United States: Wisconsin Eyeing A Controversial Section 1115 Waiver

Last Updated: May 5 2017
Article by Christian Springer

Another state is stepping up to bat following Secretary Price's and CMS Administrator Verma's letter to state governors promising enhanced flexibility for their Medicaid programs.  Wisconsin has recently unveiled its plan to submit a new Section 1115 waiver application to CMS by May 26, 2017.  In short, the Wisconsin waiver seeks to infuse the state's Medicaid program with features from the commercial sector, and it does this by borrowing some elements from the Healthy Indiana Plan (HIP 2.0) and Kentucky waivers, which Seema Verma helped design before becoming CMS Administrator.  We've discussed those waivers here before.

But there are also some key distinctions between this waiver and the Indiana and Kentucky waivers, one of the most notable ones being that the Wisconsin waiver is not a Medicaid expansion waiver.  Rather, it's simply revamping its existing Medicaid program with respect to non-pregnant, childless adults between the ages of 19 and 64 with incomes up to 100 percent of the federal poverty level (FPL).  Further, the Wisconsin waiver would establish an unprecedented "time limit" on Medicaid eligibility.

In general, the Wisconsin waiver could offer some unique opportunities for stakeholders to approach the provision of healthcare from a much more holistic perspective, taking into account factors such as education, employment, healthy lifestyles, and substance abuse challenges.  But as is the case with all waivers that seek to emulate the commercial sector with a vulnerable population like Medicaid, implementation of the Wisconsin waiver will need to be closely monitored to ensure it does not produce opposite effects to its intended design.

Below we take a look at some of the Wisconsin waiver's key design features.

Monthly Premiums

The Wisconsin waiver would establish monthly premiums ranging from $0 to $10 per household depending on household income.  For example, Medicaid beneficiaries with 0% to 20% of the federal poverty level will not need to pay monthly premiums, while beneficiaries between 81% to 100% of FPL would pay the full $10.  Importantly, the household income tiers will not affect currently applicable copayment policies of the program (but the waiver would add a $8 copay for an ER visit and a $25 copay for subsequent visits during a 12-month period).  Furthermore, third party payers would be allowed to offer premium assistance to beneficiaries.

The Wisconsin waiver would also waive 50% of the monthly premiums for beneficiaries that engage in "healthy behaviors."  Conversely, beneficiaries engaged in behaviors that "increase their health risk" will owe the full standard amount.

Additionally, the Wisconsin waiver would "lock-out" beneficiaries for up to six months who fail to make their premium payments.  These beneficiaries could, however, pay their full balance and be allowed to re-enroll.  If beneficiaries are unable to pay their full balance, they may re-enroll notwithstanding any unpaid premiums after six months.

Healthy Behavior Incentives

As mentioned above, beneficiaries could reduce their monthly premium payments by 50% if they engage in "healthy behaviors."  Individuals who are found to have a health risk behavior, but who actively manage this behavior and/or have a condition beyond their control, will also have their premiums reduced by half.  Health risk behaviors are defined as things like alcohol consumption, body weight, illicit drug use, seatbelt use, and tobacco use.  According to the Wisconsin waiver, there would a threshold that determines when these behaviors are health risks.

Health Risk Assessment (HRA)

The HRA is the principal mechanism used to determine whether beneficiaries are engaging in healthy behaviors and are eligible for reduced premiums.  It would be performed twice: at enrollment and again at the annual renewal.  HRA completion would not be a condition of eligibility and it would simply operate to reduce premiums for eligible beneficiaries.

Time Limit on Medicaid Eligibility and Work Component

Among one of the more unique aspects of the Wisconsin waiver is that it would impose a 48-month (4 years) eligibility limit for beneficiaries.  This would be calculated on a cumulative basis.  Upon reaching the limit, beneficiaries would not be eligible for Medicaid until 6-months have elapsed.

Importantly, the time that a beneficiary spends engaged in employment or training programs (work component) would not count towards their 48-month eligibility limit.  The work component would apply to beneficiaries between the ages of 19-49, and exemptions to both the time limit and work component would align with the FoodShare Employment and Training program.

Substance Abuse Identification and Treatment

The Wisconsin waiver also attempts to address the growing Opioid epidemic by requiring individuals to undergo a drug screening assessment and, if indicated, a drug test.  Beneficiaries who test positive for the drug test and do not have a valid prescription will be referred to a substance use disorder (SUD) treatment program.  Beneficiaries who fail to complete the drug assessment or drug test will be ineligible to receive Medicaid benefits entirely, and refusal to participate in a SUD treatment program will also lock out the beneficiary from benefits for six months.

Reform to the Institutions for Mental Disease (IMD) Exclusion

Another notable aspect of the Wisconsin waiver is that it seeks a residential SUD treatment waiver of the federal exclusion for IMD reimbursement.  According to Wisconsin, the state is developing a benefit to provide full coverage of residential treatment, but in order to implement this benefit, it needs Medicaid funding to be available to reimburse residential SUD treatment provided in facilities that qualify as IMDs.  This is because Medicaid limits reimbursement for services provided in IMD facilities based on a decades-old policy position that states should bear primary responsibility for funding inpatient psychiatric services, with the exception of Medicaid beneficiaries under age 21.

In addition, Wisconsin is requesting a waiver of the 15-day limit for IMD coverage that was provided in the Medicaid Managed Care rule published in May 2016.

To view Foley Hoag's Medicaid and the Law blog please click here

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Events from this Firm
12 Oct 2018, Other, Boston, United States

The New England Electricity Restructuring Roundtable has been meeting bimonthly since 1995 to discuss current topics related to important changes in the electric power industry in Massachusetts and throughout New England.

Similar Articles
Relevancy Powered by MondaqAI
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions