On Tuesday, February 16, Governor Tony Evers gave his second biennial budget address and released his 2021-23 executive budget. All told, the governor proposes an operating budget of $45.4 billion in fiscal year (FY) 2021-22 and $45.6 billion in FY 2022-23. The proposed state budget adds 308.74 FTE positions by FY 2022-23 compared to FY 2020-21. The complete budget, budget in brief, and other executive budget documents are available here.
In the governor’s proposal, the largest increases in all funds appropriations in go to the Department of Health Services (DHS), Department of Public Instruction (DPI), Wisconsin Economic Development Corporation (WEDC), Department of Workforce Development (DWD), and the University of Wisconsin (UW) System.
Below is an overview of the health-related provisions in Gov. Evers’ budget, separated by issue area.
- Requires health insurers to guarantee the issuance of health insurance to individuals that apply for coverage regardless of preexisting conditions, sexual orientation, gender identity, health status, or medical history, among other characteristics; prohibits health insurance providers from charging greater premiums or out-of-pocket costs based on those factors; prohibits health insurance providers from establishing annual or lifetime limits on health insurance plan benefits; requires all health insurance plans to provide coverage for the ten essential health benefits categories covered under the federal Affordable Care Act; and requires all health insurance plans provide coverage for certain preventive services at no cost to the plan holder.
- Eliminates balance billing for emergency and ambulatory services given by out-of-network providers as well as services provided at an in-network facility by an out-of-network provider. Requires a good-faith cost estimate be provided before services are delivered.
- Bars insurers from denying coverage for a telehealth service if an in-person version of that service is covered by an individual’s health plan.
- Establishes a state-based health insurance marketplace (i.e., a “state exchange”) by plan year 2024.
- Requires the development of a state-administered public option health plan to be offered no later than 2025, or 2022 if the federal Affordable Care Act is no longer enforceable.
- Funds the Wisconsin Healthcare Stability Plan by providing $200 million in each fiscal year to reinsure high-cost individuals across all health insurance exchanges.
- Requires a study of whether potential cost savings exist for school districts related to health insurance if all school districts were required to participate in the Group Health Insurance Program as of 2024.
- Directs the Office of the Commissioner of Insurance (OCI) to develop a plan to offer premium assistance by plan year 2024 for those between 138 percent and 250 percent of the federal poverty level.
Prescription Drug Prices
- Provides 7.5 FTE positions, $692,600 PR in FY 2021-22, and $617,800 PR in FY 2022-23 to license and regulate entities involved in the prescription drug supply chain, including pharmacy benefit management brokers and consultants, pharmacy benefit managers, pharmacy services administration organizations, and pharmaceutical sales representatives.
- Provides 16.0 FTE PR positions, $1.7 million PR in FY 2021-22, and $1.5 million PR in FY 2022-23 to establish the Office of Prescription Drug Affordability to oversee regulatory provisions enacted under the budget and analyze and develop policy initiatives. Establishes a Prescription Drug Affordability Review Board to oversee the pharmaceutical industry and drug market, analyze other state and national drug policies and practices, establish spending targets for public sector entities, and set price ceilings on price-gouging prescription drugs.
- Creates a $500,000 GPR grant in FY 2022-23 to develop a patient pharmacy benefits tool, which would provide physicians and other prescribers the ability to conveniently view a patient’s pharmacy benefits to take out-of-pocket costs into consideration when prescribing medications.
- Requires insurers in some circumstances to apply discounts and coupons to deductibles and annual out-of-pocket maximums; this is often referred to as a “co-pay accumulator” provision.
- Requires hospitals participating in the federal 340B drug discount program to report on their savings under the program and how they utilize those savings.
- Sets the maximum copay for a month’s supply of insulin at $50. Establishes an Insulin Safety Net Program for people with an urgent need for insulin as well as those with lower incomes and limited to no insurance coverage.
- Directs OCI to study the creation of a state prescription drug purchasing entity to leverage state and local purchasing power for lower prescription drug costs.
- Allows pharmacists to meet up to one-third of their continuing education requirements through volunteer work.
- Expands Medicaid to 138 percent of the federal poverty level under the federal Affordable Care Act, which is estimated to provide coverage for 90,900 people (approximately 45,100 of which are uninsured). By accepting additional federal dollars, the budget assumes $634 million GPR in savings.
- Directs almost $1 billion GPR to Medicaid providers through Medicaid expansion, including $321 million to hospitals that accept individual on Medicaid via: (a) disproportionate share hospital payments; (b) acute care hospital access payments; (c) critical access hospital access payments; and (d) pediatric supplemental payments. The governor’s budget recommends that funding increases are contingent on the state expanding Medicaid.
- Provides $646.3 million for Medicaid cost to continue.
- Establishes a $25 million ($10.5 million GPR) Medicaid community health/social determinants of health benefit for nonmedical services such as housing referrals, nutritional counseling, and stress management.
- Includes $20.9 million in FY 2022-23 to extend the postpartum Medicaid eligibility for women from 60 days to 12 months.
- Provides $3.9 million GPR for a temporary emergency physician rate increase for Medicaid services.
- Includes $1 million in FY 2022-23 for doula coverage under Medicaid.
- Creates and funds additional Medicaid benefits including psychosocial rehabilitation, certified acupuncturist services, and group physician therapy.
- Increases Medicaid provider rates for speech-language pathology, audiology, autism treatment, MAT, outpatient mental health and substance abuse services, and child-adolescent day treatment.
- Eliminates Medicaid prescription drug copayments.
- Repeals legislative review of DHS federal waivers and state plan amendments.
- Repeals the childless adults Medicaid waiver, which would eliminate work requirements, premium payments, health risk assessment and copayments for nonemergency use of an ER.
- Expands Medicaid coverage for the Residential SUD room and board costs.
Mental Health and Crisis Intervention Services
- Appropriates $40 million to increase Medicaid reimbursement rates for outpatient mental health and substance abuse services.
- Includes $12.3 million in FY 2022-23 for two regional crisis centers that provide crisis urgent care, an observation center, a crisis stabilization facility, and inpatient psychiatric beds.
- Allocates $5 million GPR in FY 2022-23 for five statewide crisis stabilization facilities.
- Provides $1.2 million for county crisis staffing and peer-run respite centers.
- Creates a $1.25 million GPR grant program for municipalities and counties that build behavioral health and law enforcement collaboration programs and $375,000 GPR for crisis intervention training.
- Draws on recommendations from the Task Force on Caregiving, providing $600 million for programs related to long-term care and caregiving, including $240 million to increase nursing home reimbursement rates and $200 million to fund a tax credit for family caregivers.
- Increases access to dental services by beginning to allow dental therapists, a mid-level dental provider, to practice in Wisconsin.
- Incentivizes dentists to accept Medicaid patients by increasing reimbursement rates by $11.9 million in FY 2021-22 and $23.8 million in FY 2022-23.