In Wisconsin:
  • Most Medicaid services are delivered primarily through Medicaid Health Maintenance Organizations (HMOs). When families are enrolled in ForwardHealth (the state Medicaid program) they are also enrolled in an HMO. If there are multiple HMOs available in the area where the family resides they are able to select between them. Once families are enrolled the HMO sends them an enrollment packet with information related to the services they can receive. Medicaid will cover certain services – such as behavioral or oral health services – if they are not among those provided by the HMO in which the beneficiary is enrolled.
  • There were a total of 1,173,355 beneficiaries enrolled in Wisconsin’s Medicaid program as of July 2011. Of these 747,046 were enrolled in managed care. 366,441 beneficiaries were enrolled in Commercial MCOs, 344,602 were enrolled in Medicaid-only MCOs, and 34,975 were enrolled in a Prepaid Inpatient Health Plan (PIHP) to receive either Long Term Care services (33,990) or Mental Health wraparound services (985). Wisconsin delivers mental health and substance abuse wraparound services to children with severe emotional disturbances through two programs called Children Come First and Wraparound Milwaukee.
Wisconsin provides EPSDT services through HealthCheck, the state’s EPSDT program. This includes all behavioral health, mental health, and dental services provided through the benefit. As of 2013, 585,552 individuals were eligible for EPSDT through Wisconsin’s Medicaid program. According to CMS data from 2013, Wisconsin achieved an EPSDT screening ratio of 97% and a participation ratio of 71%. 145,930 children received dental services of any kind, with 132,181 receiving preventive dental services.
Last updated June 2014
Medical Necessity
Under Wisconsin’s administrative code (DHS 101.03(96m)), medical necessary services are:
“(a)Required to prevent, identify or treat a recipient’s illness, injury or disability; and
(b) Meets the following standards:
  1. Is consistent with the recipient’s symptoms or with prevention, diagnosis or treatment of the recipient’s illness, injury or disability;
  2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;
  3. Is appropriate with regard to generally accepted standards of medical practice;
  4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient;
  5. Is of proven medical value or usefulness and, consistent with s. DHS 107.035, is not experimental in nature;
  6. Is not duplicative with respect to other services being provided to the recipient;
  7. Is not solely for the convenience of the recipient, the recipient’s family or a provider;
  8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and
  9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.”
Initiatives to Improve Access
Reporting & Data Collection Managed care contracts in Wisconsin require that enrolled children receive at least 80% of the expected number of HealthCheck screens; managed care organizations that fail to meet this metric face recoupment of some of their capitation payments.
Behavioral Health
Children are screened for behavioral health issues during HealthCheck preventive visits.
Managed care contract language requires that managed care organizations develop relationships—through memoranda of understanding or contracts—with community agencies that deliver behavioral health services to Medicaid beneficiaries.
Wisconsin Medicaid covers Screening, Brief Intervention, and Referral to Treatment (SBIRT) services for enrollees 10 years of ago and older. Substance abuse screening tools approved for use by the state are:
  • The AUDIT,
  • The DAST,
  • The ASSIST,
  • The CRAFFT, and
  • The POSIT.
Wisconsin Medicaid is a partner to two initiatives called Children Come First and Wraparound Milwaukee. These are multi-agency, community based programs of mental health and other drug abuse services for children with severe emotional disturbances (SED). The goal of the programs is to both keep children with SED out of institutions, and to reallocate resources previously used for institutionalization of SED children into community-based services. 
Support to Providers and Families
Support to Providers
Wisconsin Medicaid maintains a ForwardHealth Portal, which provides provider information (including provider handbooks) and serves as an interface to the MMIS. The portal also includes a page with useful links for Managed Care Organizations (MCOs).
Support to Families
Wisconsin has a program called Healthy Start, Grow Smart. This initiative created a series of fourteen free booklets, starting with Pregnancy and running through Twelve Months. These booklets are available in English and Spanish, and help new parents with developmental milestones, and information that is relevant for doctor visits during the child’s first year. Wisconsin also has a HealthCheck toll free hotline for families that have questions or problems with the program.
Care Coordination
Managed care contracts in the state encourage managed care organizations to “assist with the coordination of covered mental health services” by establishing contractual relationships with community-based mental health agencies and school-based providers.
The Wraparound Milwaukee program contacts with eight community agencies for over 100 care coordinators to facilitate the delivery of services to the SED children in the program using an individualized wraparound approach.
Oral Health
Children are given mouth exams as part of a HealthCheck preventive care exam. Children who need additional dental care are referred to a dental provider and these services are covered by HealthCheck.  
HealthCheck nursing agencies are reimbursed by Medicaid for providing dental sealants to Medicaid beneficiaries under age 21.