Wisconsin WI

Wisconsin Medicaid PA is published in two layers with opposite access postures. (1) CRITERIA/POLICY: the ForwardHealth Online Handbook (forwardhealth.wi.gov/WIPortal/Subsystem/KW/Display.aspx) holds the per-service, topic-numbered medical-necessity PA policy. It is gated behind a CPT End-User point-and-click license (radio I Accept + Submit Agreement) and is a stateful DNN/ASP.NET app driven by ViewState; direct deep-links and headless click-through bounce to Default.aspx or UnexpectedError.aspx. This is a genuine session/bot wall for the criteria layer. (2) INSTRUMENTS/FORMS: DHS publishes the canonical PA request forms as OPEN static PDFs in its Data Collection (Forms) Library at dhs.wisconsin.gov/library/collection/<f-NNNNN>, each with a stable PDF + Word + completion-instructions. WI uses a FAMILY of service-specific numbered PA forms: PA/RF master request (F-11018), plus per-service attachments e.g. PA/DRF dental (F-11035), PA/HIAS hearing (F-11020), PA/POR otological (F-11019), and the criteria-bearing PA/PDL pharmacy exemption (F-11075A). Authority = WI DHS / Division of Medicaid Services via ForwardHealth (interChange MMIS, Gainwell). Pharmacy is state-administered (PDL); BadgerCare Plus HMOs operate within state PDL. Family Care is a separate LTSS-only managed-care program. Harvested the open form layer; the Handbook criteria layer is gated (recorded as gap).

WISeR pilot states are NJ, OH, OK, TX, AZ, WA; Wisconsin not selected.

Mandatory MCO HMO enrollment for BadgerCare Plus and most SSI Medicaid; pharmacy carved out to state FFS; LTSS in separate Family Care/Partnership/PACE MCO program; foster care to Care4Kids PIHP

Last award: 2025-01-01 (BadgerCare Plus/SSI HMO contract effective). Next due: 2026-01-01 (annual renewal). Contracts extended through: 2025-12-31 (CY2025 contract on file).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How WI requires PA Wisconsin's Medicaid program, BadgerCare Plus and SSI HMO, mandates prior authorization (PA) for various services and drugs through a structured process. The state has carved out certain areas of its Medicaid coverage to different fiscal agents or managed care organizations (MCOs). Pharmacy benefits are carved out to the state's fee-for-service (FFS) system, while long-term support services (LTSS) are managed by separate MCO programs such as Family Care, Partnership, and PACE. Foster care services are handled by the Care4Kids Program Integration Health Plan (PIHP). For prescription drugs, PA is required based on medical necessity criteria, step therapy protocols, and specific documentation requirements. The provider manual outlines these guidelines and became effective on January 1, 2023. Dental services also require prior authorization through a separate form, though the specific criteria are not detailed in the provided document. ## 2. How WI publishes and reports PA Wisconsin's Medicaid program uses multiple channels to publish and report PA requirements. The ForwardHealth Online Handbook (forwardhealth.wi.gov/WIPortal/Subsystem/KW/Display.aspx) serves as a primary resource for PA policies, holding per-service, topic-numbered medical-necessity criteria. This handbook is accessible only through a CPT End-User point of access, indicating that it is intended for providers and other authorized personnel. In addition to the online handbook, Wisconsin publishes specific PA forms in its DHS library. These forms are generally open but do not include detailed service-specific criteria or effective dates. For example, Form F-11075A_PA-PDL-Exemption.pdf requires prescribers to provide member and prescription details, ICD diagnosis codes, and drug class information for certain drugs that require prior authorization. ## 3. WI's CMS-0057-F and PA-reform compliance posture Wisconsin is **not** a WISeR state. WISeR is the CMS "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — Wisconsin does not participate. The state's current PA system is governed by various documents such as the provider manual and specific PA forms, but there is no direct mention of compliance with CMS-0057-F or other federal PA reform initiatives in the source documents. The state's 1115 waiver, known as the BadgerCare Reform Demonstration, includes provisions for Medicaid expansion and managed care reforms. However, specific details on how this waiver impacts prior authorization processes are not provided in the given findings. ## 4. How WI runs its own program Wisconsin's Medicaid program is run through a combination of state-managed fee-for-service (FFS) systems and managed care organizations (MCOs). The pharmacy benefits are carved out to the state FFS system, while LTSS services are managed by separate MCO programs such as Family Care, Partnership, and PACE. Foster care services are handled by the Care4Kids PIHP. The procurement cycle for MCO contracts is annual, with the last award effective from January 1, 2025, and the next renewal due on January 1, 2026. Contracts are typically extended through December 31 of each year. The fiscal agent history shows transitions between ACS-Inc, Conduent/Gainwell, and Xerox, indicating changes in the vendors responsible for managing parts of the Medicaid program. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Carve-outs**: Wisconsin has a well-defined carve-out strategy, with pharmacy benefits managed by state FFS and LTSS services handled by separate MCO programs. - **Annual Procurement Cycle**: The annual contract amendments for MCOs provide a clear procurement cycle, with contracts typically extended through December 31 of each year. - **Provider Manual**: The provider manual for prescription drugs is detailed and effective as of January 1, 2023, indicating regular updates to PA criteria. ### What's Missing/Uncertain: - **Specific Service Criteria**: While the ForwardHealth Online Handbook contains medical-necessity criteria, it is not publicly accessible. Specific service criteria are often missing from the forms provided. - **Effective/Revised Dates**: Some documents lack specific effective or revised dates, making it difficult to track changes over time. - **Gold Card Law Details**: Any gold card law in Wisconsin is not specified in the source documents, leaving uncertainty about its impact on PA requirements and procedures.