Autismregionalmeeting Nov 2015 English (1)

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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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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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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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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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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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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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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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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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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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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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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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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Accessing Behavioral

Treatment ServicesParents and guardians will use the ForwardHealth card to accessbehavioral treatment services.

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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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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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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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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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Scenarios

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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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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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Children on State Autism Wait List

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Medicallynecessary

treatmentauthorized

Confirmbehavioral

treatmentprovider

Providersubmits PA

request

Added toCLTSWait List

Assessed forwaiver

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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Process for transitioning current

CLTS waiver participant

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Providersubmits PA

request toForwardHealth

Ongoing waiver services

Waiverparticipant

assignedtransition time

Medicallynecessary

treatmentauthorized

f l h





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





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





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





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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https://www.dhs.wisconsin.gov/clts/waiver/autism/updates.htm

http://www.forwardhealth.wi.gov/

http://www.forwardhealth.wi.gov/

https://www.dhs.wisconsin.gov/clts/waiver/autism/updates.htm



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Questions

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Autismregionalmeeting Nov 2015 English (1)

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