits plans must be
written in language that is easily understood
Get benefits plans through Member Services Department or
from your employer
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What is in Your Benefits Plan?
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What is covered?
What are the limits on services, including therapies?
What is NOT covered? (exclusions)
Who are the providers and where do you get a list of providers that take
the insurance?
Who makes medical decisions in your plan if you need to go out of the
network?
If an insurance claim is denied, you have a right to appeal. What is your
appeal process?
Can your policy be renewed automatically? Can it be cancelled? If so,
with what notice?
Who do I call for help if I don’t understand what’s in my plan?
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Health Care Reform:
How Might it Impact Children
and Youth?
Effect on Private Insurance
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No pre-existing condition clause
Remain on parent’s health insurance until age 26
Preventative health services at no out of pocket
cost
No lifetime or annual limit on coverage; however,
there CAN be a limit on total number of services
(including therapy services)
All plans need to offer Essential Health Benefits
What are Essential Health Benefits?
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Ambulatory patient services •
Emergency services
Hospitalization
Maternity and newborn care •
Mental Health and substance •
abuse disorder services,
including behavioral health
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treatment
Prescription drugs
Rehabilitative and
habilitative services and
devices
Laboratory services
Preventative and wellness
services and chronic disease
management
Pediatric services, including
oral and vision care
Getting Health Insurance in Marketplace
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Determine coverage level that will meet your family’s needs
– balance between premiums and co-pays/deductibles –
think about how often you use your coverage
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High user of services? Consider higher monthly premium but
lower deductibles and co-pays
Cost subsidies and tax credits may be available.
Are your child’s providers in the plan’s network?
Will you have to change primary care or specialty providers
in a new plan?
Accessing the Marketplace
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Next Open Enrollment Period: Nov. 1, 2015 – Jan. 15, 2016
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Available through “marketplace”, aka “exchange”
• www.healthcare.gov
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Resource: Enrollment for Health Wisconsin
• http://e4healthwi.org/
Potential Concerns
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Parents and children may have different payers and
health plans – coordination is essential
Premium payments must be maintained to keep
insurance
If you don’t have health insurance – either private
or Medicaid/BadgerCare? Fines will need to be
paid when you file your tax returns with the IRS
MEDICAID
Now, What About Medicaid?
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Medicaid’s goal is to provide basic health care services
Medicaid is sometimes referred to as:
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Title 19
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BadgerCare
Medical Assistance or MA
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Medicaid is a federal program, but managed and partially
funded by each state; each state has a different Medicaid
program
Wisconsin has generous Medicaid services – as compared to
other states
Medicaid is handled by the Wisconsin Department of Health
Services (DHS)
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Doorways into Medicaid
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Two common ways define eligibility into Medicaid:
by disability and/or by income
Disability eligibility: e.g. Katie Beckett (does not
look at family income, only the child’s income); SSI
(considers the whole family’s income and assets)
Income eligibility: e.g. BadgerCare (looks at family
income; do not need to have a disability)
Proof of citizenship required for all Medicaid
programs
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What is SSI?
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SSI is Supplemental Security Income (offered
through the Social Security Administration)
Provides monthly cash benefits and Medicaid
Income and disability criteria need to be met
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Child must have “marked and severe” limitation in
functioning AND condition must last for at least a year
For children under 18, family income considered
For youth over 18, only individual’s income considered
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Know Your Medicaid Benefits
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Medicaid benefits may vary
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The benefits offered through Medicaid depend on how you
obtained Medicaid -- your eligibility “doorway” into
Medicaid (such as the Katie Beckett program; BadgerCare
Plus, SSI)
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The differences between the doorways are mainly in the
lists of doctors and medical professionals
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Katie Beckett Program
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Children must be 18 years old or younger
Must have a disability that requires an “institutional level of
care.”
Only the child’s income is considered, not the family’s
income or assets.
Eligibility for Katie Beckett is determined every year by
“reassessment”
The “functional screen” is used to figure out the level of care
each year.
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Rosy vs. Realistic
Rosy = Ben can dress himself independently.
Realistic = Ben can dress himself independently about one
day a week, if I have the right clothes out for him.
