2023 Wisconsin Statutes & Annotations › Chapter 49 - Public assistance and children and family services. › 49.45 - Medical assistance; administration.

49.45
Medical assistance; administration.
(1)
Purpose. To provide appropriate health care for eligible persons and obtain the most benefits available under Title XIX of the federal social security act, the department shall administer medical assistance, rehabilitative and other services to help eligible individuals and families attain or retain capability for independence or self-care as hereinafter provided.
(2)
Duties.
(a)
The department shall:
1.
Exercise responsibility relating to fiscal matters, the eligibility for benefits under standards set forth in ss. 49.46 to 49.471, and general supervision of the medical assistance program.
2.
Employ necessary personnel under the classified service for the efficient and economical performance of the program and shall supply residents of this state with information concerning the program and procedures.
3.
Determine the eligibility of persons for medical assistance, rehabilitative, and social services under ss. 49.46, 49.468, 49.47, and 49.471 and rules and policies adopted by the department and may, under a contract under s. 49.78 (2), delegate all, or any portion, of this function to the county department under s. 46.215, 46.22, or 46.23 or a tribal governing body.
4.
To the extent funds are available under s. 20.435 (4) (bm), certify all proper charges and claims for administrative services to the department of administration for payment and the department of administration shall draw its warrant forthwith.
5.
Cooperate with the division for learning support in the department of public instruction to carry out the provisions of Title XIX.
6.
Appoint such advisory committees as are necessary and proper.
7.
Cooperate with the federal authorities for the purpose of providing the assistance and services available under Title XIX to obtain the best financial reimbursement available to the state from federal funds.
8.
Periodically report to the joint committee on finance concerning projected expenditures and alternative reimbursement and cost control policies in the medical assistance program.
9.
Periodically set forth conditions of participation and reimbursement in a contract with provider of service under this section.
10.
a.
After reasonable notice and opportunity for hearing, recover money improperly or erroneously paid or overpayments to a provider by offsetting or adjusting amounts owed the provider under the program, crediting against a provider's future claims for reimbursement for other services or items furnished by the provider under the program, or requiring the provider to make direct payment to the department or its fiscal intermediary.
b.
Establish a deadline for payment of a recovery imposed under this subdivision and, if a provider fails to pay all of the amount to be recovered by the deadline, require payment, by the provider, of interest on any delinquent amount at the rate of 1 percent per month or fraction of a month from the date of the overpayment.
c.
Promulgate rules to implement this subdivision.
11.
a.
Establish criteria for certification of providers of medical assistance and, except as provided in par. (b) 6m. and s. 49.48, and subject to par. (b) 7. and 8., certify providers who meet the criteria.
b.
Promulgate rules to implement this subdivision.
c.
The department shall accept relevant education, training, instruction, or other experience that an applicant obtained in connection with military service, as defined in s. 111.32 (12g), to count toward the education, training, instruction, or other experience that is required to certify providers of medical assistance if the applicant demonstrates to the satisfaction of the department that the education, training, instruction, or other experience that the applicant obtained in connection with his or her military service is substantially equivalent to the education, training, instruction, or other experience required for the certification.
12.
a.
Decertify a provider from or restrict a provider's participation in the medical assistance program, if after giving reasonable notice and opportunity for hearing the department finds that the provider has violated a federal statute or regulation or a state statute or administrative rule and the violation is, by statute, regulation, or rule, grounds for decertification or restriction. The department shall suspend the provider pending the hearing under this subdivision if the department includes in its decertification notice findings that the provider's continued participation in the medical assistance program pending hearing is likely to lead to the irretrievable loss of public funds and is unnecessary to provide adequate access to services to medical assistance recipients. As soon as practicable after the hearing, the department shall issue a written decision. No payment may be made under the medical assistance program with respect to any service or item furnished by the provider subsequent to decertification or during the period of suspension.
b.
Promulgate rules to implement this subdivision.
12r.
Notify the medical examining board, or any affiliated credentialing board attached to the medical examining board, of any decertification or suspension of a person holding a license granted by the board or the affiliated credentialing board if the grounds for the decertification or suspension include fraud or a quality of care issue.
13.
Impose additional sanctions for noncompliance with the terms of provider agreements under subd. 9. or certification criteria established under subd. 11.
14.
Assure due process in implementing subds. 12. and 13. by providing written notice, a fair hearing and a written decision.
15.
Routinely provide notification to persons eligible for medical assistance, or such persons' guardians, of the department's access to provider records.
16.
Notify the joint committee on finance and appropriate standing committees in each house of the legislature prior to renewing, extending or amending the claims processing contract under the medical assistance program.
18.
Conduct outreach for the early and periodic screening, diagnosis and treatment program as required under 42 CFR 441. This activity is limited to persons under 21 years of age who have been determined to be eligible for medical assistance.
19.
Contract with a county department under s. 46.21, 46.23, 51.42 or 51.437 to perform preadmission screening and resident review under sub. (6c).
20.
Submit a report, by May 1, 1991, and annually thereafter, to the joint committee on finance on the participation rates of children in the early and periodic screening and diagnosis program.
22.
After consulting with counties, independent living centers, consumer organizations and home health agencies, periodically identify those barriers to the provision of personal care services under s. 49.46 (2) (b) 6. j. which lead to a failure to respond to the needs and preferences of individuals who are eligible for these services and act to remove the barriers to the extent possible.
23.
Promulgate rules that define “supportive services", “personal services" and “nursing services" provided in a certified residential care apartment complex, as defined under s. 50.01 (6d), for purposes of reimbursement under s. 46.277 (5) (e).
24.
In consultation with hospitals, health maintenance organizations, county departments of social services and of human services and other interested parties, develop and, not later than January 1, 1999, implement a process for expediting medical assistance eligibility determinations for persons in urgent medical situations. The department shall promulgate any rules necessary for the implementation of that process.
24m.
Promulgate rules that require that the written plan of care for persons receiving personal care services under medical assistance be reviewed by a registered nurse at least every 60 days. The rules shall provide that the written plan of care shall designate intervals for visits to the recipient's home by a registered nurse as part of the review of the plan of care. The designated intervals for visits shall be based on the individual recipient's needs, and each recipient shall be visited in his or her home by a registered nurse at least once in every 12-month period. The rules shall also provide that a visit to the recipient is also required if, in the course of the nurse's review of the plan of care, there is evidence that a change in the recipient's condition has occurred that may warrant a change in the plan of care.
(b)
The department may:
1.
Direct a county department under s. 46.215, 46.22 or 46.23 to perform other functions, responsibilities and services, including any functions related to health maintenance organizations, limited service health organizations and preferred provider plans.
2.
Contract with any organization whether or not organized for profit to administer, in full or in part, the benefits under the medical assistance program including prepaid health care. The department shall accept bids on contracts for administrative services and services evaluating the medical assistance program as provided in ch. 16, but may accept the contract deemed most advantageous for claims processing services; or contract with any insurer authorized under the insurance code of this state to insure the program in full or in part and on behalf of the department. The department shall submit a report each December 31 to the governor, the joint committee on finance and the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under s. 13.172 (3), regarding the effectiveness of the management information system for monitoring and analyzing medical assistance expenditures.
3.
Audit all claims filed by any contractor making the payment of benefits paid under ss. 49.46 to 49.471 and make proper fiscal adjustments.
4.
Audit claims filed by any provider of medical assistance, and as part of that audit, request of any such provider, and review, medical records of individuals who have received benefits under the medical assistance program.
5.
Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.
6m.
Limit the number of providers of particular services that may be certified under par. (a) 11. or the amount of resources, including employees and equipment, that a certified provider may use to provide particular services to medical assistance recipients, if the department finds that existing certified providers and resources provide services that are adequate in quality and amount to meet the need of medical assistance recipients for the particular services; and if the department finds that the potential for medical assistance fraud or abuse exists if additional providers are certified or additional resources are used by certified providers. The department shall promulgate rules to implement this subdivision.
7.
Require, as a condition of certification under par. (a) 11., all providers of a specific service that is among those enumerated under s. 49.46 (2), 49.47 (6) (a), or 49.471 (11), as specified in this subdivision, to file with the department a surety bond issued by a surety company licensed to do business in this state. Providers subject to this subdivision provide those services specified under s. 49.46 (2), 49.47 (6) (a), or 49.471 (11) for which providers have demonstrated significant potential to violate s. 49.49 (3p) or (4m) (a) or 946.91 (2), (3) (a) or (b), (4), (5), or (6), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13. The surety bond shall be payable to the department in an amount that the department determines is reasonable in view of amounts of former recoveries against providers of the specific service and the department's costs to pursue those recoveries. The department shall promulgate rules to implement this subdivision that specify all of the following:
a.
Services under Medical Assistance for which providers have demonstrated significant potential to violate s. 49.49 (3p) or (4m) (a) or 946.91 (2), (3) (a) or (b), (4), (5), or (6), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13.
b.
The amount or amounts of the surety bonds.
c.
Terms of the surety bond, including amounts, if any, without interest to be refunded to the provider upon withdrawal or decertification from the medical assistance program.
8.
Require a person who takes over the operation, as defined in sub. (21) (ag), of a provider, to first obtain certification under par. (a) 11. for the operation of the provider, regardless of whether the person is currently certified. The department may withhold the certification required under this subdivision until any outstanding repayment under sub. (21) is made. The department shall promulgate rules to implement this subdivision.
9.
After providing reasonable notice and opportunity for a hearing, charge an assessment to a provider that repeatedly has been subject to recoveries under par. (a) 10. a. because of the provider's failure to follow identical or similar billing procedures or to follow other identical or similar program requirements. The assessment shall be used to defray in part the costs of audits and investigations by the department under sub. (3) (g) and may not exceed $1,000 or 200 percent of the amount of any such repeated recovery made, whichever is greater. The provider shall pay the assessment to the department within 10 days after receipt of notice of the assessment or the final decision after administrative hearing, whichever is later. The department may recover any part of an assessment not timely paid by offsetting the assessment against any medical assistance payment owed to the provider and may refer any unpaid assessments not collected in this manner to the attorney general, who may proceed with collection under this subdivision. Failure to timely pay in any manner an assessment charged under this subdivision, other than an assessment that is offset against any medical assistance payment owed to the provider, is grounds for decertification under par. (a) 12. A provider's payment of an assessment does not relieve the provider of any other legal liability incurred in connection with the recovery for which the assessment is charged, but is not evidence of violation of a statute or rule. The department shall credit all assessments received under this subdivision to the appropriation account under s. 20.435 (4) (iL). The department shall promulgate rules to implement this subdivision.
(2n)
Report on Medical Assistance program changes and finances.
(a)
In this subsection, “Medical Assistance program" includes any program operated under this subchapter, demonstration program operated under 42 USC 1315, and program operated under a waiver of federal law relating to medical assistance that is granted by the federal department of health and human services.
(b)
Before January 1, 2015, and every 90 days thereafter, the department shall submit to the joint committee on finance a report that contains all of the following information:
1.
An updated description of any Medical Assistance program changes implemented by the department, including any amendments to the Medical Assistance state plan.
2.
An updated estimate of the projected savings associated with any changes described under subd. 1.
3.
An updated projection of the total Medical Assistance program benefit expenditures during the fiscal biennium and an analysis of how these projected expenditures compare to the funding provided in the most recent biennial budget act.
(2p)
Approval of Medical Assistance program changes. After March 1, 2018, the department may not expand eligibility under section 2001 (a) (1) (C) of the Patient Protection and Affordable Care Act, P.L. 111-148, for the Medical Assistance program under this subchapter unless the state legislature has passed legislation to allow the expansion and that legislation is in effect.
(2t)
Submission of state plan amendments and provider payments.
(a)
The department may not submit a Medical Assistance state plan amendment to the federal department of health and human services or implement a change to the reimbursement rate for or make a supplemental payment to a provider under the Medical Assistance program under this subchapter when the amendment, rate change, or payment has an expected fiscal effect of $7,500,000 or more from all revenue sources over a 12-month period following the implementation date of the amendment, rate change, or payment without submitting the proposed state plan amendment, rate change, or payment to the joint committee on finance for review. If the cochairpersons of the joint committee on finance do not notify the department within 14 working days after the date of the submittal under this paragraph that the committee has scheduled a meeting for the purpose of reviewing the proposed state plan amendment, rate change, or payment, the department may submit the state plan amendment, implement the rate change, or make the payment. If, within 14 working days after the date of the submittal under this paragraph by the department, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed state plan amendment, rate change, or payment, the department may submit the state plan amendment, implement the rate change, or make the payment only upon approval by the committee.
(c)
Notwithstanding par. (a), the department is not required to submit a proposed change to a reimbursement rate for or supplemental payment to a provider under the Medical Assistance program under this subchapter to the joint committee on finance under par. (a) if explicit expenditure authority or funding for the specific change or supplemental payment is included in enacted legislation.
(3)
Payment.
(a)
Reimbursement shall be made to each county department under ss. 46.215, 46.22, and 46.23 for any administrative services performed in the Medical Assistance program on the basis of s. 49.78 (8).
(ag)
Reimbursement shall be made to each entity contracted with under s. 46.283 (2) for functional screenings performed by the entity.
(b)
1.
The contractor, if any, administering benefits or providing prepaid health care under s. 49.46, 49.465, 49.468, 49.47, or 49.471 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in sub. (2) (a) 4., but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
2.
The contractor, if any, insuring benefits under s. 49.46, 49.465, 49.468, 49.47, or 49.471 shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the persons eligible to receive them and for its services as insurer.
(c)
Payment for services provided under this section shall be made directly to the hospital, skilled and intermediate nursing homes, prepaid health care group, other organization or individual providing such services or to an organization which provides such services or arranges for their availability on a prepayment basis.
(d)
No payment may be made for inpatient hospital services, skilled nursing home services, intermediate care facility services, tuberculosis institution services or inpatient mental institution services, unless the facility providing such services has in operation a utilization review program and meets federal regulations governing such utilization review program.
(dm)
After distribution of computer software has been made under 1993 Wisconsin Act 16, section 9126 (13h), no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under s. 49.46, 49.47, or 49.471 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under 42 USC 1395.
(e)
1.
The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital's total reimbursement or payment to that which would be provided to an economically and efficiently operated facility.
2.
A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented under subd. 1. shall annually prepare a report of cost and other data in the manner prescribed by the department.
3.
The department may adopt a prospective payment system under subd. 1. which may include consideration of an average rate per diem, diagnosis-related groups or a hospital-specific prospective rate per discharge.
4.
If the department maintains a retrospective reimbursement system under subd. 1. for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital's fiscal year may not exceed the lower of the hospital's charges for the services or the actual and reasonable allowable costs to the hospital of providing the services, plus any disproportionate share funding that the hospital is qualified to receive under 42 USC 1396r-4.
7.
The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under 42 USC 1320c to 1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
7m.
Notwithstanding subd. 7., the daily reimbursement or payment rate for services at a hospital established under s. 45.50 (10) provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50.
9.
Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital's reimbursement or payment rate under subd. 1.
10.
Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.
10m.
All facilities listed in a certificate of approval issued to the University of Wisconsin Hospitals and Clinics Authority under s. 50.35 are a hospital for purposes of reimbursement under this section.
10r.
All facilities listed in a certificate of approval issued to a free-standing pediatric teaching hospital under s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician clinic reimbursement rates to reimburse the facilities under this section for types of services for which, before July 1, 2009, the department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.
11.
The department shall use a portion of the moneys collected under s. 50.38 (2) (a) to pay for services provided by eligible hospitals, as defined in s. 50.38 (1), other than critical access hospitals, under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for fiscal year 2008-09 divided by 57.75 percent. For each state fiscal year after state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for the fiscal year divided by 61.68 percent.
12.
The department shall use a portion of the moneys collected under s. 50.38 (2) (b) to pay for services provided by critical access hospitals under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For each state fiscal year, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (b) for the fiscal year divided by 61.68 percent.
(em)
The department shall expend moneys collected under s. 256.23 (2) to supplement reimbursement for eligible ambulance service providers, as defined in s. 256.23 (1) (a), for services provided under the Medical Assistance program under this subchapter, including services reimbursed on a fee-for-service basis and provided under managed care, by eligible ambulance service providers. Health plans shall be indemnified and held harmless for any errors made by the department or its agents in calculation of any supplemental reimbursement made under this paragraph.
(f)
1.
Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.
2.
The department may deny any provider claim for reimbursement which cannot be verified under subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in s. 49.46 (2) or 49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
2m.
The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.
3.
Contractors under sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.
(fm)
The department shall seek, on behalf of dentists who are providers, federal reimbursement for the cost of any equipment that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of the cost of the equipment that is reimbursed by the federal government.
(g)
1.
The secretary may authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of statutes, regulations, or rules applicable to the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees authorized by the secretary under this paragraph shall be issued, and shall possess at all times while they are performing their investigatory or audit functions under this section, identification, signed by the secretary, that specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Under the request of a designated person and upon presentation of the person's authorization, providers and medical assistance recipients shall accord the person access to any provider personnel, records, books, or documents or other information needed. Under the written request of a designated person and upon presentation of the person's authorization, providers and recipients shall accord the person access to any needed patient health care records of a recipient. Authorized employees may hold hearings, administer oaths, take testimony, and perform all other duties necessary to bring the matter before the department for final adjudication and determination.
2.
The department shall promulgate rules to implement this paragraph.
(h)
1m.
