autismregionalmeeting nov 2015 english (1)
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7/21/2019 Autismregionalmeeting Nov 2015 English (1)
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Wisconsin Department of Health ServicesDivision of Health Care Access and Accountability
Division of Long Term Care
November 2015
Coverage of Behavioral Treatment
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Presentation Purpose
To provide an overview of the changes to autismtreatment services and behavioral treatment for parentsand guardians.• Reason for changes• Behavioral treatment benefit information• Overall timeline• Scenarios
Note: Presentation information is current as of November 3, 2015;all dates are tentative and subject to change.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Intended Audience
• Parents and guardians of children currently receivingautism treatment services under the Children’s Long-Term Support (CLTS) Waiver Program.
• Parents and guardians of children currently on thestate Autism Wait List.
• Parents and guardians of children newly diagnosed
with behavioral treatment needs.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Transitioning Services
• Right now children are receiving autism treatmentservices through the CLTS Waiver Program. Parentsand guardians work with their waiver agency.
• In the future, children will receive behavioraltreatment, including autism treatment, as a regularMedicaid benefit.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Why the Change?
• In July 2014, the federal government directed states tocover autism treatment services under the MedicaidState Plan.
• In response, the Department of Health Services istransitioning autism treatment services from the CLTSWaiver Program to a new ForwardHealth behavioraltreatment benefit.
• ForwardHealth includes the Medicaid, BadgerCarePlus, and Katie Beckett programs.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
How Children Receive Treatment
Today Under the CLTS Waivers• As children's names are released from the state Autism
Wait List, children are enrolled in the CLTS WaiverProgram through their local waiver agency.
• Parents and guardians work with their Support andService Coordinator to identify service needs andproviders.
•
Children access autism treatment with waiver agencyoversight.
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Wisconsin Department of Health Services
How Children Receive Treatment
Today Under the CLTS Waivers (cont.)• Three treatment levels:
o Intensive
o Consultativeo Ongoing
• Treatment under the CLTS Waivers was determined byproviding a set amount of weekly treatment hours,allocated dollars, and year limits to each child.
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Wisconsin Department of Health Services
How Children Will Receive
Treatment Under ForwardHealth• Behavioral treatment will be a regular ForwardHealth
benefit, like a physician service or well-childscreening.
o Parents and guardians will no longer have to contact thewaiver agency to receive behavioral treatment services.
o Parents and guardians will work directly with a Medicaid-enrolled behavioral treatment provider.
• There will no longer be a state Autism Wait List.
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Wisconsin Department of Health Services
Behavioral Treatment Benefit
The ForwardHealth behavioral treatment benefit willinclude two different types of treatment: comprehensiveand focused.• Comprehensive treatment is an early intervention
approach designed to address multiple aspects ofdevelopment and behaviors in young children; typicallyhigher weekly hours and longer duration.
• Focused treatment is dedicated to addressing specificbehaviors or developmental deficits; typically fewerweekly hours and shorter duration.
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Wisconsin Department of Health Services
Behavioral Treatment Benefit (cont.)
• ForwardHealth covers evidence-based treatmentmodalities, including Applied Behavior Analysis andEarly Start Denver Model.
• Treatment hours will be specific to the child’sbehavioral treatment needs.
• The behavioral treatment benefit adopts a flexible
approach to meeting the child’s needs.
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Wisconsin Department of Health Services
Behavioral Treatment Benefit
(cont.)• Services must be medically necessary for the child.• Medical necessity is determined by ForwardHealth
through the prior authorization (PA) process.• The PA is requested by the behavioral treatment
provider on behalf of the child.o All PA requests for behavioral treatment are considered by ForwardHealth.o PA requests do not go through the child’s Medicaid or BadgerCare Plus
HMO.
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Wisconsin Department of Health Services
The Prior Authorization Process
1. A Medicaid-enrolled behavioral treatment provider willcomplete and submit the PA request and requireddocumentation to ForwardHealth.
2. A decision on the PA request will be made byForwardHealth.
3. The PA decision will be communicated to the provider.
4. Treatment can start with an approved PA.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Accessing Behavioral
Treatment ServicesParents and guardians will use the ForwardHealth card to accessbehavioral treatment services.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
What Is t Changing?
• Eligibility criteria for the CLTS Waiver Program willremain the same.