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Rosy = Mikayla can communicate her needs to me.
Realistic = Most of the time, people who are unfamiliar with
Mikayla do not know what she wants or cannot understand
her words or signs.
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Both Medicaid and Private Insurance?
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Medicaid is the payer of last resort – all other
insurance plans pay first
Medicaid only picks up what private insurance
formally denies. If you have Medicaid and private
insurance, all services MUST be billed first to private
insurance, or else Medicaid won’t pay at all.
Medicaid can cover private insurance co-pays
Medicaid can cover additional therapies and
services for your child above those covered by your
private health insurance.
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What Can the Medicaid Card Pay For?
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Services needed due to “medical necessity”
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diapers for children over age 4
medical transportation
personal care services
over the counter medications
mental health services
Sometimes “Health Check Other Services” needs to
be used to access services
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HealthCheck Other Services
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HealthCheck and HealthCheck Other Services are
available to children under 21 who are already
eligible for Medicaid
HealthCheck Other Services covers medically
necessary goods and services not typically covered
by Medicaid (such as over the counter medications)
An annual HealthCheck exam is needed to access
HealthCheck Other Services
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Where Can I Learn More?
Medicaid Handbooks are the benefits plan:
https://www.forwardhealth.wi.gov/WIPortal/Online
%20Handbooks/Display/tabid/152/Default.aspx
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Even though this is the “Provider Handbook”, it will
get you information that is useful regarding covered
services
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Medicaid Waiver Programs,
Prior Authorization, and
Coordination of Services
Medicaid Waiver Programs
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Waivers are a way to use Medicaid funding in a
more flexible way.
Wisconsin has several waivers.
Children’s Long Term Support (CLTS) waivers are
the waivers for kids
Family Care, IRIS and “Legacy waivers” are waiver
programs for adults
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More About Waivers
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The Children’s Long Term Support Waivers (CLTS) serve children living
with their families who meet the level of care in one of three areas of
disability:
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physical disabilities
developmental disabilities
severe emotional disabilities
The level of care required is an “institutional” level of care, the same
level of care that is needed to access Medicaid through the Katie Beckett
program. This is determined through an evaluation using the “functional
screen.”
A parental cost share is in place on a sliding fee scale. This means that
you only pay a part of the cost based on your income.
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Eligibility for Programs
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Remember “Rosy vs Realistic”
Sometimes a child won’t meet eligibility criteria. You have a
right to appeal this decision.
A child’s eligibility status might change in the future (e.g.
changing needs and abilities as a child gets older.)
The “functional screen” determines eligibility. You have the
right to ask for a functional screen to be done for your child,
even if the screener doesn’t think that your child will qualify
before they even do the screen.
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Prior Authorizations (PAs)
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Why are they so important?
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Why are they so complicated?
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PAs are important because they get our children what they need
Providers are often asked to write PA requests to get permission from
Medicaid to pay for something
PAs are complicated because we’re dealing with a lot of government rules and
regulations
Who makes the decisions to approve or deny PAs?
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Nurse consultants at the state Department of Health services review PAs
The nurses specialize in certain areas of disability
The decisions are individualized
Sometimes additional information is needed before a decision can be made
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More About PAs
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Families must be actively involved in the development of PA
requests. Families can:
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Whose job is it to get the PA?
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Offer to review the PA for accuracy
Offer to provide extra documents that can help
Get letters from other providers or support people
It is the provider’s job to complete the PA request and to follow
up, if necessary
How do I know when a PA is needed?
Typically a provider will let you know when it is needed
How do I know if/when a PA needs to be renewed?
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Again, the provider will let you know.