The failure or refusal of a provider to accord department auditors or investigators access as required under par. (g) to any provider personnel, records, books, patient health care records of medical assistance recipients, or documents or other information requested constitutes grounds for decertification or suspension of the provider from participation in the medical assistance program. No payment may be made for services rendered by the provider following decertification, during the period of suspension, or during any period of provider failure or refusal to accord access as required under par. (g).
1n.
The department shall promulgate rules to implement this paragraph.
(j)
Reimbursement for administrative contract costs under this section is limited to the funds available under s. 20.435 (4) (bm).
(k)
If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in s. 448.60 (3), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.
(L)
1.
In this paragraph:
a.
“Designated health service" has the meaning given in 42 USC 1395nn (h) (6).
b.
“Medicare" means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395 to 1395ccc.
c.
“Physician" has the meaning given in s. 448.01 (5).
d.
“Referral" has the meaning given in 42 USC 1395nn (h) (5).
2.
The department may not pay a provider for a designated health service that is authorized under this section or s. 49.46, 49.47, or 49.471, that is provided as the result of a referral made to the provider by a physician and that, under 42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of 42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under 42 USC 1395nn.
3.
A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under 42 USC 1395nn (f), as amended to August 10, 1993.
4.
Any person who fails to comply with subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.
5.
The department shall administer this paragraph consistently with 42 USC 1395nn and 42 USC 1396b (s).
(m)
1.
To be certified under sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in s. 340.01 (23g), that satisfies the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under s. 49.46 (2) (b) 3. or 49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.
2.
A person who is certified to provide transportation by specialized medical vehicle under sub. (2) (a) 11. shall ensure that every person who drives or serves as an attendant to passengers on a specialized medical vehicle, before driving or serving as an attendant, has current proficiency in the use of an automated external defibrillator, as defined in s. 256.15 (1) (cr), achieved through instruction provided by an individual, organization, or institution of higher education that is approved under s. 46.03 (38) to provide such instruction.
(3g)
Payments to federally qualified health centers.
(a)
For services provided by a federally qualified health center before July 1, 2016, to a recipient of the Medical Assistance program under this subchapter, the department shall reimburse the federally qualified health center under a payment methodology in effect on January 1, 2015, and in accordance with 42 USC 1396a (bb) (6).
(b)
For services provided by a federally qualified health center on or after July 1, 2016, to a recipient of the Medical Assistance program under this subchapter, the department shall reimburse the federally qualified health centers using a payment methodology based on the Medicaid prospective payment system under 42 USC 1396a (bb) (1) to (3). The department shall consult with federally qualified health centers in developing the payment methodology under this paragraph. The department shall phase-in over fiscal years 2016-17, 2017-18, and 2018-19 payment of new rates under the payment methodology developed under this paragraph.
(3m)
Disproportionate share hospital payments.
(a)
Subject to par. (d) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay to hospitals that serve a disproportionate share of low-income patients an amount equal to the sum of $71,600,000, as the state share of payments, and the matching federal share of payments. The department may make a payment to a hospital under this subsection under the calculation method described in par. (b) if the hospital meets all of the following criteria:
1.
The hospital is located in this state.
2.
The hospital provides a wide array of services, including services provided through an emergency department.
3.
The inpatient days for Medical Assistance recipients at the hospital were at least 6 percent of the total inpatient days at that hospital during the most recent year for which such information is available.
4.
The hospital meets applicable, minimum requirements to be a disproportionate share hospital under 42 USC 1396r-4 and any other applicable federal law.
(b)
The department shall comply with all of the following when making payments to hospitals described in par. (a):
1.
The department shall distribute the total amount of moneys described under par. (a) to be paid to hospitals with a disproportionate share of low-income patients by doing all of the following:
a.
Dividing the number of Medical Assistance recipient inpatient days at a hospital by the number of total inpatient days at the hospital to obtain the percentage of Medical Assistance recipient inpatient days at that hospital.
b.
Subject to subds. 2. and 3., providing an increase to the inpatient fee-for-service base rate for each hospital that qualifies for a disproportionate share hospital payment such that the hospital's overall fee-for-service add-on percentage under this subsection increases as the hospital's percentage of Medical Assistance recipient inpatient days increases.
2.
The department shall ensure that the total amount of moneys available to pay hospitals with a disproportionate share of low-income patients is distributed in each fiscal year.
3.
The department shall limit the maximum payment to hospitals such that all of the following are true for disproportionate share hospital payments under this subsection in a fiscal year:
a.
No single hospital receives more than $4,600,000. Beginning in fiscal year 2021-22, the amount specified under this subd. 3. a. shall equal 6.77 percent of the total amount of the state and federal shares available for disproportionate share hospital payments for the fiscal year.
b.
The amount of payment is in accordance with federal rules concerning the hospital specific limit.
(c)
If the department needs data to calculate the payments under this subsection other than the data available from the Medicaid Management Information System, the fiscal survey data, or the federal centers for Medicare and Medicaid services public records, the department shall collect the necessary data from hospitals.
(d)
The department shall seek any necessary approval from the federal department of health and human services to implement the hospital payment methodology described under pars. (a) and (b). If approval is necessary and approval from the federal department of health and human services is received, the department shall implement the payment methodology described under pars. (a) and (b). If approval is necessary and the department and the federal department of health and human services negotiate a methodology for making payments to hospitals with a disproportionate share of low-income patients that is different from the methodology described under pars. (a) and (b), the department, before implementing the negotiated payment methodology, shall submit to the joint committee on finance the negotiated payment methodology. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the submittal by the department that the committee has scheduled a meeting for the purpose of reviewing the negotiated payment methodology, the department may implement the negotiated payment methodology. If, within 14 working days after the date of the submittal by the department, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the negotiated payment methodology, the negotiated payment methodology may be implemented only on approval of the committee.
(3p)
Rural critical care access supplement.
(a)
Subject to par. (c) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay an amount equal to the sum of $4,500,000, as the state share of payments, and the matching federal share of payments, to hospitals that are not eligible for payments under sub. (3m) but that meet the criteria under sub. (3m) (a) 1. and 2. and that, in the most recent year for which information is available, charged at least 6 percent of overall charges for services to the Medical Assistance program for services provided to Medical Assistance recipients. The department may make a payment to a hospital under this subsection under a calculation method determined by the department that provides a fee-for-service supplemental payment that increases as the percentage of the total amount of the hospital's overall charges for services that are charges to the Medical Assistance program increases.
(b)
The department shall ensure that the total amount of moneys available to pay hospitals described under this subsection is distributed in each fiscal year.
(c)
The department shall limit the maximum payment to hospitals under this subsection such that the amount of payment is in accordance with federal rules concerning any hospital specific limit.
(d)
The department shall seek any necessary approval from the federal department of health and human services to implement the hospital payment supplement described under par. (a). If approval is necessary and approval from the federal department of health and human services is received, the department shall implement the payment methodology described under par. (a). If approval is necessary and the federal department of health and human services does not approve, the department may not implement the hospital payment supplement under par. (a).
(4)
Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.
(4m)
Financial record matching program.
(a)
Definitions. In this subsection:
1.
“Account" means a demand deposit account, checking account, negotiable withdrawal order account, savings account, time deposit account, or money market mutual fund account.
2.
“Applicant" means an individual applying for benefits under this subchapter.
3.
“Financial institution" means any of the following:
a.
A depository institution, as defined in 12 USC 1813 (c).
c.
A federal credit union, as defined in 12 USC 1752, or state credit union, as defined in 12 USC 1752.
f.
A broker-dealer, as defined in s. 551.102 (4).
4.
“Other individual" means an individual whose resources are required by law to be disclosed to determine the eligibility of an applicant or recipient.
5.
“Recipient" means an individual who receives benefits under this subchapter.
(b)
Matching program and agreements.
1.
The department shall operate a financial record matching program under this subsection for the purpose of verifying the assets of applicants, recipients, and other individuals with respect to any program under this subchapter that requires asset verification.
2.
The department shall enter into agreements with financial institutions doing business in this state to operate the financial record matching program under this subsection. An agreement shall require the financial institution to participate in the financial record matching program by electing either the financial institution matching option under par. (c) or the state matching option under par. (d). Any changes to the conditions of the agreement shall be submitted by the financial institution or the department at least 60 days before the effective date of the change. The department shall furnish the financial institution with a signed copy of the agreement.
3.
The department shall reimburse a financial institution up to $125 per calendar quarter for participating in the financial record matching program under this subsection.
4.
To the extent feasible, the information to be exchanged under the matching program shall be provided by electronic data exchange as prescribed by the department in the agreement under subd. 2.
(c)
Financial institution matching option. If a financial institution with which the department has an agreement under par. (b) elects the financial institution matching option under this paragraph, all of the following apply:
1.
At least once each calendar quarter, the department shall provide to the financial institution, in the manner specified in the agreement under par. (b) 2., information regarding applicants, recipients, and other individuals. The information shall include names and social security or other taxpayer identification numbers.
2.
Based on the information received under subd. 1., the financial institution shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution. If the financial institution determines that an applicant, recipient, or other individual has an ownership interest in an account at the financial institution, the financial institution shall provide the department with a notice containing the applicant's, recipient's, or other individual's name, address of record, social security number or other taxpayer identification number, and account information. The account information shall include the account number, the account type, the nature of the ownership interest in the account, and the balance of the account at the time that the record match is made. The notice under this subdivision shall be provided in the manner specified in the agreement under par. (b) 2. and, to the extent feasible, by an electronic data exchange.
(d)
State matching option. If a financial institution with which the department has an agreement under par. (b) elects the state matching option under this paragraph, all of the following apply:
1.
At least once each calendar quarter, the financial institution shall provide the department with information concerning all accounts maintained at the financial institution. For each account maintained at the financial institution, the financial institution shall notify the department of the name and social security number or other tax identification number of each person having an ownership interest in the account, together with a description of each person's interest. The information required under this subdivision shall be provided in the manner specified in the agreement under par. (b) 2. and, to the extent feasible, by an electronic data exchange.
2.
The department shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution providing information under subd. 1. Upon the request of the department, the financial institution shall provide to the department, for each applicant, recipient, or other individual who matches information provided by the financial institution under subd. 1., the address of record, the account number and account type, and the balance of the account.
(e)
Use of information by financial institution; penalty. A financial institution participating in the financial record matching program under this subsection, and the employees, agents, officers, and directors of the financial institution, may use information received from the department under par. (c) only for the purpose of matching records and may use information provided by the department in requesting additional information under par. (d) only for the purpose of providing the additional information. Neither the financial institution nor any employee, agent, officer, or director of the financial institution may disclose or retain information received from the department concerning applicants, recipients, or other individuals. Any person who violates this paragraph may be fined not less than $50 nor more than $1,000 or imprisoned in the county jail for not less than 10 days or more than one year or both.
(f)
Use of information by department. The department may use information provided by a financial institution under this subsection only for matching records under par. (d), for administering the financial record matching program under this subsection, and for determining eligibility or continued eligibility under this subchapter. The department may not disclose or retain information received from a financial institution under this subsection concerning account holders who are not applicants, recipients, or other individuals.
(g)
Financial institution liability. A financial institution is not liable to any person for disclosing information to the department under this subsection or for any other action that the financial institution takes in good faith to comply with this subsection.
(5)
Appeal.
(a)
Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing, except as provided in par. (ag) or (ar).
(ag)
A person shall request a hearing within 90 days of the date of receipt of a notice from a care management organization or managed care organization upholding its adverse benefit determination relating to any of the following or within 90 days of the date the care management organization or managed care organization failed to act on the contested matter within the time specified by the department:
1.
Denial or limited authorization of a requested services, including a determination based on the type or level of service, requirement for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.
2.
Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.
3.
Denial, in whole or in part, of payment for a service.
4.
Failure to provide services in a timely manner.
5.
Failure of a care management organization or managed care organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.
6.
Denial of an enrollee's request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.
7.
Denial of an enrollee, who is a resident of a rural area with only one care management organization or managed care organization, to obtain services outside the organization's network of contracted providers.
(ar)
If a federal regulation specifies a different time limit to request a hearing than par. (a) or (ag), the time limit in the federal regulation shall apply.
(b)
1.
Upon receipt of a timely petition under par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:
a.
The petitioner withdraws the petition in writing.
b.
The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.
c.
The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department.
d.
The issue is an adverse benefit determination described in par. (ag) 1. to 7. made by a care management organization or managed care organization and the person requesting the hearing has not exhausted the internal appeal procedure with the organization.
2.
If a recipient requests a hearing within the timely notice period specified in 42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the county department of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced, or discontinued if:
a.
The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient's behalf.
b.
The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.
3.
The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.
(5g)
Payments to tribes.
(a)
Tribal care coordination agreements. A tribal health care provider's care coordination agreement with a nontribal health care provider shall meet federal requirements, including that a service provided by the nontribal health care provider be at the request of the tribal health care provider on behalf of a tribal member who remains in the tribal health care provider's care according to the care coordination agreement; that both the tribal health care provider and nontribal health care provider are providers, as defined in s. 49.43 (10); that an established relationship exists between the tribal health care provider and the tribal member; and that the care be provided pursuant to a written care coordination agreement.
(b) Amount and distribution of payments.
1.
From the appropriation account under s. 20.435 (4) (b), the department shall make payments to eligible governing bodies of federally recognized American Indian tribes or bands or tribal health care providers in an amount and manner determined by the department. The department shall determine payment amounts on the basis of the difference between the state share of medical assistance payments paid for services rendered to tribal members for whom a care coordination agreement with nontribal health care providers is in place and the state share of medical assistance payments that would have been paid for those services absent a care coordination agreement with nontribal partners.
2. The department shall withhold from the payments under subd. 1. the state share of administrative costs associated with carrying out this subsection, up to 10 percent of the amounts calculated in subd. 1.
3. Federally recognized American Indian tribes or bands may use funds paid under this subsection for health-related purposes. The department shall consult biennially with tribes to determine the timing and distribution of payments.
(5m)
Supplemental funding for rural hospitals.
(am)
Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), (w) and (xc), the department shall distribute not more than $5,000,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under 42 USC 1396b (i) (3).
(b)
The supplemental funding for rural hospitals under par. (am) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation to that utilization in other rural hospitals.
(5r)
Supplemental funding for uncompensated care. Notwithstanding sub. (3) (e), from the appropriation account under s. 20.435 (4) (w), the department shall distribute $3,000,000 in each fiscal year to the University of Wisconsin Hospital and Clinics for care that is not otherwise compensated, except that the department may not make payments that exceed limitations based on customary charges under 42 USC 1396b (i) (3).
(6b)
Centers for the developmentally disabled. From the appropriation under s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Beginning in fiscal year 2009-10, following each placement made under s. 46.275 that involves a relocation from a center for the developmentally disabled, the department shall reduce the reimbursement to the center by an amount, as determined by the department for each placement, that is equal to the nonfederal share of the costs for the placement under s. 46.275.
(6c)
Preadmission screening and resident review.
(a)
Definitions. In this subsection:
1.
“Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. “Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.
2.
“Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.
3.
“County department" means a department under s. 46.21, 46.23, 51.42 or 51.437.
4.
“Developmental disability" means any of the following:
a.
Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.
b.
A severe, chronic disability that meets all of the conditions for individuals with related conditions as specified in 42 CFR 435.1009.
5.
“Facility" has the meaning given under 42 USC 1396r (a).
6.
“Facility care" means services provided in a facility that are in conformity with 42 USC 1396r and that are payable under sub. (6m).
6m.
“Intermediate facility" has the meaning given in s. 46.279 (1) (b).
7.
“Mental illness" has the meaning given in 42 USC 1396r (e).
(b)
Preadmission screening. Except as provided in par. (e), every individual who applies for admission to a facility or to an institution for mental diseases shall be screened to determine if the individual has developmental disability or mental illness. The department or an entity to which the department has delegated authority shall screen every individual who has been identified as having a developmental disability or mental illness to determine if the individual needs facility care. If the individual is determined to need facility care, the department or an entity to which the department has delegated authority shall also assess the individual to determine if he or she requires active treatment for developmental disability or active treatment for mental illness. If the department or entity determines that the individual requires active treatment for developmental disability, the department or entity shall determine whether the level of care required by the individual that is provided by a facility could be provided safely in an intermediate facility or under a plan that is developed under s. 46.279 (4).
(c)
Resident review. Except as provided in par. (e), the department or an entity to which the department has delegated authority shall review every resident of a facility or institution for mental diseases who has a developmental disability or mental illness and who has experienced a significant change in his or her physical or mental condition to determine all of the following:
1.
Whether the resident needs facility care.
2.
Whether the resident requires active treatment for developmental disability or active treatment for mental illness.
3.
If the department or entity determines under subd. 1. that the resident needs facility care and under subd. 2. that the resident requires active treatment for developmental disability, whether the level of care required by the resident that is provided by a facility could be provided safely in an intermediate facility or under a plan that is developed under s. 46.279 (4).
(d)
Payment for facility care.
1.
No payment may be made under sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46, 49.47, or 49.471, who has developmental disability or mental illness and for whom under par. (b) or (c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.
2.
Payment may be made under sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46, 49.47, or 49.471 and who has developmental disability or mental illness and is determined under par. (b) or (c) to need facility care, regardless of whether it is determined under par. (b) or (c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.
(e)
Exceptions.
1.
