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Medicaid: BadgerCare Waiver

The BadgerCare waiver provides robust state plan benefits to childless adults who are not pregnant, disabled, or elderly with incomes of up to and including 100% of the federal poverty level and to transitional medical assistance individuals, also known as members on extension, with incomes over 100% of the federal poverty level.

  • The waiver includes a substance use disorder program that expands the substance use disorder benefits package to cover short-term residential services in facilities that qualify as institutions for mental diseases for all Medicaid enrollees.
  • The waiver also allows Wisconsin to implement additional eligibility and cost-sharing components that apply only to the nonmandatory childless adult population.

DHS must get approval from CMS to extend the BadgerCare waiver beyond December 31, 2023. 

About Section 1115 Demonstration Waivers

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Programs. Under this authority, the Secretary may waive certain provisions of the Medicaid law to give states extra flexibility to design and improve their programs. Learn more about Section 1115 Demonstration Waivers.

BadgerCare Waiver Extension: January 1, 2024 – December 31, 2028

The Department of Health Services (DHS) will submit an application to the Centers for Medicare and Medicaid Services (CMS) in mid-November 2022. It will request a five-year extension of the current Medicaid 1115 Research and Demonstration Waiver. DHS is not seeking changes. The next demonstration period runs from January 1, 2024, to December 31, 2028.

The current waiver provides coverage to the childless adult and transitional medical assistance populations. It also gives Wisconsin authority to implement additional eligibility and cost-sharing components for childless adults, including premiums, copayments for non-emergency use of the emergency department, and a health risk assessment as a condition of eligibility. The waiver also provides coverage of short-term residential services in facilities that qualify as institutions for mental diseases for all Medicaid enrollees.

As of July 1, 2022, more than 277,000 individuals receive coverage under this demonstration authority.

Summary

Public comments were accepted from September 12 - October 14, 2022. Three public hearings were held to solicit comments on the BadgerCare waiver extension. Due to public health concerns related to the COVID-19 pandemic, DHS conducted webinars in place of in-person hearings. Refer to the documents and timeline section above to watch webinar recordings and download presentation materials. 

Summary of Public Comments

Comments are summarized below and organized by topic area of the proposed waiver extension.

Coverage of Childless Adult Population

  • One commenter supports coverage to adults up to 100% FPL but has serious concerns with the other elements in the extension targeted at individuals with incomes below the poverty line. Commenter believes that these other elements mean increased cost sharing, greater complexity and more administrative barriers that will increase churn, exacerbate racial disparities, and cause more people to go uninsured, and that these elements would have a disproportionate impact on people of color.
  • Three commenters support the state’s efforts to continue to provide coverage to childless adults. However, commenters are concerned that partial expansion inadequately addresses the needs of low-income individuals in Wisconsin. Commenters say that thousands of childless adults in Wisconsin with incomes between 100 and 138% FPL struggle to find affordable coverage, and even with premium subsidies, Marketplace plans with out-of-pocket costs, such as deductibles, are often too expensive for these individuals. 
  • Three commenters say that Medicaid expansion to 138% FPL would better address health disparities than the BadgerCare waiver, and is associated with a reduction in preventable hospitalizations. 
  • Three commenters say that Medicaid expansion to 138% FPL is more fiscally sustainable for the state as Wisconsin’s FMAP for childless adults under the waiver is 60.1% under the waiver compared to 90% if the state were to expand Medicaid.


Monthly Premiums 

  • Four commenters oppose monthly premiums citing evidence that premiums are a barrier to obtaining and maintaining Medicaid coverage and can exacerbate disparities in access to healthcare. 
  • One commenter says that while the premium being proposed may seem nominal, even small fees can pose a significant logistical hardship for those who are income constrained. 
  • Two commenters are concerned that many members will have difficulty making premium payments if they do not have access to bank accounts or credit cards.
  • One commenter cites a study published in 2019 showing that Black, Latino, Native American, and lower-income households are more likely to be unbanked, meaning that they do not have access to a bank account. 
  • One commenter points out that the state provides little training for members to learn how to use the state’s MyAccess system to make premium payments.
  • Three commenters oppose Wisconsin’s proposal to continue disenrolling beneficiaries and locking them out of coverage for up to six months for not paying premiums, which they say does not support the objectives of the Medicaid program. Commenters cite Montana and Arkansas as examples where CMS determined that premiums present a barrier to coverage, and therefore, are not likely to promote the objectives of Medicaid.
  • One commenter says that numerous studies have shown that increased cost-sharing requirements for very low-income households lead to coverage loss.

Emergency Department Copays

  • Four commenters oppose the $8 copay for non-emergent use of the Emergency Department as these copays deter patients from seeking care, which can result in negative health outcomes for patients with acute and chronic diseases. 
  • One commenter is concerned that an $8 charge for a non-emergent visit is cost-prohibitive for individuals living under 100% of the FPL.
  • One commenter says that the ED copay has a disparate impact on the homeless population. 
  • Three commenters cite studies that found that implementation of a copay on emergency services for Medicaid beneficiaries resulted in decreased utilization of such services but did not result in cost savings because of subsequent use of more intensive and expensive services.
  • One commenter believes that the proposed extension of the ED copay is not an appropriate use of waiver authority based on the criteria defined under sections 1916(f)(3),(4) and (5) of the Social Security Act, and is outside the scope of section 1115 waivers.
  • One commenter says that the ED copay will increase complexity for both patients and providers because providers will need to inform patients that the healthcare they will provide requires additional fees. Commenter also points out that providers will need to maintain and furnish lists of alternate providers who accept Medicaid and could provide care without the additional copay.
  • One commenter is concerned that individuals who are without alternatives, like urgent care or routine access to a primary care provider, will be discriminated against for a lack of providers in their area.
  • One commenter says that other programs, such as the Emergency Department Care Coordination (EDCC) program in Milwaukee, which connects patients who recently presented in the Emergency Department with a primary care medical home, have proven successful in deterring inappropriate emergency department use.