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What Medicaid Considers with PAs
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If an item or service is medically necessary and
appropriate
How much it will cost
Whether it is likely to be effective, of high quality
and prescribed at the right time for the child
Whether there is a less expensive or more
appropriate alternative
Whether the provider or recipient has overused or
misused services
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PA Steps…
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Identify the child’s needs, including in-home supports
Doctor writes prescription
Family and/or doctor identifies who will provide the services
or goods (provider)
Family works with provider to submit PA
Submit PA to private insurance and Medicaid at the same
time
PAs are approved for time and frequency; be aware of
submission rules for PA renewals
If approved, services are provided
If denied, work with the provider to file an appeal
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Appealing a Denial of a PA
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A Medicaid/BadgerCare applicant may request a “fair
hearing” from the state
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Write a letter directly to the “Wisconsin Department of
Administration, Division of Hearings and Appeals”
Complete the request using the form on the DHS website
Remember to ONLY respond to the reason for denial as
stated in the letter you receive
A “fair hearing” is NOT going to court and you DO NOT need
an attorney to represent you
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Often done as a telephone meeting
You can have someone participate to support or represent you
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Common Pitfalls
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Providers may tell you something is not covered if
they don’t want to do a PA or if the first PA was
denied.
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Providers sometimes forget to stress medical
necessity in the PA – services must be medically
necessary!
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Avoid “Duplication of Services” – need to
coordinate school and community therapies
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Avoiding Duplication of Services
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Educational necessity is something different than medical
necessity and your Prior Authorizations need to show that;
goals must be different.
Know that Medicaid likely will request a copy of the IEP with
the PA to make sure services aren’t being duplicated.
Medicaid wants to make sure that they are not paying for a
service that is already being provided at school or should be
provided at school, which is a good check of the school
system. This is especially true because often time the school
bills Medicaid for the services at school as well!
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Duplicate?
Community-Based Physical Therapy Goal:
Judie will independently transfer herself to the toilet
and in and out of the bathtub, bed and car.
Treatment – improve muscle and trunk strength.
• IEP Goal:
Judie will move independently throughout the school
building using a walker and attend all classes on
time. Treatment – gait training with a walker in
empty and crowded hallways.
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Duplicate?
Community-Based Speech and Language Goal:
Eduardo will improve speech intelligibility. Treatment
– specific bilabial (two lip consonants- b, p, m, w)
sound production.
• IEP Goal:
Eduardo will be understood by his teachers.
Treatment – work on diction and production of
specific consonants.
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Duplicate?
Community-Based Occupational Therapy Goal:
Keesha will strengthen and re-learn how to use her
right hand following surgery. Treatment – mobility
exercise and ongoing caregiver training.
• IEP Goal:
Keesha will independently complete classroom
assignments using adapted writing instruments.
Treatment – use of a weighted pencil, positioning
adaptations and the use of therapeutic techniques
to improve coordination.
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Denials Happen…What to Do?
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Appeal whenever you get the chance.
Don’t miss deadlines
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an appeal request must be filed 45 days after the denial.
IMPORTANT – if you are already receiving Medicaid, and the
appeal request is filed within 10 days, Medicaid must
continue providing benefits until the decision from the
hearing officer is received.
If the hearing officer rules that the Prior Authorization is still
denied, there is a possibility that Medicaid will ask you to
pay back the therapy costs that were charged while the
appeal was going on, if they paid for services during that
time.
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Denials Happen…What to Do?
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Develop a paper trail: documents, letters, phone calls – make sure you
get the name of the person you talk to on the phone and the date you
had that conversation. Write down the outcomes of the call and next
steps after the phone call.
When a PA is denied, get clear reasons and details as to why the PA was
denied. This may or may not be on your letter.
Write your appeal and concentrate on the reasons they gave you for the
denial.
State the facts as best you can and don’t be afraid to tell them about the
needs of your child and your family.
Bring a second set of ears like a friend, family member, therapist or even
an advocate, even if it’s a telephone hearing. If it’s a face to face
hearing, consider bringing your child.
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More than Health Care…
A Vision for the Future…
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Dreaming and imagining
Experiences and Opportunities
• Using “teachable moments” and role playing Extra
curricular and community activities
• Leadership activities
• Community activities
Planning for the future
• Tools for developing skills for independence
• Skills and interest inventories
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Never too Early to Plan for Transition!
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Next Steps…
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What concern/issue will you take on first?
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Which partners will you bring on to help you?
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What do you need to have more information
about?
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Contact Us!
Family Voices of Wisconsin
Post Office Box 5070
Madison, WI 53705
Website: www.fvofwi.org
Email: barb@fvofwi.org
Telephone: 1.608.220.9598
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