Payment under sub. (6m) may be made to a facility and no screening under par. (b) or review under par. (c) is required for an individual who is medically diagnosed as having developmental disability or mental illness, and who is not a danger to himself or herself or to others, if, immediately after release from a hospital, the individual enters the facility, as part of a medically prescribed period of recovery, for a period not to exceed 30 days and the admission is approved by the department or an entity to which the department has delegated authority.
2.
Payment under sub. (6m) may be made to a facility or institution for mental diseases for an individual who is 65 years of age or older, is medically diagnosed as having developmental disability or mental illness, is not a danger to himself or herself or to others and is competent to make an independent decision, if, following screening under par. (b) or review under par. (c), all of the following apply:
a.
It is determined that the individual needs facility care and requires active treatment for developmental disability or active treatment for mental illness.
b.
The individual chooses not to participate in active treatment.
(f)
Hearing. An individual for whom admission to a facility or institution for mental diseases is denied under par. (b) or for whom a determination under par. (c) results in prohibition of payment to a facility or institution for mental diseases under par. (d) and relocation from the facility to a facility or institution for mental diseases may request a hearing from the department.
(g)
Rule making. The department shall promulgate all of the following rules:
1.
Establishing criteria and procedures for a determination by the department under par. (d) that a resident be relocated from a facility after March 31, 1990, and before December 31, 1993.
2.
Establishing standards for the conduct of hearings under par. (f).
(6h)
Liability for disallowances. If the department or the federal health care financing administration finds a skilled nursing facility or intermediate care facility in this state that provides care to medical assistance recipients for which the facility receives reimbursement under sub. (6m) to be an institution for mental diseases, the facility shall be liable for any retroactive federal medicaid disallowances for services provided after the date of the finding.
(6j)
Limitation on certain facility coverage. The department shall determine, under a method devised by the department, the average population during the period from January 1, 1987, to June 30, 1988, of persons in each skilled nursing facility or an intermediate care facility who are mentally ill and are aged 21 to 64, except persons under 22 years of age who were receiving medical assistance services in the facility prior to reaching age 21 and continuously thereafter. Beginning July 1, 1988, the payment under sub. (6m) for services provided by a facility to persons who are mentally ill and are within the age limitations specified in this subsection may not exceed the payment for the average population of these persons in that facility, as determined by the department.
(6m)
Payment to facilities.
(a)
In this subsection:
1.
“Active treatment" has the meaning specified in 42 USC 1396r (e) (7) (G) (iii).
2.
“Cost center" means a group of similar facility expenses.
3.
“Facility" means a nursing home or a community-based residential facility that is licensed under s. 50.03 and that is certified by the department as a provider of medical assistance.
5.
“Nursing home" has the meaning given under s. 50.01 (3).
6.
“Resource Utilization Groupings" means a comparative resource utilization grouping that classifies each facility resident based on information obtained from performing, for the resident, a minimum data set assessment developed by the federal Centers for Medicare and Medicaid Services.
(ag)
Payment for care provided in a facility under this subsection made under s. 20.435 (4) (b), (gm), (o), (pa), or (w) shall, except as provided in pars. (bg), (bm), and (br), be determined according to a prospective payment system updated annually by the department. The payment system shall implement standards that are necessary and proper for providing patient care and that meet quality and safety standards established under subch. II of ch. 50 and ch. 150. The payment system shall reflect all of the following:
1.
A prudent buyer approach to payment for services, under which a reasonable price recognizing selected factors that influence costs is paid for service that is of acceptable quality.
2.
Except as provided in subd. 3r., standards established by the department that shall be based upon allowable costs incurred by facilities in the state as available from information submitted under par. (c) 3. and compiled by the department.
3m.
For each state fiscal year, rates that shall be set by the department based on information from cost reports for costs specified under par. (am) 1. bm., 4., 5m., and 6. for the most recently completed fiscal year of the facility.
3p.
For all costs specified under par. (am) 1. bm., an acuity-based payment rate system to which all of the following applies:
a.
The system may incorporate acuity measurements under the most recent Resource Utilization Groupings methodology to determine factors for case-mix adjustment.
b.
Four times annually, for each facility resident who is a Medical Assistance recipient on March 31, June 30, September 30, or December 31, as applicable, the system shall determine the average case-mix index by use of the factors specified under subd. 3p. a.
c.
The system shall incorporate payment adjustments for dementia, behavioral needs, or other complex medical conditions.
d.
The system may include incentives for providing high quality of care.
3r.
Flat-rate payment for all costs specified under par. (am) 1. a. and 2.
5.
Consideration for special needs of facility residents.
6.
Standards for capital payment that will be based upon replacement value of a facility as determined by a commercial estimator with which the department contracts and criteria and limitations as determined by the department.
7.
Assurance of an acceptable quality of care for all medical assistance recipients provided nursing home care.
(am)
In determining payments for a facility under the payment system in par. (ag), the department shall consider all of the following cost centers:
1.
Allowable direct care costs, including, if provided, any of the following:
a.
Personal comfort supplies; medical supplies; over-the-counter drugs; and nonbillable services of a ward clerk, activity person, recreation person, social worker, volunteer coordinator, teacher for residents aged 22 and older, vocational counselor for residents aged 22 and older, religious person, therapy aide, therapy assistant, and counselor on resident living.
bm.
Nonbillable services of a registered nurse, licensed practical nurse, and nurse aide.
2.
Allowable support service costs, including the following allowable facility expenses:
a.
Dietary service for the provision of meals to facility residents.
b.
Environmental service for the provision of maintenance, housekeeping, laundry and security service.
c.
Allowable fuel and utility costs, including the facility expenses that the department determines are allowable for the provision of electrical service, water and sewer services, and heat.
d.
Allowable administrative and general costs, including costs related to the facility's overall management and administration and allowable expenses that are not recognized or reimbursed in other cost centers and including the costs of commercial estimators approved by the department under par. (ar) 6.
4.
Property tax or municipal service costs paid by the owner of the facility for the facility.
5m.
Allowable interest expense of the facility, less interest income of the facility and less interest income of affiliated entities, to the extent required under the approved state plan for services under 42 USC 1396.
6.
Capital payment necessary for the provision of service over time, including allowable facility expenses for suitable space, furnishings, property insurance and movable equipment for patient care.
(ap)
If the bed occupancy of a nursing home is below the minimum patient day occupancy standards that are established by the department under par. (ar) (intro.), the department may approve a request by the nursing home to delicense any of the nursing home's licensed beds. If the department approves the nursing home's request, all of the following apply:
1.
The department shall delicense the number of beds in accordance with the nursing home's request.
2.
The department may not include the number of beds of the nursing home that the department delicenses under this paragraph in determining the costs per patient day under the minimum patient day occupancy standards under par. (ar).
3.
The nursing home may not use or sell a bed that is delicensed under this paragraph.
4.
a.
Every 12 months following the delicensure of a bed under this paragraph, for which a nursing home has not resumed licensure under subd. 5., the department shall reduce the licensed bed capacity of the nursing home by 10 percent of all of the nursing home's beds that remain delicensed under this paragraph or by 25 percent of one bed, whichever is greater. The department shall reduce the statewide maximum number of licensed nursing home beds under s. 150.31 (1) (intro.) by the number or portion of a number of beds by which the nursing home's licensed bed capacity is reduced under this subdivision.
b.
Subdivision 4. a. does not apply with respect to the delicensure of beds between October 14, 1997, and the date that is 60 days after October 14, 1997, during the period of any contract entered into by a nursing home prior to January 1, 1997, if the contract requires the nursing home to maintain its current licensed bed capacity.
5.
A nursing home retains the right to resume licensure of a bed of the nursing home that was delicensed under this paragraph unless the licensed bed capacity of the nursing home has been reduced by that bed under subd. 4. The nursing home may not resume licensure of a fraction of a bed. The nursing home may resume licensure 18 months after the nursing home notifies the department in writing that the nursing home intends to resume the licensure. If a nursing home resumes licensure of a bed under this subdivision, subd. 2. does not apply with respect to that bed.
6.
If subd. 4. b. applies and the nursing home later resumes licensure of a bed that was delicensed between October 14, 1997, and the date that is 60 days after October 14, 1997, the department shall calculate the costs per patient day using the methodology specified in the state plan that is in place at the time that the delicensed beds are resumed.
(ar)
In determining payments for a facility under par. (ag), the department may establish minimum patient day occupancy standards for determining costs per patient day and shall apply the following methods to calculate amounts payable for the rate year for the cost centers described under par. (am):
1.
For direct care costs:
a.
The department shall establish standards for payment of allowable direct care costs under par. (am) 1. bm., for facilities that do not primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state and separate standards for payment of allowable direct care costs, for facilities that primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state. The standards shall be adjusted by the department for regional labor cost variations. The department shall treat as a single labor region the counties of Dane, Dodge, Iowa, Columbia, Richland, Sauk, and Rock and shall adjust payment so that the direct care cost targets of facilities in Dane, Iowa, Columbia, and Sauk counties are not reduced as a result of including facilities in Dodge, Richland, and Rock Counties in this labor region. For facilities in Douglas, Dunn, Pierce, and St. Croix counties, the department shall perform the adjustment by use of the wage index that is used by the federal department of health and human services for hospital reimbursement under 42 USC 1395 to 1395ggg.
b.
The department shall establish the direct care component of the facility rate for each facility by comparing actual allowable direct care cost information of that facility adjusted for inflation to the standards established under subd. 1. a.
c.
If a facility has an approved program for provision of service to residents who have an intellectual disability, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under subd. 1. b. may be made to that facility according to a method developed by the department.
cm.
Funding distributed to facilities for the provision of active treatment to residents with a diagnosis of developmental disability shall be distributed in accordance with a method developed by the department which is consistent with a prudent buyer approach to payment for services.
2.
For support service costs, the department shall establish one or more standards for the payment of support service costs that take into account support service costs for a sample of all facilities within the state.
4.
For net property taxes or municipal services, payment shall be made for the amount of the previous calendar year's tax or the amount of municipal service costs for a period specified by the department, subject to a maximum limit as determined by the department.
6.
Capital payment shall be based on a replacement value for a facility. The replacement value shall be determined by a commercial estimator contracted for by the department and paid for by the facility. The replacement value shall be subject to limitations determined by the department.
(av)
The department shall calculate a payment rate for a facility by applying the criteria set forth under pars. (ag) 1. to 5. and 7., (am) 1. bm., 4., 5m. and 6., and (ar) 1., 4., and 6. to information from cost reports submitted by the facility, as affected by any adjustment for ancillary services and materials under par. (b).
(b)
The charges for ancillary materials and services that would be incurred by a prudent buyer may be included as an adjustment to the rate determined by par. (av) when so determined by the department. The department may not authorize any adjustments to the rate established under par. (av) to pay for a cost overrun that the department fails to approve under s. 150.11 (3). Ancillary materials and services for which payment may be made include, if provided, oxygen, medical transportation and laboratory and X-ray services. Payment for these services and materials shall not exceed medical assistance limitations for reimbursement of the services and materials. For services in a facility for which the department may make payment to a service provider other than a facility, the department may make payment to the facility but not in excess of the estimated amount of payment available if a separate service provider provided the service. The department may promulgate rules setting forth conditions of and limitations to this paragraph.
(bg)
The department shall determine payment levels for the provision of skilled, intermediate, limited, personal or residential care or care for individuals with an intellectual disability in the state centers for the developmentally disabled and in a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50 separately from the payment principles, applicable costs and methods established under this subsection.
(bm)
Except as provided in par. (bo), the department may establish payment methods for a facility for which any of the following applies:
1.
The facility is newly constructed.
2.
The total of licensed beds for the facility has significantly increased or decreased prior to calculation of its rate under the payment system.
3.
The facility has undergone a change in certification or licensure level.
5.
The facility has received approval or disapproval for provision of service to residents requiring supplemental skilled care due to complex medical conditions.
6.
The facility has received approval or been disapproved for provision of service to residents who have any of the following:
a.
Brain injury, as defined in s. 51.01 (2g).
b.
A diagnosis of acquired immunodeficiency syndrome.
c.
An HIV infection, as defined in s. 252.01 (2), and illness or injury associated with the development of acquired immunodeficiency syndrome.
(bo)
The department may establish payment methods for capital payment for a newly constructed facility that first provided services after June 30, 1984.
(bp)
Notwithstanding pars. (am) 6. and (ar) 6., the department may establish payment methods based on actual costs for capital payment for a facility to which, after December 31, 1982, any of the following applies:
1.
The facility was constructed.
2.
The facility was purchased.
3.
The facility incurred annual remodeling costs of more than $600,000.
4.
The facility incurred remodeling costs necessary to meet physical plant requirements under 42 USC 1396a (a) (13) (A).
(br)
If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds under applicable federal acts or programs for the reduction of operation deficits under sub. (6u), all of the following apply:
1.
Notwithstanding s. 20.435 (7) (b) or 20.437 (1) (cj) or (q) or (2) (dz), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.435 (7) (b), or the department shall direct the department of children and families to reduce allocations of funds to counties or Wisconsin Works agencies in the amount of the disallowance from the appropriation account under s. 20.437 (1) (cj) or (2) (dz), in accordance with s. 16.544 to the extent applicable.
NOTE: Subd. 1. is shown as amended eff. 7-1-24 by 2023 Wis. Act 19. Prior to 7-1-24 it reads:
1. Notwithstanding s. 20.435 (7) (b) or 20.437 (1) (cj) or (2) (dz), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.435 (7) (b), or the department shall direct the department of children and families to reduce allocations of funds to counties or Wisconsin Works agencies in the amount of the disallowance from the appropriation account under s. 20.437 (1) (cj) or (2) (dz), in accordance with s. 16.544 to the extent applicable.
2.
If a city, village or town owns and operates a facility that has received funds to reduce an operating deficit, the city, village or town shall reimburse the county in which the city, village or town is located in the amount of funds so received.
(c)
As a condition of payment under this section a facility shall:
1.
Meet the staffing standard requirements for direct care costs including the supplement, if any, made under par. (ar) 1. c. and maintain such records as prescribed by the department to document that such level of care was actually provided.
2.
Provide at the time of a patient's admission to a home, for the development and implementation of a rehabilitation plan including the development of an alternate care plan for the patient.
3.
Provide, upon request, cost information relating to the overall financial operation of the facility, including, but not limited to wages and hours worked, costs of food, housekeeping, maintenance and administration.
4.
Agree to admit patients 7 days of the week.
5.
Admit only patients if required under s. 50.035 (4n) or 50.04 (2h), who have been referred to a resource center.
6.
Provide, upon request, such information as the department considers necessary to determine allowable interest expenses under par. (am) 5m.
(d)
The department shall:
2.
Terminate payment to a facility for a patient, unless a utilization review team established pursuant to federal regulations upon review of the patient's needs and the implementation of a rehabilitation plan for that patient determines that the patient's need for care and services can only be provided in a facility and determines the appropriate level of care.
3.
Establish, maintain, and periodically update a patient needs evaluation system to be used in determining the need and level of care at a facility, which shall include the social and rehabilitative needs of the patient, provide levels of care to correspond to the actual staff time required to provide such care, and define the contents of the services to be provided.
4.
Periodically audit all nursing homes and intermediate care facilities receiving funds under this paragraph, and recover payments made where the home is not meeting the conditions under which the payment was made as specified in par. (c) 1. and 2. Erroneous information provided under par. (c) 3. shall constitute grounds for recovery.
5.
Beginning October 1, 1989, deny payment to a facility for a patient who is admitted to the facility after the department has provided newspaper notice and notice under s. 50.03 (2m) (b) that the facility violates 42 USC 1396 to 1396s and before the date, if any, that the department determines that the facility is in substantial compliance with 42 USC 1396 to 1396s.
(g)
Payment under this section to a facility may not include the cost of care reimbursable for persons eligible for medicare benefits under 42 USC 1395 to 1395zz. Medical assistance recipients are not liable for these costs. The department may require that a facility recover these costs from the appropriate agencies. The department may, by rule, require medicare certification under 42 USC 1395 to 1395zz, in whole or in part, of skilled nursing facilities. Any intermediate care facility or skilled nursing facility is subject to a fine of not less than $10 nor more than $100 for each day it refuses to recover costs or refuses to obtain the required certification.
(h)
The department may require by rule that all claims for payment of services provided facility residents under this subchapter be submitted or countersigned by the respective facility administrator. The department may specify those categories of services for which payment will be made only if the services are rendered or authorized in writing by a primary health care provider designated by the recipient for the particular category of services.
(i)
1.
On or after October 1, 1981, medical assistance payment for inpatient nursing care may only be provided for persons receiving skilled, intermediate, or limited levels of nursing care as these levels are defined under s. DHS 132.13, Wis. Adm. Code.
2.
Payment for personal or residential care is available for a person in a facility certified under 42 USC 1396 to 1396p only if the person entered a facility before the date specified in subd. 1. and has continuously resided in a facility since the date specified in subd. 1. If the person has a primary diagnosis of developmental disabilities or serious and persistent mental illness, payment for personal or residential care is available only if the person entered a facility on or before November 1, 1983.
(j)
The department may develop a separate rate of payment, under this subsection, for persons requiring intense skilled nursing care, as defined by the department.
(k)
Notwithstanding pars. (ag) to (b), (bp) and (br), the department may participate in a demonstration project on case mix nursing home reimbursement authorized under 42 USC 1315 (a) and may modify the payment system under this section, on an experimental basis, as necessary for participation in the demonstration project.
