Covered and Noncovered Services : Target Populations

Description

In addition to meeting other enrollment requirements in the Case Management service area, members must belong to at least one of the following target populations, per Wis. Stat. § 49.45(25), and be served by a Medicaid-enrolled case management provider that elected to serve members in the corresponding target populations.

Note: For the purposes of identifying which policies apply to which populations, the target populations are divided by when they were authorized in Wisconsin Statutes. Group A target populations refer to those populations authorized in statutes before July 29, 1995. Group B target populations refer to those populations authorized in the 1995-97 budget and effective on and after July 29, 1995.

Group A Target Populations

The Group A target populations include all of the following:

1. Persons age 65 or over.
2. Persons with a physician's diagnosis of Alzheimer's disease or related dementia, as defined under Wis. Stat. § 46.87(1)(a).
3. Persons who can be defined as having:
   • A developmental disability, as defined under Wis. Stat. § 51.01(5)(a).
   • A chronic mental illness, as defined under Wis. Admin. Code § DHS 101.03(25), and who are age 21 or over.
   • A physical or sensory disability, as defined in Wis. Admin. Code § DHS 101.03(122m).
   • An alcohol or drug dependency, as defined under Wis. Stats. §§ 51.01(1m) or 51.01(8), respectively.
4. Persons diagnosed as having HIV infection, as defined under Wis. Stat. § 252.01(2).
5. Persons who are SED and under age 21, as defined under Wis. Stat. § 49.45(25)(a).

In order for a member to be considered SED, one of the following must occur:

• A three-person team of mental health experts (one must be a psychiatrist or psychologist) appointed by the provider are required to find that the child is SED. The finding and activities leading to the determination that a child is SED are not covered as part of Medicaid case management services. Providers are required to document and retain these findings in the member's clinical record.
• The member meets the requirements under Wis. Stat. § 46.56. This makes the member eligible for admission to an Integrated Services Project as a child with severe emotional and behavioral problems.

ForwardHealth provides definitions of the above illnesses and disabilities.

Group B Target Populations

The Group B target populations include all of the following:

1. Families with a child/children at risk of serious physical, mental, or emotional dysfunction (also referred to as family case management). This target population has five subgroups:
   • Families with a child/children with special health care needs, including children with lead poisoning
   • Families with a child/children who is/are at risk of maltreatment
   • Families with a child/children involved in the juvenile justice system
   • Families where the primary caregiver has a mental illness, developmental disability, or substance abuse disorder
   • Families where the mother required PNCC services
2. Children enrolled in a Birth to 3 Program under Wis. Admin. Code ch. DHS 90
3. Children with asthma
4. Individuals infected with tuberculosis
5. Women age 45 to 64
6. Incarcerated youth under the age of 21 or that were former foster care, subsidized guardianship, or court-ordered Kinship Care youth and are currently under 26 years old

ForwardHealth provides information on Group B target population enrollment requirements, required documentation, and target population definitions.