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Medicaid Card Services

ISSUE:

Since 1996, many people who rely on Medicaid card services and service providers have expressed concern about increases in prior authorization modifications, denials and in delays in processing requests. There is a question whether the prior authorization process is being used to reduce, deny or delay needed services as a way to decrease the use of Medicaid services, even when the need is justified. Parents and providers have stated that the prior authorization process is cumbersome and bureaucratic resulting in fewer families and providers willing to navigate the process to obtain important services.

POSITION:

The WCDD supports Medicaid policies and practices that ensure individuals receive the services and supports they need in a timely, efficient manner.

LEGISLATIVE INITIATIVES:

WCDD supports the following legislative initiatives:

• Create a separation between the oversight provided to the prior authorization process and the appeal process that should protect the consumer. To insure impartiality, locate Hearing Officers in a Department other than the Department of Health and Family Services, which oversees prior authorization process .
• Establish rules that clearly define "Medical Necessity" with careful consideration of children with long term health and rehabilitative needs.
• Establish a separate process and funding stream that enables the long term rehabilitative and care management of children and adults with special health care needs to be approved annually for a certain level of ongoing service. Limit the prior authorization process to managing episodic needs for service such as defined in a traditional medical utilization review model.
• Redirect the flow of federal Medicaid dollars captured from the provision of School-Based Services from the Wisconsin General Fund to the school districts providing those services. The current system creates improper incentives for service to be delivered through the schools in lieu of community-based services despite the significant differences in delivery models.
• Authorize a mandatory study every 3-5 years to analyze the cost/benefit of administering the unwieldy and costly prior authorization process .
• Establish regulations ensuring that provider audits conducted by the Medicaid program have an educational option when non-criminal intent is noted for minor violations.
• Establish regulations that limit Department of Health and Family Services authority in implementing tighter standards for audit than those published and provided to Medicaid Providers of Service.

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