(L)
For purposes of s. 46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under s. 46.277 (5) (e).
(m)
To hold a bed in a facility, the department may pay the full payment rate under this subsection for up to 30 days for services provided to a person during the pendency of an undue hardship determination, as provided in s. 49.453 (8) (b) 3.
(6tw)
Payments to city health departments. From the appropriation account under s. 20.435 (7) (b), if the department selects the payment procedure under sub. (52) (a), the department may make payments to local health departments, as defined under s. 250.01 (4) (a) 3. Payment under this subsection to such a local health department may not exceed on an annualized basis payment made by the department to the local health department under s. 49.45 (6t), 2003 stats., for services provided by the local health department in 2002.
(6u)
Supplemental payments to certain facilities and care management organizations.
(ag)
In this subsection:
1.
“Care management organization" means a care management organization, as defined in s. 46.2805 (1), that contracts under s. 46.284 (4) (d) for provision of services with a facility that is established under s. 49.70 (2) or that is owned and operated by a city, village, or town.
2.
“Facility" has the meaning given in sub. (6m) (a) 3.
(am)
Notwithstanding sub. (6m), from the appropriations under s. 20.435 (4) (o), and (w), for reduction of operating deficits, as defined under the methodology used by the department in December 2000, incurred by a facility that is established under s. 49.70 (1) or that is owned and operated by a city, village, or town, and as payment to care management organizations, the department may not distribute to these facilities and to care management organizations more than $39,100,000 in each fiscal year, as determined by the department. The total amount that a county certifies under this subsection may not exceed 100 percent of otherwise-unreimbursed care. In distributing funds under this subsection, the department shall perform all of the following:
1.
Estimate the availability of federal medical assistance funds that may be matched to county funds or funds of a city, village or town for the reduction of operating deficits incurred by the facility.
2.
Based on the amount estimated available under subd. 1., develop a method to distribute this allocation to the individual facilities that have incurred operating deficits that shall include:
a.
Development of criteria for determining operating deficits.
b.
Agreement by the county in which is located the facility established under s. 49.70 (1) and agreement by the city, village, or town that owns and operates the facility that the applicable county, city, village, or town shall provide funds to match federal medical assistance matching funds under this paragraph.
bm.
Identification by the county in which is located the facility established under s. 49.70 (1) of all county funds expended in each calendar year to operate the facility, and certification by the county to the department of this amount.
c.
Consideration of the size of a facility's operating deficit.
3.
Distribute the allocation under the distribution method that is developed, unless a county has failed to comply with subd. 2. bm.
4.
If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) and (w) that result in a lesser allocation amount than that allocated under this paragraph, allocate not more than the lesser amount so approved by the federal department of health and human services.
5.
If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) and (w) that result in a lesser allocation amount than that allocated under this paragraph, submit a revision of the method developed under subd. 2. for approval by the joint committee on finance in that state fiscal year.
6.
If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds distributed under subd. 3., apply the requirements under sub. (6m) (br).
7.
If a facility that is otherwise eligible for an allocation of funds under this section is found by the federal health care financing administration or the department to be an institution for mental diseases, as defined under 42 CFR 435.1009, cease distributing to that facility funds under this section after the date on which the finding is made.
(b)
Notwithstanding the limitation on the amount of disbursements under par. (am) (intro.), from the appropriation under s. 20.435 (4) (wm), the department shall, using the criteria specified in par. (am) 1. to 7., disburse any federal medical assistance funds that are received by the state as federal financial participation for operating deficits incurred by a facility that is operated by a county, city, village, or town and that are in excess of the amount of federal financial participation anticipated and budgeted as revenue in the biennial budget act for the fiscal year in which the funds are received.
(6w)
Hospital operating deficit reduction. From the appropriation under s. 20.435 (4) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a hospital, as defined under s. 50.33 (2) (a) and (b), that is operated by the state, established under s. 49.71 or owned and operated by a city or village, the department shall allocate up to $3,300,000 in each fiscal year to these hospitals, as determined by the department, and shall perform all of the following:
(a)
For the reduction of operating deficits incurred by the hospital, estimate the availability of federal medicaid funds that may be matched to any of the following:
1.
State general purpose revenues, for a hospital operated by the state.
2.
County funds, for a hospital established under s. 49.71.
3.
Funds of a city or village, for a hospital owned and operated by a city or village.
(b)
Based on the amount estimated available under par. (a), develop a method to distribute this allocation to the individual hospitals that have incurred operating deficits that shall include:
1.
Development of criteria for determining operating deficits.
2.
With respect to funds to match federal medicaid matching funds under this section, any of the following, as applicable:
a.
Provision by the state of matching funds from general purpose revenues for a hospital operated by the state.
b.
Agreement to provide matching funds by the county in which is located a hospital established under s. 49.71.
c.
Agreement to provide matching funds by the city or village that owns and operates a hospital.
3.
Consideration of the size of a hospital's operating deficit.
(c)
Except as provided in par. (d), distribute the allocation under the distribution method that is developed.
(d)
If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) that result in a lesser allocation amount than that allocated under this subsection or disallows use of the allocation of federal medicaid funds under par. (c), reduce allocations under this subsection and distribute on a prorated basis, as determined by the department.
(6x)
Funding for essential access city hospital.
(a)
Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department shall distribute all of the following, except that the department may not allocate funds to a hospital to the extent that the allocation would exceed any limitation under 42 USC 1396b (i) (3):
1.
Not more than $2,997,700 in fiscal year 2011-12 and not more than $2,988,700 in each fiscal year after fiscal year 2011-12 to an essential access city hospital that has previously received the supplemental payment for being an essential access city hospital.
2.
Not more than $999,200 in fiscal year 2011-12 and not more than $996,200 in each fiscal year after fiscal year 2011-12 to a hospital that would qualify for an essential access city hospital supplemental payment, under the criteria described in the 2010-11 inpatient hospital state plan, except that the hospital did not meet the criteria to be an essential access city hospital during fiscal year 1995-96.
3.
If the federal department of health and human services allows the payment, $300,000 from the appropriation account under s. 20.435 (4) (b) annually to a hospital that meets all of the following criteria:
a.
The hospital is located in a city that has a municipal border that is also a state border.
b.
The hospital has a Medical Assistance recipient patient mix that consists of at least 25 percent of residents from a state that borders this state.
c.
The hospital is located in a city with a poverty level, as determined from the 2000 U.S. census, that is greater than 5 percent.
d.
The hospital is located in a city with a population of less than 15,000 people.
(b)
The department shall develop procedures for solicitation and review of requests for funds and a method to distribute the funds under par. (a) to an individual hospital that shall include establishment of criteria for the designation as an essential access city hospital.
(c)
Except as provided in par. (d), the department shall distribute the funds under par. (a) under the distribution method that is developed under par. (b).
(d)
If the federal department of health and human services approves for state expenditure in any state fiscal year amounts under s. 20.435 (4) (o) that result in a lesser distribution amount than that distributed under this subsection or disallows use of federal medicaid funds under par. (a), the department of health services shall reduce the distributions under this subsection.
(e)
The department need not promulgate as rules under ch. 227 the procedures, method of distribution and criteria required for distribution under this subsection.
(6y)
Supplemental funding for certain hospitals.
(a)
Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department may distribute funding in each fiscal year to provide supplemental payment to hospitals that enter into a contract under s. 49.02 (2) to provide health care services funded by a relief block grant, as determined by the department, for hospital services that are not in excess of the hospitals' customary charges for the services, as limited under 42 USC 1396b (i) (3). If no relief block grant is awarded under this chapter or if the allocation of funds to such hospitals would exceed any limitation under 42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into a contract under s. 49.02 (2).
(ap)
Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (o) and (xc), the department shall distribute not more than $8,000,000 in each fiscal year as supplemental payments to hospitals that satisfy the criteria established by the American College of Surgeons for classification as a Level I adult trauma center, except that the department may not make payments that exceed limitations based on customary charges under 42 USC 1396b (i) (3).
(ar)
Notwithstanding sub. (3) (e), the department may, from the appropriation account under s. 20.435 (4) (xc), make supplemental payments to hospitals based on hospital performance, in accordance with a payment methodology developed by the department, except that the department may not make payments that exceed limitations based on customary charges under 42 USC 1396b (i) (3).
(b)
The department need not promulgate as rules under ch. 227 the procedures, methods of distribution, and criteria required for distribution under par. (a).
(6z)
Supplemental funding for certain hospitals serving low-income patients.
(a)
Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department may distribute funding in each fiscal year to supplement payment for services to hospitals that enter into indigent care agreements, in accordance with the approved state plan for services under 42 USC 1396a, with relief agencies that administer the medical relief block grant under this chapter, if the department determines that the hospitals serve a disproportionate number of low-income patients with special needs. If no medical relief block grant under this chapter is awarded or if the allocation of funds to such hospitals would exceed any limitation under 42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into indigent care agreements. The department may not distribute funds under this subsection to the extent that the distribution would do any of the following:
1.
Be inconsistent with 42 USC 1396r-4 (c) (3).
2.
Exceed the limitation on payment under 42 USC 1396r-4 (f) (B) in any fiscal year.
(b)
The department need not promulgate as rules under ch. 227 the procedures, methods of distribution and criteria required for distribution under par. (a).
(7)
Personal funds.
(a)
Before July 1, 2024, a recipient who is a patient in a public medical institution or an accommodated person and has a monthly income exceeding the payment rates established under 42 USC 1382 (e) may retain $45 unearned income or the amount of any pension paid under 38 USC 5503 (d), whichever is greater, per month for personal needs. Beginning on July 1, 2024, the maximum amount of unearned income a recipient may retain per month under this paragraph is $55. Except as provided in s. 49.455 (4) (a), the recipient shall apply income in excess of the amount of any pension paid under 38 USC 5503 (d) or $55, whichever is greater, less any amount deducted under rules promulgated by the department, toward the cost of care in the facility.
(b)
Where a facility participating in the medical assistance program has been delegated in writing by a resident within that facility to manage and control the personal funds of the resident including but not limited to those funds identified in par. (a) the facility shall establish for the resident a personal fund account. All deposits and withdrawals of funds shall be documented by the facility to indicate the amount and date of deposit and amount, date and purpose of withdrawal. Such documentation shall be maintained in the resident's records.
(c)
Upon the removal of a resident from the facility as a result of death or permanent transfer, the facility shall transfer the balance of the resident's trust account to the personal representative of the resident's estate, the legal guardian of the resident or if appropriate to the resident personally. A copy of the trust account records shall be transferred with the funds. No facility or any of its employees or representatives may benefit from the distribution of a deceased resident's personal funds unless they are specifically named in the resident's will or constitute an heir at law.
(d)
1.
The department shall accept from any person a verified complaint concerning any violation of this subsection. The department shall forward to the accused within 10 days a copy of such complaint. The department, upon such investigation as it deems necessary, may dismiss the complaint or may find probable cause to believe that a violation of this subsection has occurred.
2.
If the department finds probable cause to believe that a violation of this subsection has occurred, it may assess a forfeiture of not less than $25 nor more than $500 for each occurrence, and in addition may order that any amount illegally charged against a resident's account be restored. The department shall immediately inform the complainant and respondent of any such decision and the amount of forfeiture or repayment, if any. If the department is not notified in writing that a party wishes to contest a decision within 15 working days after the parties are informed of such decision, the department's determination shall be deemed final and may not be appealed to a court.
3.
The department shall inform the nursing home administrators examining board of all decisions made under this paragraph.
4.
The department's determination of serious misconduct under this subsection shall be cause for terminating the facility's participation in the state-funded portion of the medical assistance program under this subchapter.
(e)
Nursing homes shall adopt a uniform accounting system prescribed by the department for purposes of managing residents personal fund accounts.
(8)
Per-visit limits on home health services reimbursement.
(a)
In this subsection:
2.
“Licensed practical nurse" has the meaning given in s. 146.40 (1) (c).
2m.
“Nurse aide" has the meaning given in s. 146.40 (1) (d).
3.
“Occupational therapist" has the meaning given in s. 448.96 (4).
4.
“Patient care visit" means a personal contact with a patient that is made by a registered nurse, licensed practical nurse, nurse aide, physical therapist, occupational therapist, or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under s. 49.46, 49.47, or 49.471. “Patient care visit" does not include time spent by a nurse, therapist, or nurse aide on case management, care coordination, travel, record keeping, or supervision that is related to the patient care visit.
5.
“Physical therapist" has the meaning given in s. 448.50 (3).
6.
“Registered nurse" has the meaning given in s. 146.40 (1) (f).
7.
“Speech-language pathologist" means an individual engaged in the practice of speech-language pathology, as regulated under ch. 459.
(b)
Reimbursement under s. 20.435 (4) (b), (gm), (o), and (w) for home health services provided by a certified home health agency or independent nurse shall be made at the home health agency's or nurse's usual and customary fee per patient care visit, subject to a maximum allowable fee per patient care visit that is established under par. (c).
(c)
The department shall establish a maximum statewide allowable fee per patient care visit, for each type of visit with respect to provider, that may be no greater than the cost per patient care visit, as determined by the department from cost reports of home health agencies, adjusted for costs related to case management, care coordination, travel, record keeping and supervision.
(8r)
Payment for certain obstetric and gynecological care. The rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in s. 36.60 (1) (cm), or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125 percent of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.
(8v)
Incentive-based pharmacy payment system. The department shall establish a system of payment to pharmacies for legend and over-the-counter drugs provided to recipients of medical assistance that has financial incentives for pharmacists who perform services that result in savings to the medical assistance program. Under this system, the department shall establish a schedule of fees that is designed to ensure that any incentive payments made are equal to or less than the documented savings. The department may discontinue the system established under this subsection if the department determines, after performance of a study, that payments to pharmacists under the system exceed the documented savings under the system.
(9)
Free choice. Any person eligible for medical assistance under s. 49.46, 49.468, 49.47, or 49.471 may use the physician, chiropractor, dentist, pharmacist, podiatrist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, podiatrist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, podiatrist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist, podiatrist, or dentist may be required to practice exclusively in the medical assistance program.
(9m)
Referrals. The department may, consistent with sub. (9), specify services for which reimbursement will be made only if the services are provided in accordance with a referral, in writing, which specifies the services to be rendered and the duration of such services. The referral form shall describe the referred services as required by the department.
(9p)
Prior authorization prohibited for wheelchair repairs.
(a)
In this subsection, “recipient of medical assistance" means an individual who receives medical assistance under any of the following:
1.
A program operated under this subchapter.
2.
A demonstration program operated under 42 USC 1315.
3.
A program operated under a waiver of federal law relating to medical assistance that is granted by the federal department of health and human services.
(b)
The department may not require any person to obtain prior authorization from the department for a repair to a wheelchair used by a recipient of medical assistance that satisfies the following criteria:
1.
If the repair is to a power wheelchair, the cost of the repair is less than $300.
2.
If the repair is to a manual wheelchair, the cost of the repair is less than $150.
3.
The cost of the repair is a covered benefit under the program of which the individual is a recipient.
(9r)
Complex rehabilitation technology.
(a)
In this subsection:
1.
“Complex needs patient" means an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation.
2.
“Complex rehabilitation technology" means items classified within Medicare as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. “Complex rehabilitation technology” includes complex rehabilitation manual and power wheelchairs, adaptive seating and positioning items, and other specialized equipment such as standing frames and gait trainers, power seat elevation or power standing components of power wheelchairs, as well as options and accessories related to any of these items.
3.
“Individually configured" means having a combination of sizes, features, adjustments, or modifications that a qualified complex rehabilitation technology supplier can customize to the specific individual by measuring, fitting, programming, adjusting, or adapting as appropriate so that the device operates in accordance with an assessment or evaluation of the individual by a qualified health care professional and is consistent with the individual's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
4.
“Medicare" means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395 et seq.
5.
“Qualified complex rehabilitation technology professional" means an individual who is certified as an assistive technology professional by the Rehabilitation Engineering and Assistive Technology Society of North America.
6.
“Qualified complex rehabilitation technology supplier" means a company or entity that meets all of the following criteria:
a.
Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology.
b.
Is an employer of at least one qualified complex rehabilitation technology professional to analyze the needs and capacities of the complex needs patient in consultation with qualified health care professionals, to participate in the selection of appropriate complex rehabilitation technology for those needs and capacities of the complex needs patient, and to provide training in the proper use of the complex rehabilitation technology.
c.
Requires a qualified complex rehabilitation technology professional to be physically present for the evaluation and determination of appropriate complex rehabilitation technology for a complex needs patient.
d.
Has the capability to provide service and repair by qualified technicians for all complex rehabilitation technology it sells.
e.
Provides written information at the time of delivery of the complex rehabilitation technology to the complex needs patient stating how the complex needs patient may receive service and repair for the complex rehabilitation technology.
7.
“Qualified health care professional" means any of the following:
a.
A physician licensed under subch. II of ch. 448.
b.
A physical therapist who is licensed under subch. III of ch. 448 or who holds a compact privilege under subch. XI of ch. 448.
NOTE: Subd. 7. b. is shown as affected by 2021 Wis. Acts 23 and 251 and as merged by the legislative reference bureau under s. 13.92 (2) (i). The cross-reference to subch. XI of ch. 448 was changed from subch. X of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. X of ch. 448.
c.
An occupational therapist who is licensed under subch. VII of ch. 448 or who holds a compact privilege under subch. XII of ch. 448.
