Medicaid Prior Authorization

	The Issue	The Latest Scoop	Action Steps	Lead Contacts	More Information

The Issue

Are you or your child one of the many people having problems with prior authorization for medically necessary Medicaid card services? Medicaid card services pay for medically necessary therapies (such as speech, physical or occupational therapies), personal care services, specialized equipment like wheelchairs, and specialized medical supplies such as diapers. Many of these services are needed to maintain and improve functioning and prevent the need for more costly care.

Since 1996, many people who rely on Medicaid care services and service providers have expressed concern about increases in prior authorization modifications, denials and in delays in processing requests. Parents and providers have stated that the prior authorization process is cumbersome and bureaucratic. This results in families and providers spending precious time and resources on repetitive paperwork, appeals and follow up instead of caring for individuals with special needs.

Following a legislative audit of the Department of Health & Family Services (DHFS) regarding Prior Authorization for therapies, DHFS has made some important improvements to the process including:

• Letter to Mark Moody July 24, 2003 Regarding DRAFT: A Proposed Extension of Medically Necessary Prior Authorization Approval Periods.
• Eliminating the need for Prior Authorization for children enrolled in the Birth-3 Program.
• Reducing the obligation of Provider's repeated submission of MD's prescriptions with each Prior Authorization.
• Updating the current Prior Authorization form & providing further education to providers.
• Publishing two substantial Medicaid updates to providers that attempt to clarify medical necessity and its application to the prior authorization process.
  http://www.dhfs.state.wi.us/medicaid/updates/2002/2002-32.htm AND
  http://www.dhfs.state.wi.us/medicaid/updates/2001/2001-november.htm
• Provider Training and Training resources on Prior Authorization. Provider ETN training was conducted in February 2002. A training CD-ROM was made available for providers November 1, 2002.
• DHFS has submitted a “DRAFT Proposal to Extend Prior Authorization (PA) for Therapies”. This Draft also includes clarifications of Medical Necessity that may be more appropriately applied to individuals with special health care needs. This Draft is pending review by consumers, advocates and providers. Please provide input to Lynn Steffes, Medicaid Project Consultant @ stefbiz@wi.rr.com.
• DHFS has submitted a “DRAFT Wisconsin Medicaid Family Participation Form for Therapy Services”. This Draft is pending review by consumers, advocates and providers. Please provide input to Lynn Steffes, Medicaid Project Consultant @ stefbiz@wi.rr.com.

We are optimistic that with input from consumers, advocates and providers that these improvements may assist in dealing with the issue of repetitive Prior Authorizations. Particularly for individuals who have already met the current Wisconsin Medicaid standards of Medical Necessity and the need for a more contemporary definition of Medical Necessity that addresses the needs of children and adults with long-term disabilities.

The Latest Scoop (Updated: 08/18/2008)

In his recent State of the State address Governor Doyle announced that he wanted to expand Family Care statewide. The Department’s Family Care proposal is calling for Counties to group together and formulate regions where Care Management Organizations (CMO’s) will be in charge of long term care services using managed care concepts. The regional entities could be either or public or public-private partnerships. Currently most counties have been banding together to establish regions.

Last fall the Department issued a Request for Information/Request for Proposal solicitation to get input from entities interested in pursuing these managed care concepts. These entities have submitted proposals to the Department of Health and Family Services for planning grants. At this point four regions have been awarded planning grants to look at developing their long term care services for individuals with disabilities. If all goes as planned, when this system is fully implemented within the next 5-7 years, waiting lists for long term services will disappear. Implementation may start as soon as this Fall.

Action Steps

1. Support the expansion of Family Care with the stipulation that it include options for self-determination in each region of the state.
2. Support adequate funding to assure that individuals with disabilities will get the quality services and supports they need to allow them full access to the community they wish to live in, to work in a job of their choice and authority and supports needed to control the direction of their own lives when Family Care is fully implemented.
   

Lead Contacts

Mitch Hagopian
Wisconsin Coalition for Advocacy
16 N Carroll Suite 400
Madison WI 53703
608/267-0214
mitchh@w-c-a.org

If you are not yet a member of the DAWN network, we hope that you will join us. Please register at http://www.dawninfo.org/ea/index.cfm.

More Information

• Issue alerts:
  
• Advocacy Resources:
  
  1. Sample Parent Letter to Legislators regarding Medicaid Issues, Lynn Steffes, Fall 2000 (pdf)
     
  2. Navigating Medicaid Prior Authorization for Therapy Services, Lynn Steffes, Fall 2000
     
  3. Resources from ABC for Health
     
  4. School-Based and Community-Based Therapy Services, April 1999
     
  5. Prior Authorization Resource Document for Families (PDF), Lynn Steffes, PT, February 2001
• Background Papers:
  
  1. January 15, 2003 letter to Secretary Nelson, Lynn Steffes, PT Survival Coalition/WCDD Medicaid Project Consultant
     
  2. Family Medicaid Survey Results, February 2003, (In Word or PDF)
     
  3. Provider Medicaid Survey Results, February 2003, (In Word or PDF)
     
  4. Annotated Proposed Rewrite of "Medically Necessary" Definition (PDF), November 2002
     
  5. Children with Disabilities and Concerns about Medicaid: An Aid to Help Parents Communicate their Concerns to Legislators, ARC-Wisconsin, Spring 2000
     
  6. Legislative Audit Bureau Confirms Advocates' Prior Authorization Concerns, Lynn Steffes, August 2001
     
  7. Letter from the co-chairs of the Joint Legislative Audit Committee to the Department of Health and Family Services, December 2001.
     
  8. 2002 December 4th letter to Secretary Dubé, Lynn Steffes, December 2002
     
     
• Fiscal Information:
  
• Stories of Wisconsin's citizens with disabilities:
  
  
• Testimony of a parent (Tracy) to the Legislative Audit Committee, PDF, December 2002
  
• Testimony of a parent (Lori) to the Legislative Audit Committee, PDF, December 2002
  
• Letter from a frustrated parent to the Legislative Audit Committee, August 2000
  
• Testimony of a parent to the Legislative Audit Committee, October 2001
  
• Testimony of a parent to the Legislative Audit Committee, October 2001
  
• Links to relevant disability information:
  
• Fiscal Information:
  
• Stories of Wisconsin's citizens with disabilities:
  
• Links to relevant disability information:
  
  • www.ucpa.org - Advocacy & Public Policy
  • www.familiesusa.org - ImPRESSive-a Media Tip Sheet for Advocates
  • www.dhfs.state.wi.us- Programs or Recipient Publications
  • www.FamilyVoices.org