• The CLTS Waiver Program will continue to provide anarray of supports and services, including support andservice coordination, to meet children’s assessedneeds.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
What Is t Changing? (cont.)
• Eligibility requirements for the Medicaid, BadgerCare Plus,and Katie Beckett programs will remain the same.
• ForwardHealth will continue to coordinate benefits withcommercial insurance. Providers must bill commercialinsurance before billing Medicaid.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Overall Timeline
November 2015• Providers who wish to provide behavioral treatment under the
ForwardHealth benefit are required to enroll in WisconsinMedicaid as a behavioral treatment provider.
January 1, 2016• The behavioral treatment benefit will be available and PA
requests will begin to be processed.• Children on the state Autism Wait List may begin the PA process.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Overall Timeline (cont.)
Summer 2016:• All children receiving autism treatment through the CLTS
Waiver Program will have completed the PA process.
By December 31, 2016• All behavioral treatment services will be provided under the
ForwardHealth benefit.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Scenarios
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Scenario #1
A child currently on the state Autism Wait List:• Parent or guardian will confirm that a Medicaid-enrolled
behavioral treatment provider can serve child.• Between November 2015 and January 2016, selected provider
will complete and submit a PA request for the child.• A decision will be made on the PA request and communicated
back to the provider.• On or after January 1, 2016, behavioral treatment may begin for
the child with an approved PA request.• The child’s name will be added to the county CLTS Wait List, if
applicable.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Scenario #1 (cont.)
• Once the child’s name is released from the CLTS Wait List, theparent or guardian will work with the waiver agency todetermine if additional services are needed.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Children on State Autism Wait List
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Medicallynecessary
treatmentauthorized
Confirmbehavioral
treatmentprovider
Providersubmits PA
request
Added toCLTSWait List
Assessed forwaiver
services
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Scenario #2
A current CLTS Waiver participant receiving behavioral treatment:• In November 2015, the waiver participant will be assigned a
transition time between May and October 2016.•
Between January and June 2016, the Medicaid-enrolled behavioraltreatment provider will complete a PA request on the child’s behalf.• After a PA determination is made, the waiver agency will meet with
the parent or guardian to complete a new assessment and determineif additional waiver services are needed.
• The child will continue to receive autism treatment through thewaiver until a PA determination is made and the assessment iscomplete.
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Process for transitioning current
CLTS waiver participant
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Providersubmits PA
request toForwardHealth
Ongoing waiver services
Waiverparticipant
assignedtransition time
Medicallynecessary
treatmentauthorized
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Scenario #3
A Medicaid-eligible child is newly diagnosed with a behavioraltreatment need:• The family identifies a Medicaid-enrolled behavioral treatment provider
who agrees to provide behavioral treatment for the child.• The selected provider completes and submits a PA request for the child.• A PA decision is made and communicated to the provider.• Behavioral treatment starts for the child with an approved PA request. • If the family has additional needs outside of behavioral treatment, the
parent or guardian should contact the waiver agency to determineeligibility for waiver services.
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Wi i D f H l h S i
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Children Newly Diagnosed with a
Behavioral Treatment Need
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Doctorvisit
DiagnosisMedicallynecessarytreatmentauthorized
Contactbehavioraltreatmentprovider
Providersubmits PA
request
Wi i D t t f H lth S i
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Children Newly Diagnosed with a
Behavioral Treatment Need andCLTS Service Needs
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Doctorvisit
DiagnosisMedicallynecessarytreatmentauthorized
CLTSWait List
Contactwaiver
agency forwaiver
services
Contact
behavioraltreatmentprovider
Providersubmits PA
request
Startreceiving
waiverservices
Wi i D t t f H lth S i
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Coverage of Behavioral Treatment by Wisconsin’s Medicaid Program
Wisconsin Department of Health Services
Additional information
• Learn more about the changes and sign up for email updatesat: dhs.wi.gov/clts/waiver/autism/updates.htm
• To learn more about the transition of behavioral treatmentservices from the CLTS Waivers to ForwardHealth, contactyour waiver agency.
• If your behavioral treatment provider has questions about theForwardHealth benefit, refer them to the ForwardHealthPortal at www.forwardhealth.wi.gov
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Wisconsin Department of Health Services
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C g f B h i l T t t b Wi i ’ M di id P g
Wisconsin Department of Health Services
Questions
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