NOTE: The cross-reference to subch. XII of ch. 448 was changed from subch. XI of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. XI of ch. 448.
d.
A chiropractor licensed under ch. 446.
e.
A physician assistant licensed under subch. IX of ch. 448.
NOTE: The cross-reference to subch. IX of ch. 448 was changed from subch. VIII of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. VIII of ch. 448.
(b)
The department shall promulgate rules and other policies for use of complex rehabilitation technology by recipients of Medical Assistance. The department shall include in the rules all of the following:
1.
Designation of billing codes as complex rehabilitation technology including creation of new billing codes or modification of existing billing codes. The department shall include provisions allowing quarterly updates to the designations under this subdivision.
2.
Establishment of specific supplier standards for companies or entities that provide complex rehabilitation technology and limiting reimbursement only to suppliers that are qualified complex rehabilitation technology suppliers.
3.
A requirement that Medical Assistance recipients who need a complex rehabilitation manual wheelchair, complex rehabilitation power wheelchair, or other complex rehabilitation seating component to be evaluated by all of the following:
a.
A qualified health care professional who does not have a financial relationship with a qualified complex rehabilitation technology supplier.
b.
A qualified complex rehabilitation technology professional.
4.
Establishment and maintenance of payment rates for complex rehabilitation technology that are adequate to ensure complex needs patients have access to complex rehabilitation technology, taking into account the significant resources, infrastructure, and staff needed to appropriately provide complex rehabilitation technology to meet the unique needs of complex needs patients.
5.
A requirement for contracts with the department that managed care plans providing services to Medical Assistance recipients comply with this subsection and the rules promulgated under this subsection.
6.
Protection of access to complex rehabilitation technology for complex needs patients.
(c)
This subsection is not intended to affect coverage of speech generating devices, including healthcare common procedure coding system codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, and E2599, under the Medical Assistance program.
(d)
When reviewing prior authorization requests for complex rehabilitation technology items, the department and managed care plans shall act within 10 working days of receiving complete, clinically relevant written documentation necessary to make a determination.
(e)
The department shall, consistent with this subsection and without imposing any additional requirements or restrictions under this subsection, reimburse a provider for a complex rehabilitation technology with prior authorization when prescribed by a physician, medically necessary, and used by a recipient of Medical Assistance who is a resident of a nursing home if the complex rehabilitation technology will do any of the following:
1.
Contribute to the recipient's independent completion of activities of daily living.
2.
Support the recipient's occupational, vocational, or psychosocial activities.
3.
Provide the recipient the independent ability to move about the facility or to attain or retain self-care.
(9s)
Disclosure. Any person who is an employee of, or an owner, partner, member, stockholder or investor in, any legal entity providing services which are reimbursed under this section, shall notify the department, on forms provided by the department for that purpose, if such person is an employee of, or an owner, partner, member, stockholder or investor in, any other legal entity providing services which are reimbursed under this section.
(10)
Rule-making powers and duties. The department is authorized to promulgate such rules as are consistent with its duties in administering medical assistance. The department shall promulgate a rule defining the term “part-time intermittent care" for the purpose of s. 49.46.
(11)
Penalty. Any person who receives or assists another in receiving assistance under this section, to which the recipient is not entitled, shall be subject to the penalties under ss. 946.91 and 946.93.
(12)
Machine-readable medical assistance cards.
(a)
The department shall assist the commissioner of insurance to conduct the study of health insurance identification cards under s. 601.57 (1).
(b)
If the commissioner of insurance promulgates rules under s. 601.57 (2) establishing a health insurance identification card system and its computerized support system, the department shall develop a plan to coordinate a system of machine-readable identification cards for medical assistance recipients with the systems established by the commissioner and shall submit the plan to the governor, and to the legislature under s. 13.172 (2), before issuing a request for proposals under par. (c).
(c)
The department shall request proposals for a system of machine-readable identification cards for medical assistance recipients and a computerized support system for the cards that will accept and respond to electronically conveyed requests from health care providers for information related to medical assistance recipients, such as eligibility, coverages and authorizations. The request for proposals shall specify that the systems are to be operating by January 1, 1997.
(13)
Financial reports.
(a)
The department may require service providers to prepare and submit cost reports or financial reports for purposes of rate certification under Title XIX, cost verification, fee schedule determination or research and study purposes. These financial reports may include independently audited financial statements which shall include balance sheets and statements of revenues and expenses. The department may withhold reimbursement or may decrease or not increase reimbursement rates if a provider does not submit the reports required under this paragraph or if the costs on which the reimbursement rates are based cannot be verified from the provider's cost or financial reports or records from which the reports are derived.
(b)
The department may require any provider who fails to submit a cost report or financial report under par. (a) within the period specified by the department to forfeit not less than $10 nor more than $100 for each day the provider fails to submit the report.
(15)
Community care organization project guarantee. Upon termination of the community care organization demonstration projects in Barron, La Crosse and Milwaukee counties, any client who was receiving services through any of those projects may continue to receive the full range of community care organization services. The cost of the services shall continue to be paid by medical assistance.
(15r)
Emergency medical transportation reimbursement. The department shall submit a state plan amendment to the federal department of health and human services to allow payment of supplemental reimbursements under the Medical Assistance program under this subchapter to public ambulance service providers, as defined in s. 256.01 (3), for ground emergency medical transportation through certified public expenditures. For purposes of this subsection, any ambulance service provider that is owned by any municipality or group of municipalities, regardless of whether or not the ambulance service provider is organized as a nonprofit corporation, is considered a public ambulance service provider. If the state plan amendment under this subsection is approved, the department shall pay to an ambulance service provider that complies with a certified public expenditure arrangement, as established by the department, a supplemental reimbursement equal to the amount of federal financial participation for ground emergency medical transportation services in accordance with state and federal law and regulations, except that the total reimbursement under the Medical Assistance program for the transportation may not exceed the actual cost to the ambulance service provider of providing the transportation. If the federal department of health and human services disapproves the state plan amendment, the department may not pay the supplement under this subsection.
(16)
Certification. On or after January 1, 1984, the department may only continue to certify as a medical assistance provider a community-based residential facility that is so certified on December 31, 1983. On or after January 1, 1984, no community-based residential facility may be certified for more beds than the number for which it was certified on December 31, 1983.
(18)
Recipient cost sharing.
(ac)
Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.
(ag)
Except as provided in pars. (am), (b), and (c), and subject to par. (d), a recipient specified in par. (ac) shall pay all of the following:
1.
A copayment of $1 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b).
2.
A copayment of $3 for each prescription of a drug that bears a brand name, as defined in s. 450.12 (1) (a).
(am)
1.
Except as provided in subd. 2., no person is liable under this subsection for services provided through prepayment contracts.
2.
A person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 is liable under this subsection for services provided through a prepayment contract in the amounts and according to the procedures specified by the department.
(b)
The following services are not subject to recipient cost sharing under this subsection:
1.
Any service provided to a person receiving care as an inpatient in a skilled nursing home or intermediate care facility certified under 42 USC 1396 to 1396k.
2.
Any service provided to a person who is less than 18 years old. This subdivision does not apply if the person's family income exceeds 100 percent of the poverty line and he or she is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.
3.
Any service provided under s. 49.46 (2) to a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy.
4.
Emergency services.
5.
Family planning services, as defined in s. 253.07 (1) (b).
6.
Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under s. 46.215 or 46.22.
7.
Home health services or, if a home health agency is unavailable, nursing services.
11.
Personal care services.
12.
Case management services.
(c)
The department may limit any medical assistance recipient's liability under this subsection for services it designates.
(d)
No person who designates a pharmacy or pharmacist as his or her sole provider of prescription drugs and who so uses that pharmacy or pharmacist is liable under this subsection for more than $12 per month for prescription drugs received.
(19)
Assigning medical support rights.
(a)
As a condition of eligibility for medical assistance, a person shall, notwithstanding other provisions of the statutes, be deemed to have assigned to the state, by applying for or receiving medical assistance, any rights to medical support or other payment of medical expenses from any other person, including rights to unpaid amounts accrued at the time of application for medical assistance as well as any rights to support accruing during the time for which medical assistance is paid.
(b)
If a person charged with the care and custody of a dependent child or children does not comply with the requirements of this subsection, the person is ineligible for medical assistance. In this case, medical assistance payments shall continue to be made on behalf of the eligible child or children.
(bm)
The department or the county department under s. 46.215 or 46.22 shall notify applicants of the requirements of this subsection at the time of application.
(c)
If the mother of a child was enrolled in a health maintenance organization or other prepaid health care plan under medical assistance at the time of the child's birth, birth expenses that may be recovered by the state under this subsection are the birth expenses incurred by the health maintenance organization or other prepaid health care plan.
(20)
Exemption from continuation requirements. An insurer, as defined in s. 632.897 (1) (d), with which the department contracts under sub. (2) (b) 2. for the provision of health care to medical assistance recipients is exempt from the continuation of group coverage requirements of s. 632.897 with regard to those recipients, their spouses and dependents.
(21)
Taking over provider's operation; repayments required.
(ag)
In this subsection, “take over the operation" means obtain, with respect to an aspect of a provider's business for which the provider has filed claims for medical assistance reimbursement, any of the following:
1.
Ownership of the provider's business or all or substantially all of the assets of the business.
2.
Majority control over decisions.
3.
The right to any profits or income.
4.
The right to contact and offer services to patients, clients, or residents served by the provider.
5.
An agreement that the provider will not compete with the person at all or with respect to a patient, client, resident, service, geographical area, or other part of the provider's business.
6.
The right to perform services that are substantially similar to services performed by the provider at the same location as those performed by the provider.
7.
The right to use any distinctive name or symbol by which the provider is known in connection with services to be provided by the person.
(ar)
Before a person may take over the operation of a provider that is liable for repayment of improper or erroneous payments or overpayments under ss. 49.43 to 49.497, full repayment shall be made. Upon request, the department shall notify the provider or the person that intends to take over the operation of the provider as to whether the provider is liable.
(b)
If, notwithstanding the prohibition under par. (ar), a person takes over the operation of a provider and the applicable amount under par. (ar) has not been repaid, the department may, in addition to withholding certification as authorized under sub. (2) (b) 8., proceed against the provider or the person. Within 30 days after the certified provider receives notice from the department, the amount shall be repaid in full. If the amount is not repaid in full, the department may bring an action to compel payment, may proceed under sub. (2) (a) 12., or may do both.
(c)
The department may enforce this subsection within 4 years following a transfer.
(d)
This subsection supersedes any provision of chs. 180, 181, 185, and 193.
(e)
The department shall promulgate rules to implement this subsection.
(22)
Medical assistance services provided by health maintenance organizations. If the department contracts with health maintenance organizations for the provision of medical assistance it shall give special consideration to health maintenance organizations that provide or that contract to provide comprehensive, specialized health care services to pregnant teenagers. If the department contracts with health maintenance organizations for the provision of medical assistance, the department shall determine which medical assistance recipients who have attained the age of 2 but have not attained the age of 6 and who are at risk for lead poisoning have not received lead screening from those health maintenance organizations. The department shall report annually to the appropriate standing committees of the legislature under s. 13.172 (3) on the percentage of medical assistance recipients under the age of 2 who received a lead screening test in that year provided by a health maintenance organization compared with the percentage that the department set as a goal for that year.
(23)
Assistance for childless adults demonstration project.
(a)
The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide health care coverage to adults who are under the age of 65, who have family incomes not to exceed 100 percent of the poverty line before application of the 5 percent income disregard under 42 CFR 435.603 (d), and who are not otherwise eligible for medical assistance under this subchapter, the Badger Care health care program under s. 49.665, or Medicare under 42 USC 1395 et seq.
(b)
If the waiver is granted and in effect, the department may promulgate rules defining the health care benefit plan, including more specific eligibility requirements and cost-sharing requirements. Cost sharing may include an annual enrollment fee, which may not exceed $75 per year. Notwithstanding s. 227.24 (3), the plan details under this subsection may be promulgated as an emergency rule under s. 227.24 without a finding of emergency. If the waiver is granted and in effect, the demonstration project under this subsection shall begin on the effective date of the waiver.
(d)
In determining income for purposes of eligibility under this subsection, the department shall apply s. 49.471 (7) (d) to the individual to the extent the federal department of health and human services approves, if approval is required.
(e)
The department shall apply the definition of family income under s. 49.471 (1) (f) and the regulations defining household under 42 CFR 435.603 (f) to determinations of income for purposes of eligibility under this subsection.
(f)
The department may provide services to individuals who are eligible under this subsection through a medical home initiative under sub. (24j).
(g)
The department shall submit to the secretary of the federal department of health and human services an amendment to the waiver requested under par. (a) that authorizes the department to do all of the following with respect to the childless adults demonstration project under this subsection:
1.
Impose monthly premiums as determined by the department.
2.
Impose higher premiums for enrollees who engage in behaviors that increase their health risks, as determined by the department.
3.
Require a health risk assessment for all enrollees.
4.
Limit an enrollee's eligibility under the demonstration project to no more than 48 months. The department shall specify the eligibility formula in the waiver amendment.
5.
Require, as a condition of eligibility, that an applicant or enrollee submit to a drug screening assessment and, if indicated, a drug test, as specified by the department in the waiver amendment.
6.
Provide employment and training services to childless adults receiving Medical Assistance under this subsection.
(23b)
Childless adults demonstration project reform waiver implementation required.
(a)
In this subsection:
1.
“Community engagement activity” includes any of the following:
a.
Work in exchange for money, goods, or services.
b.
Unpaid work, such as volunteer work or community service.
c.
Self-employment.
d.
Participation in a work, job training, or job search program, as approved by the department, including the employment and training program under s. 49.79 (9), the Wisconsin Works program under ss. 49.141 to 49.161, programs under the federal workforce innovation and opportunity act, and tribal work programs.
2.
“Exempt individual” means an individual who is any of the following:
a.
Receiving temporary or permanent disability benefits from the federal or state government or a private source.
b.
Determined by the department to be physically or mentally unable to work.
c.
Verified as unable to work in a statement from a social worker or other health care professional.
d.
Experiencing chronic homelessness.
e.
Serving as primary caregiver for a person who cannot care for himself or herself.
f.
Receiving or applying for unemployment compensation and complying with the work requirements for unemployment compensation.
g.
Participating regularly in an alcohol or other drug abuse treatment or rehabilitation program, except for alcoholics anonymous or narcotics anonymous but including cultural interventions specific to American Indian tribes or bands.
h.
Attending high school at least half time or enrolled in an institution of higher education, including vocational programs or high school equivalency programs, at least half time.
i.
Exempt from work requirements under the food stamp program under s. 49.79.
(b)
Beginning as soon as practicable after October 31, 2018, and ending no sooner than December 31, 2023, the department shall do all of the following with regard to the childless adults demonstration project under sub. (23):
1.
Require in each month persons, except exempt individuals, who are eligible to receive Medical Assistance under sub. (23) and who are at least 19 years of age but have not attained the age of 50 to participate in, document, and report 80 hours per calendar month of community engagement activities. The department, after finding good cause, may grant a temporary exemption from the requirement under this subdivision upon request of a Medical Assistance recipient.
2.
Require persons with incomes of at least 50 percent of the poverty line to pay premiums in accordance with par. (c) as a condition of eligibility for Medical Assistance under sub. (23).
3.
Require as a condition of eligibility for Medical Assistance under sub. (23) completion of a health risk assessment.
4.
Charge recipients of Medical Assistance under sub. (23) an $8 copayment for nonemergency use of the emergency department in accordance with 42 USC 1396o-1 (e) (1) and 42 CFR 447.54.
5.
Disenroll from Medical Assistance under sub. (23) for 6 months any individual who does not pay a required premium under subd. 2. and any individual who is required under subd. 1. to participate in a community engagement activity but who does not participate for 48 aggregate months in the community engagement activity.
(c)
1.
Persons who are eligible for the demonstration project under sub. (23) and who have monthly household income that exceeds 50 percent of the poverty line shall pay a monthly premium amount of $8 per household. A person who is eligible to receive an item or service furnished by an Indian health care provider is exempt from the premium requirement under this subdivision.
2.
The department may disenroll under par. (b) 5. a person for nonpayment of a required monthly premium only at annual eligibility redetermination after providing notice and reasonable opportunity for the person to pay. If a person who is disenrolled for nonpayment of premiums pays all owed premiums or becomes exempt from payment of premiums, he or she may reenroll in Medical Assistance under sub. (23).
3.
The department shall reduce the amount of the required household premium by up to half for a recipient of Medical Assistance under sub. (23) who does not engage in certain behaviors that increase health risks or who attests to actively managing certain unhealthy behaviors.
(d)
The department shall comply with any other requirements not specified elsewhere in this subsection that are imposed by the federal department of health and human services in its approval effective October 31, 2018.
(e)
Before December 31, 2023, the demonstration project requirements under this subsection may not be withdrawn and the department may not request from the federal government withdrawal, suspension, or termination of the demonstration project requirements under this subsection unless legislation has been enacted specifically allowing for the withdrawal, suspension, or termination.
(f)
The department shall comply with all applicable timing in and requirements of s. 20.940.
(24)
Primary care provider pilot. The department may request a waiver from the secretary of the federal department of health and human services under 42 USC 1396n (b) (1) to permit the establishment of a primary care provider pilot project. If the waiver is granted, the department may establish a primary care provider pilot project under which primary care providers act as case managers for medical assistance beneficiaries. If the department establishes a primary care provider pilot project, it shall reimburse a case manager for the allowable charges for case management services provided to a beneficiary participating in the pilot project.