Mandatory Health Risk Assessments

  • Five commenters oppose continuation of mandatory health risk assessment because they are not likely to improve health outcomes and add administrative complexity.
  • Three commenters believe that such a requirement is likely to deter eligible enrollees and serve as an unnecessary barrier to coverage. Commenters cited research that has found that positive consequences for completing healthy behaviors are more likely to motivate individuals than facing negative outcomes. 
  • One commenter says that the practical implication of reducing premiums for non-tobacco users through a health risk assessment is to create a tobacco surcharge, which does not encourage users to quit but rather discourages them from enrolling in healthcare.
  • One commenter says that the few studies that have evaluated the effectiveness of these incentive in Medicaid programs have found the participants are more likely to participate in short-term or one-time activities with immediate pay out of incentives versus those designed to encourage permanent lifestyle changes.
  • One commenter says that a mandatory health risk assessment will not provide a significant new value-add for clinical decision-making.
  • One commenter says that a financial incentive is not likely to motivate individuals to improve their health behavior; rather, it will motivate individuals to access a lower premium by potentially presenting inaccurate information on their health risk assessment. 
  • Based on based its work with patients to help them understand their health history and how their social and economic situations contribute to their health and health risk, one commenter is concerned about the potential for patients to inaccurately self-attest to questions about their own health habits and conditions preventing healthy habits. For this reason, commenter is concerned that the use of patient responses to determine premium reductions could discriminate against low-income individuals. Commenter acknowledges that this policy was discontinued in March 2020 due to the public health emergency.
  • One commenter is concerned that a lack of patient readiness to answer a question related to substance use could result in loss of access to insurance and a lost care opportunity.
  • One commenter is concerned about the state’s lack of clarity regarding the administration of health risk assessment, specifically the mechanics of how the information will be shared with providers so that it can be incorporated in a patient care plan, and how frequently if will administered and updated to reflect the most recent health information, which can trigger lower premiums.

Treatment Needs Questionnaire

  • One commenter believes that requiring beneficiaries respond to a substance use treatment needs question increases barriers to care, plays into false stereotypes, and increases stigma. Commenter says that while this questionnaire is not a drug test, requiring a response to this question as a condition of eligibility sends a clear, albeit unfounded, message of suspicion.
  • One commenter believes that the treatment needs question may violate substance abuse and confidentiality rules in 42 CFR Part 2 established by SAMHSA since it requires a beneficiary to
  • potentially disclose their substance use history to a nonmedical professional, prior to their enrollment.
  • One commenter is concerned that if an applicant indicates a need for SUD care on the treatment needs questionnaire, there may not be sufficient mechanisms in place to ensure that adequate, culturally-appropriate options are available for those who need it.

Work Requirement

  • Although not part of this extension proposal, one commenter appreciates CMS’s decision to rescind authorization of the eligibility time limit that was suspended so long as certain covered adults met a work-verification requirement.

Miscellaneous

  • One commenter says that it recognizes that current state law in Wisconsin significantly restricts the Wisconsin Department of Health Services administrative flexibility or discretion to modify the waiver in response to public comments.

DHS Response: DHS appreciates these comments; however, 2017 Wisconsin Act 370 requires DHS to submit an extension request that is the same as the current waiver unless legislative approval is granted to change it, which DHS has not received.

Details 
Summary of Tribal Government Comments

Comments received during the Tribal Consultation at the quarterly Tribal Health Directors meeting on September 14, 2022, along with comments received throughout the 30-day public comment period from Tribal Governments, are summarized below. 

  • Tribal Government Comment Summary: One Tribal Health Director at the Tribal Health Directors meeting on September 14, 2022 expressed general support for the waiver extension’s policy to cover childless adult up to 100% FPL. The tribal health director notes that they have no objections, the extension will benefit some tribal members, the budget neutrality proposal is appreciated, and the Health Risk Assessment (HRA) requirement is burdensome on Tribal Nations. This member made a formal motion to the Tribal Health Directors to support the waiver, which was approved by quorum. 
Consideration of Public Comments in Final Waiver

DHS appreciates the public’s input on the Section 1115 BadgerCare waiver extension. Based on the comments received, both written and those given through oral testimony, and due to state legislation that requires DHS to submit an extension request that is the same as the current waiver unless legislative approval is granted to change it, DHS does not propose making any changes to the waiver extension. 

BadgerCare Waiver Amendment for Health Savings Accounts

In 2020, Wisconsin submitted an amendment request to CMS to add health savings accounts for the childless adult population under the BadgerCare waiver. CMS approval is pending. 

BadgerCare Waiver Amendment and Extension: October 31, 2018 – December 31, 2023

Last revised January 18, 2024