Wis. ForwardHealth Online Handbook, Hospice, Topic #404

Medicaid SSI HMOs provide the same benefits as Medicaid fee-for-service (for example, medical, dental [in certain counties

only], mental health/substance abuse, and vision) at no cost to their members through a care management model. Medicaid SSI

members and SSI-related Medicaid members may be eligible to enroll in an SSI HMO.

SSI-related Medicaid members receive coverage from Wisconsin Medicaid because of a disability determined by the Disability

Determination Bureau.

Member Enrollment

Certain eligible SSI members and SSI-related Medicaid adult members are required to enroll in an SSI HMO. The following

groups are excluded from the requirement to enroll in an SSI HMO:

• Members under 19 years of age

• Members of a federally recognized tribe

• Dual eligible members

• MAPP (Medicaid Purchase Plan) eligible members

• Members enrolled in a LTC (long-term care) MCO (managed care organization) or waiver program

Continuity of Care

Special provisions are included in the contract for SSI HMOs for continuity of care for SSI members and SSI-related Medicaid

members. These provisions include the following:

• Coverage of services provided by the member's current provider for the first 90 days of enrollment in the SSI program or

until the first of the month following completion of an assessment and care plan, whichever comes later. The contracted

provider should get a referral from the member's HMO after this.

• Honoring a PA (prior authorization) that is currently approved by ForwardHealth. The PA must be honored for 90 days or

until the month following the HMO's completion of the assessment and care plan, whichever comes later.

To assure payment, non-contracted providers should contact the SSI HMO to confirm claim submission and reimbursement

processes. If an SSI HMO is not honoring a PA that is currently approved by ForwardHealth, the provider should first contact

the HMO. If the provider is not able to resolve their issue with the HMO, the provider should contact ForwardHealth Provider

Services.

For new authorizations during the member's first 90 days of enrollment, the provider is required to follow the SSI HMO's PA

process. SSI HMOs may use PA guidelines that differ from fee-for-service guidelines; however, these guidelines may not result in

less coverage than fee-for-service.

Care Management

SSI HMO health plans employ a care management model to ensure high-quality care to members. The care management model

provides each enrollee with the following:

• An initial health assessment

• A comprehensive care plan

• Assistance in choosing providers and identifying a primary care provider

• Assistance in accessing social and community services

• Information about health education programs, treatment options, and follow-up procedures

• Advocates on staff to assist members in choosing providers and accessing needed care

ForwardHealth requires all SSI HMO health plans to have dedicated care managers to assist providers in meeting the medical

care needs of members. SSI HMOs, through their care management teams, will serve as single points of contact for providers

who need assistance addressing the health care needs of members, especially those who have multiple points of contact within the

health care system.

The SSI HMO care management teams will be responsible, when it is deemed appropriate, for notifying primary care providers of

members' emergency room visits, hospital discharges, and other major medical events, as well as sharing patient-specific care

management plans with appropriate providers to reduce hospital admissions and readmission, to reduce appointment no-shows,

and to improve compliance with health care recommendations such as medication regimens.