(24g)
Physician practice payment pilot.
(a)
The department shall develop a proposal to increase medical assistance reimbursement to providers to which at least one of the following applies:
1.
The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
2.
The secretary determines that the provider performs well with respect to all of the following aspects of care:
a.
Adoption of written standards for patient access and patient communication.
b.
Use of data to show that standards for patient access and patient communication are satisfied.
c.
Use of paper or electronic charting tools to organize clinical information.
d.
Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
e.
Adoption and implementation of guidelines that are based on evidence for treatment and management of at least 3 chronic conditions.
f.
Active support of patient self-management.
g.
Systematic tracking of patient test results and systematic identification of abnormal patient test results.
h.
Systematic tracking of referrals using a paper or electronic system.
i.
Measuring the quality of the performance of the physician practice and of individual physicians within the practice, including with respect to provision of clinical services, patient outcomes, and patient safety.
j.
Reporting to members of the physician practice and to other persons on the quality of the performance of the physician practice and of individual physicians.
(c)
The department's proposal under par. (a) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or 2., and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than July 1, 2011.
(d)
The department shall submit the proposal under par. (a) to the joint committee on finance. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department's submittal that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal beginning January 1, 2010. If, within 14 working days after the date of the department's submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department may implement the proposal only upon approval of the committee. If the committee reviews the proposal and approves it, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal beginning January 1, 2010.
(e)
By October 1, 2012, the department shall, if it was required under par. (d) to increase reimbursement to providers that satisfy a condition under par. (a) 1. or 2., submit a report to the joint committee on finance on whether the increased reimbursement results in net cost reductions for the Medical Assistance program under this subchapter and a recommendation as to whether to continue the increased reimbursement. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department's submittal that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may implement its recommendation. If, within 14 working days after the date of the department's submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may discontinue the increased reimbursement only upon the approval of the committee.
(24j)
Medical home pilot projects.
(a)
The department may administer the medical home initiative as a service delivery mechanism to provide and coordinate care for individuals who are eligible for a Medical Assistance program under this subchapter that provides services under a fee-for-service model. The department may administer a medical home initiative to serve individuals who are members of any of the following populations:
1.
Children who are in out-of-home care or are receiving adoption assistance under 42 USC 670 to 679c.
2.
Pregnant women.
3.
Individuals who are exiting mental health facilities or correctional facilities.
4.
Individuals with a diagnosis of serious mental illness or substance abuse disorder.
5.
Adults with two or more chronic medical conditions.
6.
Other groups of individuals with conditions that the department determines would benefit from services through a medical home.
(b)
The department shall provide to individuals through any medical home initiative administered under this subsection the benefits described under s. 49.46 (2) (a) and (b). The department may provide to individuals though any medical home initiative administered under this subsection benefits in addition to the standard plan benefits that are targeted to the population receiving services through the medical home.
(c)
The department may elect to administer any medical home initiative under this subsection in a limited geographical area.
(d)
The department may make an all-inclusive payment to the provider offering services through a medical home.
(e)
If the federal department of health and human services approves the department's request to administer a medical home initiative, the department shall automatically enroll an individual who is eligible for a medical home initiative under this subsection in the medical home initiative. At any time after the first 6 months of enrollment in the medical home initiative, the individual who is enrolled in the medical home initiative may opt out of participation in the medical home initiative.
(24k)
Dental reimbursement pilot project.
(a)
1.
Subject to approval of the federal department of health and human services under par. (b), the department, as a pilot project, shall distribute moneys allocated in each fiscal year for the purpose of increasing the reimbursement rate under Medical Assistance for pediatric dental care and adult emergency dental services, as defined by the department, that are provided in Brown, Marathon, Polk, and Racine counties. If, after increasing the reimbursement rate for counties specified in this subdivision, the moneys allocated for this purpose exceed $100,000, the department shall increase the reimbursement rate under Medical Assistance for pediatric dental care and adult emergency dental services in other counties, as determined by the department, where Medical Assistance recipients have the greatest need for pediatric dental care and adult emergency dental services.
2.
For dental services provided on a fee-for-service basis as of July 1, 2015, the reimbursement rate increase specified in subd. 1. shall be distributed on a fee-for-service basis. For dental services provided as of July 1, 2015, by a health maintenance organization that contracts with the department to provide Medical Assistance services at a capitated rate, the department shall distribute the reimbursement rate increase under subd. 1. to the health maintenance organization. The department shall include in a contract with a health maintenance organization that provides dental services described in subd. 1. in the counties specified in subd. 1. a requirement that the health maintenance organization reimburse providers of services in accordance with the reimbursement rate increase pilot project under subd. 1. The department may not distribute the reimbursement rate increase under subd. 1. to federally qualified health centers that receive a grant under 42 USC 254b.
(b)
The department shall request any waiver from and submit any amendments to the state Medical Assistance plan to the federal department of health and human services necessary for the reimbursement rate increase pilot project under par. (a). If any necessary waiver request or state plan amendment request is approved, the department shall implement par. (a) beginning on the effective date of the waiver or plan amendment.
(c)
No later than January 1, 2020, and biennially thereafter, the department shall submit a report to the chief clerk of each house of the legislature under s. 13.172 (2), each standing committee of the legislature with jurisdiction over health or public benefits under s. 13.172 (3), and the joint committee on finance that includes all of the following information on the pilot project under this subsection:
1.
The number of Medical Assistance recipients who received services under the pilot program in total and specified by those who received pediatric care and who received adult emergency dental services.
2.
An estimate of the potential reduction in health care costs and emergency department use by Medical Assistance recipients due to the pilot project.
3.
The feasibility of continuing the pilot project and expanding the project in specific areas of the state or statewide.
4.
The amount of moneys distributed under the pilot project and, if moneys allocated for the pilot project were not distributed, a summary on why the moneys were not distributed.
5.
An analysis of Medical Assistance recipient populations who received services under the pilot project and populations who may benefit from the pilot project.
(24m)
Home health care and personal care pilot program.
From the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), in order to test the feasibility of instituting a system of reimbursement for providers of home health care and personal care services for medical assistance recipients that is based on competitive bidding, the department shall:
(a)
By September 1, 1990, select a county in this state and solicit bids from providers of home health care and personal care services in that county for the provision, on a contractual basis, of home health and personal care services authorized under ss. 49.46 (2) (a) 4. d. and (b) 6. j. and 49.47 (6) (a) 1.
(b)
Award contracts for the provision of home health care and personal care services from the bids received under par. (a) only if the department determines that the contracts would result in a lower cost alternative to fee-for-service reimbursement.
(24n)
Reimbursement for dental services by facilities serving individuals with disabilities.
(a)
Subject to approval of the federal department of health and human services under par. (b), the department shall distribute moneys in each fiscal year to increase the Medical Assistance reimbursement rates for all eligible dental services rendered by facilities that provide at least 90 percent of their dental services to individuals with cognitive and physical disabilities, as determined by the department. Under this subsection, the enhanced reimbursement rates for dental services would equal 200 percent of the Medical Assistance reimbursement rates that would otherwise be paid for these dental services.
(b)
The department shall request any waiver from and submit any amendments to the state Medical Assistance plan to the federal department of health and human services necessary for the Medical Assistance reimbursement rate increase under par. (a). If any necessary waiver request or state plan amendment request is approved, the department shall implement par. (a) beginning on the effective date of the waiver or plan amendment.
(24s)
Family planning project.
(a)
The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to provide optional services for family planning, as defined in s. 253.07 (1) (a), under medical assistance [to any female between the ages of 15 and 44 whose family income does not exceed 200 percent of the poverty line for a family the size of the female's family]. The department shall implement any waiver granted.
NOTE:  Par. (a) was created by 2011 Wis. Act 32, s. 1441b, eff. 7-1-11 and amended by 2011 Wis Act 32, s. 1441bg, eff. 1-1-15. Although the language in brackets was removed from the creation of par. (a) in s. 1441b by the governor's partial veto, the amendment by s. 1441bg of par. (a) does not reflect the removal of that language.
(b)
The department shall request a waiver, or an amendment to the waiver requested under par. (a), from the secretary of the federal department of health and human services to require all of the following:
1.
As a condition of receiving services under par. (a), parental notification for family planning services for any female under 18 years of age.
2.
The department to determine eligibility to receive family planning services under par. (a) for a female under 18 years of age using the family income of the female's parent or guardian instead of only the female's income.
(25)
Case management services.
(a)
In this subsection, “severely emotionally disturbed child" means an individual under 21 years of age who has emotional and behavioral problems that:
1.
Are severe in degree;
2.
Are expected to persist for at least one year;
3.
Substantially interfere with the individual's functioning in his or her family, school or community and with his or her ability to cope with the ordinary demands of life; and
4.
Cause the individual to need services from 2 or more agencies or organizations that provide social services or services or treatment for mental health, juvenile justice, child welfare, special education or health.
(am)
Except as provided under pars. (be), (bg), and (bj) and sub. (24), case management services under s. 49.46 (2) (b) 9. and (bm) are reimbursable under Medical Assistance only if provided to a Medical Assistance beneficiary who receives case management services from or through a certified case management provider in a county, city, village, or town that elects, under par. (b), to make the services available and who meets at least one of the following conditions:
1.
Has a developmental disability, as defined under s. 51.01 (5) (a).
2.
Has a serious and persistent mental illness.
3.
Has Alzheimer's disease, as defined under s. 46.87 (1) (a).
4.
Is an alcoholic, as defined under s. 51.01 (1).
5.
Is drug dependent, as defined under s. 51.01 (8b).
6.
Is physically disabled, as defined by the department.
7.
Is a severely emotionally disturbed child.
8.
Is age 65 or over.
9.
Is a member of a family that has a child who is at risk of serious physical, mental or emotional dysfunction, as defined by the department.
10.
Has HIV infection, as defined in s. 252.01 (2).
11.
Is a child who is eligible for early intervention services under s. 51.44.
12.
Is infected with tuberculosis.
13.
Is a child with asthma.
14.
Is a woman who is aged 45 to 64 and who is not a resident of a nursing home or otherwise receiving case management services under this paragraph.
(b)
A county, city, village, town or, in a county having a population of 750,000 or more, the department may elect to make case management services under this subsection available in the county, city, village or town to one or more of the categories of beneficiaries under par. (am) through the medical assistance program. A county, city, village, town or, in a county having a population of 750,000 or more, the department that elects to make the services available shall reimburse a case management provider for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government.
(be)
A private nonprofit agency that is a certified case management provider may elect to provide case management services to medical assistance beneficiaries who have HIV infection, as defined in s. 252.01 (2). The amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.435 (1) (am).
(bg)
An independent living center, as defined in s. 46.96 (1) (ah), that is a certified case management provider and satisfies the criteria in s. 46.96 (3m) (a) 1. to 3. and (am) may elect to provide case management services to one or more of the categories of medical assistance beneficiaries specified under par. (am). The amount of allowable charges for the services under the medical assistance program that is not provided by the federal government shall be paid from nonfederal, public funds received by the independent living center from a county, city, village or town or from funds distributed as a grant under s. 46.96.
(bj)
The department of corrections may elect to provide case management services under this subsection to persons who are under the supervision of that department under s. 938.183, 938.34 (4h), or 938.357 (3) or (4), who are Medical Assistance beneficiaries, and who meet one or more of the conditions specified in par. (am). The amount of the allowable charges for those services under the Medical Assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.410 (3) (hm), (ho), or (hr).
(bm)
Case management services under this subsection may not be provided to a person under par. (am) 7. unless any of the following is true:
1.
A team of mental health experts appointed by the case management provider determines that the person is a severely emotionally disturbed child. The team shall consist of at least 3 members. The case management provider shall appoint at least one member of the team who is a licensed psychologist or a physician specializing in psychiatry. The case management provider shall appoint at least 2 members of the team who are members of the professions of school psychologist, school social worker, registered nurse, social worker, child care worker, occupational therapist or teacher of emotionally disturbed children. The case management provider shall appoint as a member of the team at least one person who personally participated in a psychological evaluation of the child.
2.
Individuals who are designated by the coordinating committee have, or a service coordination agency has, determined under s. 46.56 (8) (d) that the person is a child, as defined in s. 46.56 (1) (bm), with emotional and behavioral disabilities.
(c)
Except as provided in pars. (b), (be), (bg), and (bj), the department shall reimburse a provider of case management services under this subsection only for the amount of the allowable charges for those services under the Medical Assistance program that is provided by the federal government.
(d)
This subsection does not apply to case management services provided under sub. (15) or s. 49.46 (2) (a) 2. or through a community support program under s. 49.46 (2) (b) 6. L.
(25g)
HIV care coordination.
(a)
In this subsection, “care coordination" includes coordination of outpatient medical care, specialty care, inpatient care, dental care, and mental health care and medical case management.
(b)
The department shall develop a proposal to increase medical assistance reimbursement to each provider that receives a grant under s. 252.12 (2) (a) 8. and to which at least one of the following applies:
1.
The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
2.
The secretary determines that the provider performs well with respect to all of the following aspects of care:
a.
Adoption of written standards for patient access and patient communication.
b.
Use of data to show that standards for patient access and patient communication are satisfied.
c.
Use of paper or electronic charting tools to organize clinical information.
d.
Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
e.
Adoption and implementation of guidelines that are based on evidence for treatment and management of HIV-related conditions.
f.
Active support of patient self-management.
g.
Systematic tracking of patient test results and systematic identification of abnormal patient test results.
h.
Systematic tracking of referrals using a paper or electronic system.
i.
Measuring the quality of the performance of the provider and of individuals who perform services on behalf of the provider, including with respect to provision of clinical services, patient outcomes, and patient safety.
j.
Reporting to employees and contractors of the provider and to other persons on the quality of the performance of the provider and of individuals who perform services on behalf of the provider.
(c)
The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (b) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011.
(d)
The department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal under par. (b) beginning January 1, 2011.
(e)
A provider may not seek medical assistance reimbursement under this subsection and sub. (25) (be) for the same services.
(26)
Managed care system. The department shall study alternatives for a system to manage the usage of alcohol and other drug abuse services, including day treatment services, provided under the medical assistance program. On or before September 1, 1988, the department shall submit a plan for a medical assistance alcohol and other drug abuse managed care system to the joint committee on finance. If the cochairpersons of the committee do not notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan within 14 working days after the date of the department's submittal, the department may implement the plan. If within 14 working days after the date of the department's submittal the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan, the department may not implement the plan until it is approved by the committee, as submitted or as modified. If a waiver from the secretary of the federal department of health and human services is necessary to implement the proposed plan, the department of health services may request the waiver, but it may not implement the waiver until it is authorized to implement the plan, as provided in this subsection.
(26g)
Intensive care coordination program.
(a)
Subject to par. (i), the department shall create and implement a program to reimburse participating hospitals and health care systems for intensive care coordination services provided to recipients of Medical Assistance under this subchapter who are not enrolled in coverage under Medicare, 42 USC 1395 et seq.
(b)
To apply to participate in the reimbursement program under this subsection, a hospital or health care system shall submit to the department a description of its intensive care coordination program that includes all of the following:
1.
A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.
2.
The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.
3.
A description of the hospital's or health care system's intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.
4.
A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care:
a.
Discharge instructions and contacts for following up on care and treatment.
b.
Referral information.
c.
Appointment scheduling.
d.
Medication instructions.
e.
Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization.
f.
Information about other health and social resources, such as transportation and housing.
5.
A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization.
6.
The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.
(c)
The department shall do all of the following:
1.
Encourage, but not require, any hospital or health care system that seeks to apply to participate in the reimbursement program under this subsection to collaborate with any managed care organization with which it has an agreement to provide services to Medical Assistance recipients. The department may not limit patient populations eligible to participate in the intensive care coordination program under this subsection to either those individuals enrolled in managed care to receive Medical Assistance services or those individuals currently receiving Medical Assistance services on a fee-for-service basis. The department may not deny a hospital or health care system applicant for the reimbursement program under this subsection solely because the applicant does not have an agreement to implement an intensive care coordination program with a managed care organization.
2.
Respond to the hospital or health care system indicating whether additional information is required to evaluate the application for the reimbursement program under this subsection.
3.
After consulting with hospitals, health care systems, and other providers, develop uniform outcome measures to use in determining the efficacy of the program.
4.
If the hospital or health care system is selected for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement.
5.
If the department does not receive a proposal for the reimbursement program under this subsection, solicit proposals for the reimbursement program under this subsection from other health care providers under s. 146.81 (1).
(d)
The department shall provide as reimbursement for intensive care coordination to participants in the program under this subsection $250 initially for each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the hospital or health care system enrolls in intensive care coordination. The initial enrollment for each recipient lasts for 6 months, and if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population, the participant receives an additional $250 for each enrollee at the end of the 6 months. The program participant may enroll each Medical Assistance recipient in one additional 6-month period for an additional $250 per enrollee initial reimbursement payment and $250 per enrollee at the end of the additional 6-month period if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population. The department shall pay no more than $1,500,000 cumulatively in each fiscal year from all funding sources for reimbursements under this paragraph.
(e)
Annually, each hospital and health care system that is participating in the reimbursement program under this subsection shall submit a report to the department containing all of the following:
1.
The number of Medical Assistance recipients served by intensive care coordination.
2.
For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination.
3.
Any demonstrated outcomes, as specified by the department under par. (c) 3., for Medical Assistance recipients.
