We left off at page 40, the section of the bill that explains how retired employees can use accumulated sick and vacation time as credits toward their insurance in retirement. The majority of this post focuses on the potential changes to Medical Assistance in Wisconsin. I decided that I will skip the section of the bill that deals with the collective bargaining rights and come back to that at the end. I think that it's important to go through the lesser known portions of the bill. There are some portions of the bill that I will cover in this section that are less explicit in dealing with collective bargaining, they cover issues of insurance selection. The discussion of the collective bargaining rules and restrictions has the potential to get very contentious, and I'm still hoping to find a bill supporter as a co-author for this write-up to give a more rounded evaluation.
Page 40 and 41 continue the discussion about the use of sick time to cover insurance. Page 42 (Section 101, 40.51) references the selection of health care coverage an employer (other than the state) can offer employees. Employers are steered to the group insurance board (which I discussed in Part 1). This section gives individual departments the ability to establish their own eligibility rules and contribution requirements, which allows for some flexibility to meet the department needs. This section also explicitly restricts an employer from paying more than 88% of the average premium for the insurance plan, enforcing the employee contribution of at least 12% that Walker insists is necessary. The group insurance board in this section is also given the ability to designate the insurance terms for graduate assistants, teaching assistants, and employees-in-training in the University of Wisconsin System. The board is required to consult with the UW Board of Regents when making these decisions, so it is possible that the questionable non-partisanship of the group insurance board may be balanced by the recruiting requirements of the UW system.
Section 112 starts at the bottom of page 44 and relates to potential changes to the state of Wisconsin's Medical Assistance program (Badgercare, Medicare, Seniorcare, etc.). The first portion of this section is devoted to outlining the study of various types of potential changes to these programs that should be investigated. It is easiest and most accurate to copy this section here, so:
“The department shall study potential changes to the Medical Assistance
state plan and to waivers of federal law relating to medical assistance obtained from
the federal department of health and human services for all of the following
purposes:
1. Increasing the cost effectiveness and efficiency of care and the care delivery system for Medical Assistance programs.
2. Limiting switching from private health insurance to Medical Assistance programs.
3. Ensuring the long−term viability and sustainability of Medical Assistance programs.
4. Advancing the accuracy and reliability of eligibility for Medical Assistance programs and claims determinations and payments.
5. Improving the health status of individuals who receive benefits under a Medical Assistance program.
6. Aligning Medical Assistance program benefit recipient and service provider incentives with health care outcomes.
7. Supporting responsibility and choice of medical assistance recipients.”
If any of these studies find potential increased efficiency and/or cost efficiency for these programs, this bill gives authority to make a multitude of changes to the program, such as:
“1. Require cost sharing from program benefit recipients up to the maximum allowed by federal law or a waiver of federal law.
2. Authorize providers to deny care or services if a program benefit recipient is unable to share costs, to the extent allowed by federal law or waiver.
3. Modify existing benefits or establish various benefit packages and offer different packages to different groups of recipients.
4. Revise provider reimbursement models for particular services.
5. Mandate that program benefit recipients enroll in managed care.
6. Restrict or eliminate presumptive eligibility.
7. To the extent permitted by federal law, impose restrictions on providing benefits to individuals who are not citizens of the United States.
8. Set standards for establishing and verifying eligibility requirements.
9. Develop standards and methodologies to assure accurate eligibility determinations and redetermine continuing eligibility.
10. Reduce income levels for purposes of determining eligibility to the extent allowed by federal law or waiver and subject to the limitations under par. (e) 2.”
I'm hoping to review the current state Medical Assistance codes soon to determine how many of these potential changes are already in existence and how many would be new potential changes to the program. While some of these potential solutions are concerning, such as requiring managed care plans in areas with limited doctor availability, others (like changes to reimbursement models) seem like they would be common review processes. Any changes like those listed above are supposed to be submitted to the joint committee on finance for review prior to taking effect, but if the joint committee on finance doesn't schedule a meeting within 14 working days to review the rule, the rule takes effect without any further review (“(d) Before promulgating a rule under par. (c), the department shall submit to the joint committee on finance the proposed rule and any plan that the department develops as a result of the study under par. (b). If the co-chairpersons of the committee do not notify the department within 14 working days after the date of the department’s submittal that the committee has scheduled a meeting for the purpose of reviewing the proposed rule or plan, the proposed rule may be promulgated and
any plan may be implemented as proposed by the department”). This could lead to the potential of changes to Medical Assistance without a complete review. If the committee does notify the department that they have scheduled a meeting to consider the changes within 14 days, the rule may only be implemented if it is approved by the committee. If any of the rules considered do not meet federal guidelines, the bill requires that the department submit a waiver request to the federal government.
Another concerning statute in this part of the bill states “the department may promulgate a rule under par. (c) as an emergency rule... the department is not required to provide evidence that promulgating a rule under par. (c) as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated”. While the ability to make short-term changes to a state program during emergencies is understandable, the lack of a requirement to prove the 'emergency' leaves a concern of abuse of this section. These emergency rules would remain in effect either until their repeal date is reached or they are accepted as permanent rules, but there is no information in the bill as to how the repeal date would be determined and/or how the department would determine this repeal date, so the 'emergency' rules could in fact be in effect for quite some time.
Starting at section 15 the Bill outlines general guidelines for payment for medical services under Medical Assistance. Basically it seems geared at explicitly stating that providers treating Medical Assistance patients can be paid up to, but not more than, their standard per visit rate. This seems to make sense, as paying a provider more than they would get for standard visits would not be a cost-saving measure. Ultimately the department determines the pay rate for each service, and one would anticipate that rate would actually be below the flat fee that the provider would normally charge. There's a small section (49.45) that references payments to pharmacists who identify cost-saving measures for people on Medical Assistance. It doesn't clarify what type of cost saving measures they envision, but I'm assuming it's things like steering patients toward generic alternatives and/or counseling services for chronic medication usage. This has the potential to have some significant cost impacts, as pharmacists are in a unique position to counsel patient's about medications. Section 122 also limits the cost of prescription drugs for a person on Medical Assistance to $12/month if that person designates and uses a single pharmacy for all of their prescription needs, but this amount can be changed by the rules process discussed above.
From this point to page 58, where the retirement and pay/collective bargaining for public employee section starts, there are multiple small sections about identifying eligible participants for Medical Assistance, more clarification of payment schedules, etc.
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