Aug. 19, 2009 — The state budget bill, passed on June 29, included several significant changes affecting access to health care in Wisconsin. Read a summary of some of those changes as well as some items that were vetoed by Gov. Doyle.
This article is published courtesy of the August 2009 State Bar Health Law Section newsletter.
Julie
Rusczek
Christina Severin
Barbara Zabawa
By Julie Rusczek, Drinker Biddle & Reath LLP, Christina Severin, Hall Render Killian Heath & Lyman PC, and Barbara Zabawa, Whyte Hirschboeck Dudek SC
The Wisconsin Biennial State Budget, or 2009 Act 28, was signed into law by Gov. Jim Doyle on June 29, 2009. The first on-time state budget in more than 30 years included several significant changes affecting access to health care in Wisconsin. This report summarizes some of those changes as well as some items that were vetoed by Gov. Doyle.
Increasing Access. Through a budget adjustment bill in early 2009 and the recently passed biennial budget, hospitals (except for critical access and psychiatric hospitals) are subject to a new provider assessment that will total approximately $1.1 billion over the course of three years. Medicaid reimbursement for hospitals, including both fee-for-service and managed care, will increase by more than $1.8 billion during that same period. In addition to providing other support for the Medicaid program, the new assessment will enable the state to expand its BadgerCare Plus program for uninsured childless adults.
The recent budget bill also further expands eligibility criteria for the state’s BadgerCare Plus programs. Individuals under age 65 who have lost their employer-sponsored health care coverage due to their employer’s or former employer’s bankruptcy, and subsequently received health care coverage through certain voluntary employment benefit associations, may be eligible to purchase limited coverage for themselves and their family members. This expanded eligibility criteria comes at a time when an increasing number of employers are experiencing bankruptcy.
Expanding Coverage. While short of comprehensive reform, the budget bill did include several significant changes to insurance coverage in the state.
Coverage for treatment of autism spectrum disorders. Wisconsin joins several other states in requiring certain insurance policies and plans to provide coverage for treatment of autism spectrum disorders. The treatment must be ordered by a physician and provided or supervised by particular health care providers, and is further subject to both minimum coverage levels and specific coverage types. However, these financial and durational minimums need not be met if an appropriate health care provider determines that less treatment is medically appropriate. These amounts will be adjusted annually beginning in 2011 in accordance with the consumer price index, and while the coverage may be subject to deductibles or other co-payments, there may not be any limitations or exclusions (for example, on the number of treatment visits).
Dependents of insured persons. Expanded coverage of the dependents of insured persons was also included in the budget bill. Specifically, certain policies and plans are required to provide coverage for an adult child of the applicant or insured if the child is unmarried, over 17 but less than 27 years old, and is excluded from group health coverage by his/her employer, subject to a premium contribution analysis. However, adult children who are unmarried, full-time students and were called to active or reserve duty before the age of 27 while attending an institution of higher education on a full-time basis would also be eligible regardless of current age.
Contraceptives and other family planning services. Provisions in the budget bill also increase access to and coverage of contraceptives and other family planning services in several ways. For example, the bill requires certain insurance policies and plans to provide coverage for drugs and devices approved to prevent pregnancy, as well as any necessary procedures or other services needed to prescribe, maintain, or otherwise provide these contraceptives. In addition, the bill allows for expansion of the state’s BadgerCare Plus family planning program to include eligible men, and requires pharmacists to dispense lawfully prescribed contraceptives, subject to an appropriate and valid prescription and any legal or ethical obligations existing under state law.
Independent review program for adverse determinations. Finally, the budget bill also made changes to the state’s independent review program for adverse determinations made by health insurers. Previously, only determinations related to experimental treatment or medical necessity were eligible for independent review. In addition, insured persons who selected the independent review option were bound by the decision of the independent review organization (IRO) and could not appeal the decision to a court of law. The budget bill expanded the types of insurer decisions eligible for independent review to include two new categories of decisions; rescission of an insurance policy or certificate, and coverage denial determinations based on pre-existing exclusions. Importantly, unlike decisions related to experimental treatment or medical necessity, IRO decisions regarding pre-existing condition exclusion denials or policy rescissions are not binding on the insured and may be appealed.
Patient Health Care Records. Wisconsin’s law on patient health care records in many ways is more stringent than the HIPAA privacy standards. However, the definition of patient health care records that are subject to Wisconsin’s privacy protections in Chapter 146 of the Wisconsin statutes was much narrower than the HIPAA definition of “protected health information.” Essentially, patient health care records included only those records prepared by or under the supervision of a health care provider. Wis. Stat. § 146.81(4). The budget bill expands what qualifies as a patient health care record to include “all records made by an ambulance service provider” as well as emergency medical technicians or first responders. 2009 Act 28, § 2429. It also now includes “billing statements and invoices for treatment or services provided by a health care provider.” Id. This broader definition encompasses more records that will now clearly be subject to Wisconsin’s more stringent privacy protections.
Notable Vetoes. Gov. Doyle vetoed many provisions of the enrolled bill that would have required the Department of Health Services (DHS) to implement several new requirements and programs related to expanded coverage for Medicaid beneficiaries. These requirements and programs included: 1) assignment of each individual enrolled in a Medicaid managed care organization to a primary care provider, who would receive a monthly fee for care coordination; 2) provision of case management services to children with medically complex conditions who are enrolled in Medicaid; 3) enrollment of each pregnant woman enrolled in a Medicaid managed care organization in a prenatal care coordination program; and 4) provision of a chronic disease management and case coordination program for each individual enrolled in Medicaid managed care organization who is diagnosed with diabetes, asthma, congestive heart failure, coronary artery disease, or a primary or secondary behavioral health diagnosis, including substance abuse and depression.
The next legislative floor period begins on Sept. 15, 2009.
This article is published courtesy of the August 2009 State Bar Health Law Section newsletter. The State Bar offers its members the opportunity to network with other lawyers who share a common interest through its 26 sections. Section membership includes access to newsletters, email lists to facilitate information sharing, and other resources.