4.
Any other information required by the department.
(f)
For each hospital or health care system eligible for the reimbursement program under this subsection, the department shall calculate the costs saved to the Medical Assistance program by avoiding emergency department visits by subtracting the sum of reimbursements made under par. (d) to the participant from the sum of costs of visits to the emergency department as reported under par. (e) 2. that were expected to occur without intensive care coordination but did not because of enrollment in the program under this subsection. If the result of the calculation is positive in the first 6 months of the recipient's enrollment in the program under this subsection, the department shall distribute 25 percent of the amount saved to the hospital, health care system, or managed care organization subject to pars. (g) and (i). If the result of the calculation is positive after 12 months of the recipient's enrollment in the program under this subsection, the department shall distribute a share of the savings to the hospital, health care system, or managed care organization such that the total amount of shared savings payments made equals half of the savings for the entire 12-month period, subject to pars. (g) and (i).
(g)
If a hospital or health care system participating in the program under this subsection provides services to Medical Assistance recipients enrolled in managed care, the department shall make any payment under the program under this subsection under par. (d) or (f) to the managed care organization with which the hospital or health care system has an agreement to provide services to Medical Assistance recipients. The managed care organization shall pass the payments made under pars. (d) and (f) on to the hospital or health care system no later than 30 days after receiving the payment from the department. The department shall make payments under pars. (d) and (f) to a hospital or health care system that provides services to Medical Assistance recipients who are not enrolled in managed care directly to the hospital or health care system.
(h)
No later than 24 months after the date on which the first hospital or health care system is able to enroll individuals in the intensive care coordination program under this subsection, the department shall submit a report to the joint committee on finance summarizing the information reported under par. (e) including the costs saved by avoiding emergency department visits as calculated under par. (f).
(i)
The department shall seek any necessary approval from the federal department of health and human services to implement the program under this subsection. If the federal department of health and human services disapproves the request for approval, the department may implement the reimbursement under par. (d), the savings distribution under par. (f), or both or any part of the program under this subsection.
(j)
If the federal department of health and human services does not disapprove a request for approval under par. (i) or if federal approval is not required, the department shall implement at least 2 pilot programs under this subsection by the later of September 1, 2018, or the date that is 30 days after the date of federal approval, if approval is needed.
(27)
Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v).
(29)
Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46, 49.47, and 49.471.
(29w)
Mental health services. In providing mental health benefits under this subchapter, the department shall do all of the following:
(a)
Allow a severely emotionally disturbed child, as defined in sub. (25) (a), to access in-home therapy without having to show a failure to succeed in outpatient therapy.
(b)
Allow qualifying families to participate in in-home therapy even if a child in that family is enrolled in a day treatment program.
(29x)
Emergency detention transport reimbursement.
(a)
Subject to par. (b), the department shall provide reimbursement as provided under s. 49.46 (2) (b) 3. to counties for transport of individuals who are recipients of medical assistance for purposes of emergency detention under s. 51.15 (2) as provided under s. 51.15 (2) (e). The department shall establish criteria that any 3rd-party vendor that is not a law enforcement agency or ambulance service provider must meet in order for the county to obtain reimbursement for transport provided by that 3rd-party vendor under the Medical Assistance program.
(b)
The department shall request any necessary federal approval required to provide reimbursement under par. (a), and, if approval is granted or if no federal approval is required, the department shall provide reimbursement as provided under par. (a). If federal approval is necessary but not granted, the department may not provide reimbursement under par. (a).
(29y)
Mental health consultation reimbursement.
(a)
In this subsection:
1m.
“Clinical consultation" means, for a student up to age 21, communication from a mental health professional or a qualified treatment trainee working under the supervision of a mental health professional to another individual who is working with the client or to a parent of the student to inform, inquire, and instruct regarding all of the following and to direct and coordinate clinical service components:
a.
The client's symptoms.
b.
Strategies for effective engagement, care, and intervention for the client.
c.
Treatment expectations for the client across service settings.
2m.
“Parent” means any of the following:
a.
A parent.
b.
A foster parent.
c.
A guardian.
d.
A relative, other than a parent, who lives with the student.
(b)
The department shall, subject to any approval necessary from the federal department of health and human services, reimburse clinical consultation from the Medical Assistance program under this subchapter.
(29z)
Buprenorphine prior authorization review. The department shall review its prior authorization policy on buprenorphine-containing products provided to Medical Assistance program recipients. On November 1, 2018, and every 6 months thereafter, the department shall submit to the standing committees of the legislature with jurisdiction over health under s. 13.172 (3) a report describing the department's findings on the prior authorization policy on buprenorphine-containing products and its progress on eliminating prior authorization requirements for buprenorphine-containing products in populations where removal of prior authorization is appropriate. The department is not required to submit the report under this subsection after the date the prior authorization requirement for use of buprenorphine-containing products by Medical Assistance program recipients is eliminated for all appropriate populations.
(30)
Services provided by community support programs.
(a)
A county shall provide the portion of the cost of services under s. 49.46 (2) (b) 6. L. that is not provided by the federal government.
(b)
The department shall reimburse a provider of services under s. 49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.
(30c)
Licensed treatment professionals. To the extent allowable by the federal department of health and human services, the department shall certify and reimburse under the Medical Assistance program under this subchapter licensed treatment professionals, as defined in s. 51.03 (6) (a), for mental health services provided at a school regardless of whether the school site is designated as a clinic office and regardless of whether the licensed treatment professional is employed by, a contractor of, or affiliated with a clinic. The department shall seek any approval necessary from the federal department of health and human services to provide reimbursement to licensed treatment professionals under this subsection.
(30e)
Community-based psychosocial service programs.
(a)
When services are reimbursable. Services under s. 49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
1.
Reimbursement for the services under s. 49.46 (2) (b) 6. Lm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
2.
The county in which the individual resides elects to make the services under s. 49.46 (2) (b) 6. Lm. available in the county through the medical assistance program.
3.
The individual's psychosocial health needs require more than outpatient counseling, but less than the services provided by a community support program under s. 51.421.
4.
The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under par. (b) 3.
5.
Any other condition required by rule under par. (b) 4. is satisfied.
(b)
Rules. The department shall promulgate rules regarding all of the following:
1.
Standards for determining whether an individual is eligible under par. (a) 3.
2.
The scope of psychosocial services that may be provided under s. 49.46 (2) (b) 6. Lm.
3.
Requirements for certification of community-based psychosocial service programs.
4.
Any other conditions for coverage of community-based psychosocial services under the Medical Assistance Program.
(c)
Provider reimbursement. A county that elects to make the services under s. 49.46 (2) (b) 6. Lm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
(d)
Provision of services on regional basis. Notwithstanding par. (c) and subject to par. (e), in counties that elect to deliver the services under s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to criteria established by the department, the department shall reimburse a provider of the services for the amount of the allowable charges for those services under the Medical Assistance program that is provided by the federal government and for the amount of the allowable charges that is not provided by the federal government.
(e)
Report; release of funds.
1.
Prior to implementing, and receiving funding for implementing, the regional basis provision of services under par. (d), the department shall submit to the joint committee on finance, no later than March 1, 2014, a request for the release of funds and a report on its proposal for implementation that includes all of the following:
a.
A description of the criteria that the department will apply in its regionalization model.
b.
A description of how the regions will be established and the degree of county participation in that process.
c.
An updated list of the counties that have indicated, by the date of the report, that they will offer the services under s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to the criteria established by the department.
d.
An evaluation of the estimated long-term costs of the proposed regional model.
2.
If the cochairpersons of the committee do not notify the department within 14 working days after the date that the department submits the report and the funding request that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released and the department may implement its proposal for the regional basis provision of services on July 1, 2014. If, within 14 working days after the date that the department submits the report and the funding request, the cochairpersons notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released, and the department may implement its proposal for the regional basis provision of services, only upon approval of the committee.
(30f)
Psychotherapy and alcohol and other drug abuse services. The department shall include licensed mental health professionals, as defined in s. 632.89 (1) (dm), and psychologists as providers of psychotherapy and of alcohol and other drug abuse services. Except for services provided under sub. (30e), the department may not require that licensed mental health professionals or licensed psychologists be supervised; may not require that clinical psychotherapy or alcohol and other drug abuse services be provided under a certified program; and, notwithstanding subs. (9) and (9m), may not require that a physician or other health care provider first prescribe psychotherapy or alcohol and other drug abuse services to be provided by a licensed mental health professional or licensed psychologist before the professional or psychologist may provide the services to the recipient. This subsection does not affect the department's powers under ch. 50 or 51 to establish requirements for facilities that are licensed, certified, or operated by the department.
(30g)
Community recovery services.
(a)
When services are reimbursable. Community recovery services under s. 49.46 (2) (b) 6. Lo. provided to an individual are reimbursable under the Medical Assistance program only if all of the following conditions are met:
1.
An approved amendment to the state medical assistance plan permits reimbursement for the services under s. 49.46 (2) (b) 6. Lo. in the manner provided under this subsection.
2.
The county in which the individual resides elects to provide the community recovery services under s. 49.46 (2) (b) 6. Lo. through the Medical Assistance program.
3.
The individual, the community recovery services, and the community recovery services provider meet any condition set forth in the approved amendment to the medical assistance plan.
(b)
Limit on the amount of reimbursement. If community recovery services are reimbursable under par. (a), the department shall reimburse each participating county for the portion of the federal share of allowable charges for the community recovery services provided by the county that exceeds that county's proportionate share of $600,000 in fiscal year 2010-2011 and for 95 percent of the federal share of allowable charges for the community recovery services provided by the county in each fiscal year thereafter. The portion of the federal share of allowable charges not reimbursed to counties shall be transferred to the appropriation account under s. 20.435 (5) (kx).
(30j)
Reimbursement for peer recovery coach services.
(a)
In this subsection:
1.
“Competent mental health professional” means a physician who has completed a residence in psychiatry; a psychologist; a private practice school psychologist licensed under ch. 455; a marriage and family therapist licensed under s. 457.10 or 457.11; a professional counselor licensed under s. 457.12 or 457.13; an advanced practice social worker granted a certificate under s. 457.08 (2); an independent social worker granted a certificate under s. 457.08 (3); a clinical social worker licensed under s. 457.08 (4); a clinical substance abuse counselor or independent clinical supervisor certified under s. 440.88, or any of these individuals practicing under a currently valid training or temporary license or certificate granted under applicable provisions of ch. 457. “Competent mental health professional" does not include an individual whose license or certificate is suspended, revoked, or voluntarily surrendered, or whose license or certificate is limited or restricted, when practicing in areas prohibited by the limitation or restriction.
2.
“Peer recovery coach” means an individual who practices in the recovery field and who provides support and assistance to individuals who are in treatment or recovery from mental illness or a substance use disorder.
(b)
The department shall reimburse under the Medical Assistance program under this subchapter any service provided by a peer recovery coach if the service satisfies all of the following conditions:
1.
The recipient of the service provided by a peer recovery coach is in treatment for or recovery from mental illness or a substance use disorder.
2.
The peer recovery coach provides the service under the supervision of a competent mental health professional who has been trained in all of the following subjects:
a.
Understanding the peer role in recovery and supporting clear and meaningful peer roles.
b.
Recovery orientation.
c.
Model principles of recovery.
d.
Training of peer recovery coaches.
e.
Professional health system navigation.
f.
Applicable laws and policies.
g.
Community resources.
h.
Quality, strength-based, and person-centered supervision.
i.
Identification and evaluation of peer competencies.
j.
Confidentiality, ethics, and professional boundaries.
k.
Antidiscrimination in employment, staff development, and employment practices.
L.
Peer-delivered services advocacy.
3.
The peer recovery coach provides the service in coordination with the Medical Assistance recipient's individual treatment plan and in accordance with the recipient's individual treatment goals.
4.
The peer recovery coach providing the service has completed all of the following training requirements, as established by the department by rule, after consulting with members of the recovery community:
a.
Forty hours of training in advocacy, mentoring and education, recovery and wellness support, and ethical responsibility that includes training of at least 10 hours in advocacy, at least 10 hours in mentoring and education, at least 10 hours in recovery and wellness support, and at least 10 hours in ethical responsibility.
b.
Twenty-four hours of supervised volunteer or paid work experience involving advocacy, mentoring and education, recovery and wellness support, ethical responsibility, or a combination of those areas.
(c)
The department shall certify under Medical Assistance peer recovery coaches to provide services in accordance with this subsection.
(d)
The department shall request from the federal department of health and human services any waiver of federal Medicaid law, state plan amendment, or other federal approval necessary to implement this subsection and s. 49.46 (2) (b) 14p.
(30m)
Certain services for developmentally disabled.
(a)
Except as provided in par. (am), a county shall provide the portion of payment that is not provided by the federal government for all of the following services to individuals with developmental disability who are eligible for medical assistance:
1.
Services under s. 51.06 (1m) (d).
2.
Services in an intermediate care facility for persons with an intellectual disability, as defined in s. 46.278 (1m) (am), other than a state center for the developmentally disabled.
3.
Services for which payment is permitted under sub. (6c) (d) 2. that are provided in a nursing facility, as defined in s. 46.279 (1) (c).
(am)
1.
The department shall provide the portion of the payment that is not provided by the federal government for any of the services specified in par. (a) 1. to 3. that are provided to an individual with developmental disability who is eligible for medical assistance, as determined under the contract under s. 46.279 (4m).
2.
For individuals receiving the family care benefit under s. 46.286, the care management organization that manages the family care benefit for the recipient shall pay the portion of the payment that is not covered by the federal government for services that are described under par. (a) 1. and are covered services under the family care benefit; the department shall pay the remainder of the portion of the payment that is not covered by the federal government.
(b)
No payment under this section may be made for services specified under par. (a) or (am) unless the individual who receives the services is provided protective placement under s. 55.06 (9) (a), 2003 stats., or s. 55.12, is provided emergency protective services under s. 55.05 (4), 2003 stats., or s. 55.13, or is provided an emergency protective placement under s. 55.06 (11) (a), 2003 stats., or s. 55.135 or a temporary protective placement under s. 55.06 (11) (c), 2003 stats., or s. 55.135 (5) or 55.055 (5).
(c)
No payment under this section may be made for services specified under par. (a) 2. or 3. that are provided to an individual who was placed in or admitted to an intermediate facility, as defined in s. 46.279 (1) (b), or nursing facility, as defined in s. 46.279 (1) (c), unless one of the following applies:
1.
Any placement or admission that is made after April 30, 2005, complied with the requirements of s. 46.279.
2.
For an individual who was provided protective placement under ch. 55 at any time, any annual review that is conducted under s. 55.18 (1) (a) (intro.) after April 30, 2005, complies with the requirements of s. 55.18 (1) (ar).
(30r)
Services in a mental health institute. A county shall provide the portion of payment that is not provided by the federal government for services under s. 49.46 (2) (b) 6. e. in a mental health institute under s. 51.05.
(30x)
Licensed midwife services.
(a)
Provider reimbursement. Beginning January 1, 2016, services under s. 49.46 (2) (b) 12t. provided to an individual are reimbursable under the Medical Assistance program if an amendment to the state medical assistance plan approved by the federal department of health and human services permits reimbursement under s. 49.46 (2) (b) 12t.
(b)
Plan amendment. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of par. (a). The department may not pay reimbursement under par. (a) unless the amendment to the state plan allowing reimbursement under s. 49.46 (2) (b) 12t. is approved and in effect.
(31)
Long-Term Care Partnership Program.
(a)
The department shall submit to the federal department of health and human services, not later than 3 months after October 27, 2007, an amendment to the state medical assistance plan that establishes in this state a Long-Term Care Partnership Program, as described in this subsection, and shall implement the program if the amendment to the state plan is approved. Under the program, the department shall exclude an amount equal to the amount of benefits that an individual receives under a qualifying long-term care insurance policy, as described in par. (b), when determining any of the following:
1.
The individual's resources for purposes of determining the individual's eligibility for medical assistance.
2.
The amount to be recovered from the individual's estate if the individual receives medical assistance.
(b)
To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:
1.
The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.
2.
The policy meets the definition of a qualified long-term care insurance policy under 26 USC 7702B (b).
3.
The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in 42 USC 1396p (b) (5).
4.
The policy includes the applicable inflation protection specified in 42 USC 1396p (b) (1) (C) (iii) (IV).
5.
The commissioner of insurance certifies to the department that the policy meets the criteria under subds. 2. to 4.
(c)
1.
The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.
2.
The training program approved under this paragraph shall include initial training that is not less than 8 hours long and ongoing training sessions that are not less than 4 hours long per session. Individuals who sell long-term care insurance policies shall be required to attend an ongoing training session every 24 months after the initial training. The commissioner may approve the initial and ongoing training sessions for continuing education requirements under s. 628.04 (3).
3.
The training under this paragraph shall cover at a minimum long-term care insurance, long-term care services, qualified partnerships, and the relationship between qualified partnerships and other public and private coverage of long-term care costs.
(d)
An insurer that issues a long-term care insurance policy described in par. (b) shall be required to submit reports to the secretary of the federal department of health and human services, in accordance with regulations developed by the secretary, that include notice of when benefits are paid under the policy, the amount of the benefits, notice of the termination of the policy, and any other information required by the secretary.
(e)
1.
