44.1 core plan for Transitional childless adults (TCLA)

44.1 Introduction 44.1.1 Certification Periods for TCLA 44.1.2 Covered Services 44.1.2.1 Prescription Drug Coverage

44.1 Introduction

BadgerCare Plus Core Plan for Childless Adults (Core Plan) is an expansion of the BadgerCare Plus program to allow health care coverage to adults who do not meet the non-financial criteria for BadgerCare Plus or Medicaid. Individuals enrolled in the Milwaukee General Assistance Medical Program (GAMP) and other participating county/tribal agency general assistance (GA) medical programs as of 12/26/08, will automatically be enrolled in the BadgerCare Plus Core Plan effective January 1, 2009, and will be referred to as Transitional Childless Adults (TCLA). TCLA member's enrollment and benefits will be managed by state and other staff.

44.1.1 Certification periods for TCLA

The TCLA enrollment period will be from 12-14 months. The certification end dates will be staggered between December 2009 and February 2010, and will be based on the birth month of the member. If the member’s birth date falls between:

January and April, the certification end date will be 12/31/09.
May and August, the certification end date will be 1/31/2010
September and December, the certification end date will be 2/28/10

TCLA certification will be 'frozen’ until the certification end date unless the member:

Becomes eligible for Medicare, Medicaid, or BadgerCare Plus Standard or Benchmark Plans;
Turns age 65. The certification will end at the end of the month in which they turn 65;
Dies;
Becomes incarcerated;
Obtains health insurance coverage;
Moves to an IMD or other medical institution or
No longer resides in the state of Wisconsin

Note: If otherwise eligible, a TCLA member who moves to a county that did not have a GA/GR medical program, will continue to receive TCLA benefits. Members must renew their benefits and enroll into the BC+ Core plan at the end of their TCLA certification period . In addition, the TCLA member must complete a physical exam prior to the end of the certification period in order to renew enrollment. A six month Restrictive Re-enrollment Period will be imposed if the physical exam requirement is not met.

44.1.2 Covered Services

The BadgerCare Plus Core Plan for Childless Adults covers basic health care services including primary care and preventive care, generic and a limited number of brand name prescription drugs. All members will receive TCLA benefits under the BadgerCare Plus Core Plan on a fee-for-service basis from January 1, 2009 through March 31, 2009. Effective April 1, 2009, TCLA members in Milwaukee County will be enrolled in the state-contracted HMOs that serve Wisconsin’s Medicaid and BadgerCare Plus population. Members will be sent enrollment choice materials beginning in January and will enroll through the State’s enrollment broker as they currently do with the BadgerCare Plus population. The date of HMO enrollment for TCLA members in other counties has not yet been determined. The covered services offered to TCLA members are as follows:

COVERED SERVICES	CO-PAYMENT
Visits to the doctor Includes office visits and surgical procedures. Mental health visits are only covered when they are with a psychiatrist. For substance abuse, physician services are covered. Routine eye exams are not covered.	$0.50 to $3 per service, limited to $30 per provider per calendar year. No co-payments for emergency services, preventive care, anesthesia, or clozapine management.
Hospital services This includes inpatient and outpatient visits. Inpatient mental health and substance abuse services are not covered.	For outpatient visits, $3 per visit. For inpatient visits, $3 per day. For each stay, you will not have to pay more than $75 in co-payments. You will not have to pay more than $300 per year in co-payments for all of your hospital services.
Emergency room visits and ambulance rides for emergencies.	$0
Emergency dental services.	$0
Prescription drugs - See 44.1.2.1.	See 44.1.2.1.
Physical therapy, occupational therapy, and speech therapy There is a limit of 20 visits per year for each type of therapy. Cardiac rehabilitation is included under physical therapy.	$0.50 to $3 per service. Co-payments will not be charged after the first 30 hours or $1,500 of each type of therapy, whichever occurs first, each calendar year.
Durable Medical Equipment This has a benefit limit of $2,500 per year. Rental items count towards the limit.	$0.50 to $3 per priced unit.
Disposable Medical Supplies This is limited to syringes, diabetic pens, and items used with durable medical equipment.	$0.50 to $3 per priced unit.
Dialysis and other kidney-related services for people with end-stage renal disease, who do not qualify for Medicare end-stage renal disease services.	$0

44.1.2.1 Prescription Drug Coverage

To ensure continuity of care for GA Medical Program members who are transitioned to the TCLA program, the following additions to Core Plan covered services have been made for this population. Mental Health Drugs

From January 1, 2009 through March 31, 2009, the TCLA Core Plan will cover any mental health drug the member was taking in December 2008 to treat depression, Alzheimer’s disease, Parkinson’s disease, epilepsy and other seizure disorders, bipolar disease and schizophrenia, and drugs used to treat attention deficit disorder.
Beginning April 1, 2009, the Core Plan will cover mental health drugs. If the member is taking drugs for Alzheimer’s disease, bipolar disease or schizophrenia, s/he will continue on any drug used to treat these conditions as long as s/he remains enrolled in the TCLA Core Plan.
Beginning April 1, 2009, the TCLA Core Plan will continue to cover the specific drug the member is currently taking to treat depression, Parkinson’s disease, epilepsy and other seizure disorders, and attention deficit disorder, as long as s/he remains enrolled in the Core Plan. If the member needs to change to a different drug for these conditions, it may not be covered under the BadgerCare Plus Core Plan.

Asthma and Diabetes Drugs From January 1, 2009 through March 31, 2009, the Core Plan will cover any insulin the member was taking in December 2008 to treat diabetes and some inhalers s/he was taking to treat asthma.

Beginning April 1, 2009, the only insulins that will be covered under the Core Plan are Humalog and Lantus.
Beginning April 1, 2009, the only asthma inhalers that will be covered under the Core Plan are Flovent, Serevent and Proventil HFA.
Other asthma and diabetes medications may be covered under the Badger Rx Gold program.

All Other Medications

Beginning January 1, 2009, generic drugs and a limited number of over the counter (OTC) drugs will be covered under the TCLA Core Plan.
Beginning January 1, 2009, brand name drugs and other drugs not covered under the TCLA Core Plan will be available through the Badger Rx Gold program.

This page last updated in Release Number: 08-09

Release Date: 12/11/08

Effective Date: 0101/09