Medicaid Reimbursement for Outpatient Hospital Services

Public Notice

Health Services

Medicaid Reimbursement for Outpatient Hospital Services :

Measurement Year 201 6 Pay-for-Performance Program Updates

The State of Wisconsin reimburses hospitals for outpatient services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and Chapter 49 of the Wisconsin Statutes. This program, administered by the State's Department of Health Services (the Department), is called Medical Assistance or Medicaid. In addition, Wisconsin has expanded this program to create the BadgerCare Plus program under the authority of Title XIX and Title XXI of the Social Security Act and Chapter 49 of the Wisconsin Statutes. Collectively, these programs are herein referred to as the Wisconsin Medicaid Program (WMP). Federal statutes and regulations require that a State Plan be developed that provides the methods and standards for reimbursement of covered services. Such a plan is currently in effect.

To promote quality outcomes for its members, the WMP currently operates a pay-for-performance (P4P) program covering outpatient hospital services: the Withhold P4P program, funded by a 1.5% withhold from fee-for-service (FFS) outpatient hospital claims. The program uses hospital-specific results on enumerated quality metrics to reward top-performing hospitals with a distribution of the funds withheld under the program each year. The program operates on an April 1 – March 31 measurement year (MY), with payout by the December 31 following the conclusion of an MY.

Effective April 1, 201 5 , DHS will be updating this P4P program for MY 201 6 (April 1, 201 5 – March 31, 201 6 with payout by December 31, 201 6 ). The following changes will be contained in the April 1, 201 5 outpatient hospital state plan amendment:

 T he list of quality measures for the Withhold P4P program will be updated to reflect data availability and program improvement for MY 201 6 .

 A n updated P4P Guide will be published detailing all of the above changes to the Wisconsin Medicaid Hospital P4P programs for MY 201 6 .

This notification is intended to provide notice of the type of changes that are included in the amendment. Interested parties should obtain a copy of the actual proposed plan amendment to comprehensively review the scope of all changes.

Proposed Change

It is estimated that these changes will have no material impact on projected annual aggregate Medicaid expenditures in state fiscal year 201 5 (July 1, 201 4 – June 30, 201 5 ) or state fiscal year 201 6 (July 1, 201 5 – June 30, 201 6 ). DHS maintains the same hospital budget approved by the Legislature.

The Department’s proposal involves no change in the definition of those eligible to receive benefits under Medicaid, and the benefits available to eligible recipients remains the same. The effective date for these proposed changes will be April 1, 201 5 .

Copies of the Proposed Change

A copy of the proposed change may be obtained free of charge at your local county agency or by calling or writing as follows:

Regular Mail

Division of Health Care Access and Accountability

P.O. Box 309

Madison , WI 53701−0309

State Contact

David Hoffert, Hospital Policy and Rate Setting Section Chief

Bureau of Fiscal Management

[phone] (phone)

[phone] (fax)

[e-mail]

A copy of the proposed change is available for review at the main office of any county department of social services or human services.

Written Comments

Written comments are welcome. Written comments on the proposed change may be sent by fax, email, or regular mail per the above information. All written comments received will be reviewed, considered, and made available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made to the proposed change based on comments received.