Wisconsin Department of Health Services

Coverage of Behavioral Treatment

Wisconsin Department of Health Services
Division of Health Care Access and Accountability
Division of Long Term Care
November 2015

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

Presentation Purpose
To provide an overview of the changes to autism
treatment services and behavioral treatment for parents
and 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.
Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

Intended Audience
Parents and guardians of children currently receiving
autism treatment services under the Childrens LongTerm Support (CLTS) Waiver Program.
Parents and guardians of children currently on the
state Autism Wait List.
Parents and guardians of children newly diagnosed
with behavioral treatment needs.

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

Transitioning Services
Right now children are receiving autism treatment
services through the CLTS Waiver Program. Parents
and guardians work with their waiver agency.
In the future, children will receive behavioral
treatment, including autism treatment, as a regular
Medicaid benefit.

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

Why the Change?

In July 2014, the federal government directed states to
cover autism treatment services under the Medicaid
State Plan.
In response, the Department of Health Services is
transitioning autism treatment services from the CLTS
Waiver Program to a new ForwardHealth behavioral
treatment benefit.
ForwardHealth includes the Medicaid, BadgerCare
Plus, and Katie Beckett programs.
Coverage of Behavioral Treatment by Wisconsins 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 Waiver
Program through their local waiver agency.
Parents and guardians work with their Support and
Service Coordinator to identify service needs and
providers.
Children access autism treatment with waiver agency
oversight.

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

How Children Receive Treatment

Today Under the CLTS Waivers (cont.)

Three treatment levels:

o Intensive
o Consultative
o Ongoing
Treatment under the CLTS Waivers was determined by
providing a set amount of weekly treatment hours,
allocated dollars, and year limits to each child.

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

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-child
screening.
o Parents and guardians will no longer have to contact the
waiver agency to receive behavioral treatment services.
o Parents and guardians will work directly with a Medicaidenrolled behavioral treatment provider.

There will no longer be a state Autism Wait List.

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

Behavioral Treatment Benefit

The ForwardHealth behavioral treatment benefit will
include two different types of treatment: comprehensive
and focused.
Comprehensive treatment is an early intervention
approach designed to address multiple aspects of
development and behaviors in young children; typically
higher weekly hours and longer duration.
Focused treatment is dedicated to addressing specific
behaviors or developmental deficits; typically fewer
weekly hours and shorter duration.
Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Wisconsin Department of Health Services

Behavioral Treatment Benefit (cont.)

ForwardHealth covers evidence-based treatment
modalities, including Applied Behavior Analysis and
Early Start Denver Model.
Treatment hours will be specific to the childs
behavioral treatment needs.
The behavioral treatment benefit adopts a flexible
approach to meeting the childs 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 childs 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 will
complete and submit the PA request and required
documentation to ForwardHealth.
2. A decision on the PA request will be made by
ForwardHealth.
3. The PA decision will be communicated to the provider.
4. Treatment can start with an approved PA.

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Wisconsin Department of Health Services

Accessing Behavioral
Treatment Services

Parents and guardians will use the ForwardHealth card to access

behavioral treatment services.

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Wisconsin Department of Health Services

What Is Not Changing?

Eligibility criteria for the CLTS Waiver Program will
remain the same.
The CLTS Waiver Program will continue to provide an
array of supports and services, including support and
service coordination, to meet childrens assessed
needs.

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Wisconsin Department of Health Services

What Is Not Changing? (cont.)

Eligibility requirements for the Medicaid, BadgerCare Plus,
and Katie Beckett programs will remain the same.
ForwardHealth will continue to coordinate benefits with
commercial insurance. Providers must bill commercial
insurance before billing Medicaid.

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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 Wisconsin
Medicaid 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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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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Wisconsin Department of Health Services

Scenarios
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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 childs name will be added to the county CLTS Wait List, if
applicable.
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Wisconsin Department of Health Services

Scenario #1 (cont.)
Once the childs name is released from the CLTS Wait List, the
parent or guardian will work with the waiver agency to
determine if additional services are needed.

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Wisconsin Department of Health Services

Children on State Autism Wait List

Confirm
behavioral
treatment
provider

Medically
necessary
treatment
authorized

Provider
submits PA
request

Added to
CLTS
Wait List

Assessed for
waiver
services

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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 behavioral
treatment provider will complete a PA request on the childs behalf.
After a PA determination is made, the waiver agency will meet with
the parent or guardian to complete a new assessment and determine
if additional waiver services are needed.
The child will continue to receive autism treatment through the
waiver until a PA determination is made and the assessment is
complete.
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Wisconsin Department of Health Services

Process for transitioning current

CLTS waiver participant

Waiver
participant
assigned
transition time

Provider
submits PA
request to
ForwardHealth

Medically
necessary
treatment
authorized

Ongoing waiver services

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Wisconsin Department of Health Services

Scenario #3
A Medicaid-eligible child is newly diagnosed with a behavioral
treatment 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 determine
eligibility for waiver services.

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Wisconsin Department of Health Services

Children Newly Diagnosed with a

Behavioral Treatment Need
Doctor
visit

Diagnosis

Contact
behavioral
treatment
provider

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Provider
submits PA
request

Medically
necessary
treatment
authorized

25

Wisconsin Department of Health Services

Children Newly Diagnosed with a

Behavioral Treatment Need and
CLTS Service Needs
Doctor
visit

Diagnosis

Contact
waiver
agency for
waiver
services

Contact
behavioral
treatment
provider

Provider
submits PA
request

CLTS
Wait List

Start
receiving
waiver
services

Coverage of Behavioral Treatment by Wisconsins Medicaid Program

Medically
necessary
treatment
authorized

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Wisconsin Department of Health Services

Additional information
Learn more about the changes and sign up for email updates
at: dhs.wi.gov/clts/waiver/autism/updates.htm
To learn more about the transition of behavioral treatment
services from the CLTS Waivers to ForwardHealth, contact
your waiver agency.
If your behavioral treatment provider has questions about the
ForwardHealth benefit, refer them to the ForwardHealth
Portal at www.forwardhealth.wi.gov

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Wisconsin Department of Health Services

Questions

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