Notwithstanding par. (b) (intro.), the department, when making a determination under par. (a) 1. or 2. with respect to an individual, shall disregard an amount equal to the insurance benefit payments that are made to or on behalf of the individual under a qualified long-term care insurance policy under 26 USC 7702B (b) that was purchased in a state that had a state plan amendment that provided for a qualified state long-term care partnership, as defined in 42 USC 1396p (b) (1) (C) (iii), at the time of the purchase of the policy.
2.
The department shall comply with standards established by the federal department of health and human services in accordance with section 6021 (b) of the federal Deficit Reduction Act of 2005.
(32)
Community care for the elderly. The department may request a waiver under 42 USC 1315 to permit the establishment of a community care for the elderly demonstration project to provide medical care, case management services, adult day care and other support services that promote independence and enhance the quality of life of frail elderly persons. If the waiver is approved, the department may establish the community care for the elderly demonstration project and pay a fixed per person fee for the services.
(34)
Medical assistance manual. The department shall prepare a medical assistance manual that is clear, comprehensive and consistent with this subchapter and 42 USC 1396a to 1396u and shall, no later than July 1, 1992, provide the manual to counties for use by county employees who administer the medical assistance program.
(35m)
Computer system redesign. The department shall ensure that any redesign or replacement of the computer network that is used by counties on May 12, 1992, to determine eligibility for medical assistance includes the capability of determining eligibility for medical assistance under s. 49.47 (4) (c) 2.
(36)
Homeless beneficiaries. The department or a county department under s. 46.215, 46.22, or 46.23 may not place the word “homeless" on the medical assistance identification card of any person who is determined to be eligible for medical assistance benefits and who is homeless.
(37)
Plans of care. The department may seek a waiver of the requirement under 42 USC 1396n (c) (1) that the department review and approve every written plan of care developed for each individual who receives, under 42 USC 1396n (c) (1), home or community-based services under ss. 49.46 (2) (b) 8. and 49.47 (6) (a) 1. The waiver of the requirement, if granted, shall apply to those county departments or private nonprofit agencies that administer the services and that the department finds and certifies have implemented effective quality assurance systems for service plan development and implementation. If the federal health care financing administration approves the department's request for waiver of the requirement, the department shall, in evaluating a quality assurance system for certification, consider all of the following:
(a)
The adequacy, safety and comprehensiveness of plans of care developed for individuals and of the services provided to them.
(b)
Opportunities for individuals to exercise choice and be involved in the provision of services.
(c)
Overall conformance to required state and federal quality assurance standards.
(d)
Factors in addition to those in pars. (a) to (c) that are required by the federal health care financing administration, if any.
(38)
Home or community-based services for disabled workers. The department shall request a waiver from the secretary of the federal department of health and human services to authorize federal financial participation for medical assistance coverage of persons described in ss. 49.46 (1) (a) 14. and 49.47 (4) (as).
(39)
School medical services.
(a)
Definitions. In this subsection:
1.
“School" means a public school described under s. 115.01 (1), a charter school, as defined in s. 115.001 (1), the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing. It includes school-operated early childhood programs for developmentally delayed and disabled 4-year-old and 5-year-old children.
2.
“School medical services" means health care services that are provided in a school to children who are eligible for medical assistance that are appropriate to a school setting, as provided in the amendment to the state medical assistance plan under par. (am).
(am)
Plan amendment. No later than September 30, 1995, the department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of pars. (b) and (c). If the amendment to the state plan is approved, school districts, cooperative educational service agencies, and the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin Educational Services Program for the Deaf and Hard of Hearing claim reimbursement under pars. (b) and (c). Paragraphs (b) and (c) do not apply unless the amendment to the state plan is approved and in effect. The department shall submit to the federal department of health and human services an amendment to the state plan if necessary to permit the application of pars. (b) and (c) to the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin Educational Services Program for the Deaf and Hard of Hearing.
(b)
School medical services.
1.
`Payment for school medical services.' If a school district or a cooperative educational service agency elects to provide school medical services and meets all requirements under par. (c), the department shall reimburse the school district or the cooperative educational service agency for 60 percent of the federal share of allowable charges for the school medical services that it provides and, as specified in subd. 2., for allowable administrative costs. If the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing elects to provide school medical services and meets all requirements under par. (c), the department shall reimburse the department of public instruction for 60 percent of the federal share of allowable charges for the school medical services that the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing provides and, as specified in subd. 2., for allowable administrative costs. A school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, claims for common carrier transportation costs as a school medical service unless the department receives notice from the federal health care financing administration that, under a change in federal policy, the claims are not allowed. If the department receives the notice, a school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, unreimbursed claims for common carrier transportation costs incurred before the date of the change in federal policy. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. All other expenses for the school medical services provided by a school district or a cooperative educational service agency shall be paid for by the school district or the cooperative educational service agency with funds received from state or local taxes. The school district, the Wisconsin Center for the Blind and Visually Impaired, the Wisconsin Educational Services Program for the Deaf and Hard of Hearing, or the cooperative educational service agency shall comply with all requirements of the federal department of health and human services for receiving federal financial participation.
2.
`Payment for school medical services administrative costs.' The department shall reimburse a school district or a cooperative educational service agency specified under subd. 1. and shall reimburse the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing for 90 percent of the federal share of allowable administrative costs, using time studies, beginning in fiscal year 1999-2000. A school district or a cooperative educational service agency may submit, and the department of health services shall allow, claims for administrative costs incurred during the period that is up to 24 months before the date of the claim, if allowable under federal law.
(c)
Certification and reporting requirements. The department shall promulgate rules establishing specific certification and reporting requirements with respect to school medical services under this subsection.
(39m)
State plan amendment for pharmacist reimbursement. The department shall submit to the federal department of health and human services an amendment to the state Medical Assistance plan to permit Medical Assistance reimbursement to pharmacists who meet the training requirements specified by the department to administer vaccines, as determined by the department, to a person 6 to 18 years of age. The department shall provide Medical Assistance reimbursement under this subsection if the federal department of health and human services approves the amendment to the state Medical Assistance plan. A pharmacist or pharmacy shall enroll in the federal Vaccines for Children Program under 42 USC 1396s to be eligible for Medical Assistance reimbursement under this subsection.
(40)
Periodic record matches. If the department contracts with the department of children and families under s. 49.197 (5), the department shall cooperate with the department of children and families in matching records of medical assistance recipients under s. 49.32 (7).
(41)
Crisis intervention services.
(a)
In this subsection, “crisis intervention services" means crisis intervention services for the treatment of mental illness, intellectual disability, substance abuse, and dementia that are provided by a crisis intervention program operated by, or under contract with, a county, if the county is certified as a medical assistance provider.
(b)
If a county elects to become certified as a provider of crisis intervention services, the county may provide crisis intervention services under this subsection in the county to medical assistance recipients through the medical assistance program. A county that elects to provide the services shall pay the amount of the allowable charges for the services under the medical assistance program that is not provided by the federal government. The department shall reimburse the county under this subsection only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
(c)
Notwithstanding par. (b), if a county elects to deliver crisis intervention services under the Medical Assistance program on a regional basis according to criteria established by the department, all of the following apply:
1.
After January 1, 2020, the department shall require the county to annually contribute for the crisis intervention services an amount equal to 75 percent of the annual average of the county's expenditures for crisis intervention services under this subsection as determined by the department.
2.
The department shall reimburse the provider of crisis intervention services in the county the amount of allowable charges for those services under the Medical Assistance program, including both the federal share and nonfederal share of those charges, that exceeds the amount of the county contribution required under subd. 1.
3.
If a county submits a certified cost report under sub. (52) (b) to claim federal medical assistance funds, the claim based on certified costs made by a county for amounts under subd. 2. cannot include any part of the nonfederal share of the amount under subd. 2.
(42)
Personal care services.
(c)
The department may charge a fee to certify a provider of personal care services described under par. (d) 3. e., except that no fee may be imposed on an individual who is eligible for the veterans fee waiver program under s. 45.44. Fees collected under this paragraph shall be credited to the appropriation account under s. 20.435 (6) (jm).
(d)
Personal care services under s. 49.46 (2) (b) 6. j. provided to an individual are reimbursable under medical assistance only if all of the following conditions are met:
1.
The provider of the personal care services receives prior authorization from the department for all personal care services that are provided to the individual in excess of 50 hours in a calendar year.
2.
The individual is not eligible to receive home health services under medicare, as defined in sub. (3) (L) 1. b.
3.
The provider of the personal care services is one of the following:
a.
An independent living center meeting the criteria to receive a grant under s. 46.96.
b.
A county department under s. 46.215, 46.22, 46.23, 51.42, or 51.437.
c.
A federally recognized American Indian tribe or band certified to provide services to medical assistance beneficiaries.
d.
A home health agency licensed under s. 50.49.
e.
Any other entity certified under sub. (2) (a) 11. to provide personal care services under s. 49.46 (2) (b) 6. j.
(42m)
Physical and occupational therapy.
(a)
If, in authorizing the provision of physical or occupational therapy services under s. 49.46 (2) (b) 6. b. or 49.471 (11) (i), the department authorizes a reduced duration of services from the duration that the provider specifies in the authorization request, the department shall substantiate the reduction that the department made in the duration of the services if the provider of the services requests any additional authorizations for the provision of physical or occupational therapy services to the same individual.
(b)
The division of the department that is responsible for health care financing shall monitor compliance with the requirement under par. (a) in concert with representatives of the Wisconsin Physical Therapy Association and the Wisconsin Occupational Therapy Association.
(43)
Case management services for high-cost recipients. The department may establish a program to provide case management services for medical assistance recipients with high-cost chronic health conditions or high-cost catastrophic health conditions. If the department establishes a program to provide these case management services, the department shall provide reimbursement for providers of these case management services under the medical assistance program.
(44)
Prenatal, postpartum and young child care coordination. Providers in Milwaukee County that are certified to provide care coordination services under s. 49.46 (2) (b) 12. may be certified to provide to medical assistance recipients prenatal and postpartum care coordination services and care coordination services for children who have not attained the age of 7. Providers in the city of Racine that are certified to provide care coordination services under s. 49.46 (2) (b) 12. and are participating in a program under s. 253.16 may be certified to provide to medical assistance recipients prenatal and postpartum care coordination services and care coordination services for children who have not attained the age of 2. A provider of those care coordination services shall provide to a person receiving those services the information relating to shaken baby syndrome and impacted babies required under s. 253.15 (6). The department shall provide reimbursement for those care coordination services only if at least one of the following conditions is met:
(a)
The recipient is a resident of Milwaukee County or the city of Racine and has received services under s. 49.46 (2) (b) 12. and is pregnant or has given birth within 8 weeks after the individual ceased to receive services under s. 49.46 (2) (b) 12.
(b)
The recipient is a resident of Milwaukee County or the city of Racine, is pregnant and has received a risk assessment approved by the department.
(c)
The recipient is a resident of Milwaukee County or the city of Racine, has given birth within the 8 weeks immediately preceding the request for services under s. 49.46 (2) (b) 12m. and has received a risk assessment approved by the department.
(44m)
Extension of parent eligibility when child dies. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to extend the eligibility of a parent, for up to 90 days, under the Medical Assistance program under this subchapter or the Badger Care health care program under s. 49.665 if the parent's child dies while both the parent and the child are covered under the Medical Assistance program or the Badger Care health care program and the parent would lose eligibility solely due to the death of the child. The department shall implement any waiver that is granted.
(45)
In-home and community mental health and alcohol and other drug abuse services.
(a)
Services under s. 49.46 (2) (b) 6. fm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
1.
Reimbursement for the services under s. 49.46 (2) (b) 6. fm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
2.
The county, city, town or village in which the individual resides elects to make the services under s. 49.46 (2) (b) 6. fm. available in the county, city, town or village through the medical assistance program.
(b)
A county, city, town or village that elects to make the services under s. 49.46 (2) (b) 6. fm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
(47)
Adult day care centers.
(a)
In this subsection, “adult day care center" means an entity that provides services for part of a day in a group setting to adults who need an enriched health-supportive or social experience and who may need assistance with activities of daily living, supervision or protection.
(b)
No person may receive reimbursement for the provision of services to clients in an adult day care center unless the adult day care center is certified by the department under sub. (2) (a) 11. as a provider of medical assistance.
(c)
The biennial fee for the certification required under par. (b) of an adult day care center is $127. Fees collected under this paragraph shall be credited to the appropriation account under s. 20.435 (6) (jm).
(d)
The department, by rule, may increase any fee specified in par. (c).
(dm)
Every 24 months, on a schedule determined by the department, an adult day care center shall submit through an online system prescribed by the department a report in the form and containing the information that the department requires, including payment of any fee due under par. (c). If a complete report is not timely filed, the department shall issue a warning to the operator of the adult day care center. The department may revoke an adult day care center's certification for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department.
(e)
If the department takes enforcement action against an adult day care center for violating a certification requirement established under sub. (2) (a) 11., and the department subsequently conducts an on-site inspection of the adult day care center to review the adult day care center's action to correct the violation, the department may impose a $200 inspection fee on the adult day care center.
(47m)
Family Care funding.
(a)
In this subsection, “care management organization” means a care management organization under contract with the department of health services as described under s. 46.284.
(b)
The department shall collaborate with care management organizations and the federal centers for Medicare and Medicaid services to develop an allowable payment mechanism to increase the direct care and services portion of the capitation rates to address the direct caregiver workforce challenges in the state.
(d)
The department may not implement the plan developed under this subsection unless the department receives federal approval. The department may supplement the appropriation under s. 20.435 (4) (b) from the appropriation under s. 20.865 (4) (a) for implementation of the payment mechanism under par. (b). The department may only use moneys for the payment mechanism under par. (b). Notwithstanding s. 13.101, the joint committee on finance is not required before making a supplementation under this paragraph.
(48)
Payment of medicare part B outpatient hospital services coinsurances. The department shall include in the state plan for medical assistance a methodology for payment of the medicare part B outpatient hospital services coinsurance amounts that are authorized under ss. 49.46 (2) (c) 2., 4., and 5m., 49.468 (1) (b), 49.47 (6) (a) 6. b., d., and f., and 49.471 (6) (j) 1.
(49)
Prescription drug prior authorization.
(a)
The secretary shall exercise his or her authority under s. 15.04 (1) (c) to create a prescription drug prior authorization committee to advise the department on issues related to prior authorization decisions made concerning prescription drugs on behalf of medical assistance recipients. The secretary shall appoint as members at least all of the following:
1.
Two physicians, as defined in s. 448.01 (5), who are currently in practice.
2.
Two pharmacists, as defined in s. 450.01 (15).
3.
One advocate for recipients of medical assistance who has sufficient medical background, as determined by the department, to evaluate a prescription drug's clinical effectiveness.
(b)
The prescription drug prior authorization committee shall accept information or commentary from representatives of the pharmaceutical manufacturing industry in the committee's review of prior authorization policies.
(49g)
Billing for prescription drugs.
(a)
In this subsection:
1d.
“Abortion" has the meaning given in s. 253.10 (2) (a).
1g.
“Abortion provider" means a person that provides abortion services or is an affiliate of a person that provides abortion services.
1m.
“Covered entity" has the meaning given in 42 USC 256b (a) (4) (C) and (K).
2.
“Prescription drug" has the meaning given in s. 450.01 (20).
(b)
When billing the Medical Assistance program under this subchapter for reimbursement for a prescription drug, a covered entity that is an abortion provider shall bill the actual acquisition cost of the prescription drug for which coverage is provided under s. 49.46 (2) (b) 6. h. and a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h.
(49m)
Prescription drug cost controls; purchasing agreements.
(a)
In this section:
1.
“Brand name" has the meaning given in s. 450.12 (1) (a).
2.
“Generic name" has the meaning given in s. 450.12 (1) (b).
3.
“Prescription drug" has the meaning given in s. 450.01 (20).
(b)
The department may enter into a multi-state purchasing agreement with another state or a purchasing agreement with a purchaser of prescription drugs if the other state or purchaser agrees to participate in one or more of the activities specified in par. (c) 1. to 4.
(c)
The department may design and implement a program to reduce the cost of prescription drugs and to maintain high quality in prescription drug therapies, which shall include all of the following:
1.
A list of the prescription drugs that are included as a benefit under ss. 49.46 (2) (b) 6. h. and 49.471 (11) (a) that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.
2.
Establishing supplemental rebates under agreements with prescription drug manufacturers for prescription drugs provided to recipients under Medical Assistance and Badger Care and to eligible persons under s. 49.688 and, if it is possible to implement the program without adversely affecting supplemental rebates for Medical Assistance, Badger Care, and prescription drug assistance under s. 49.688, to beneficiaries of participants under par. (b).
3.
Utilization management and fraud and abuse controls.
4.
Any other activity to reduce the cost of or expenditures for prescription drugs and maintain high quality in prescription drug therapies.
(d)
The department may enter into a contract with an entity to perform any of the duties and exercise any of the powers of the department under this subsection.
(50)
Disease management.
(a)
In this subsection, “disease management" means an integrated and systematic approach for managing the health care needs of patients who are at risk of or are diagnosed with a specific disease, using all of the following:
1.
Best practices.
2.
Prevention strategies.
3.
Clinical practice improvement.
4.
Clinical interventions and protocols.
5.
Outcomes research, information, and technology.
6.
Other tools and resources to reduce overall costs and improve measurable outcomes.
(b)
The department may contract with an entity, under the department's request-for-proposal procedures, to engage in disease management activities on behalf of recipients of medical assistance.
(51)
Medical care transportation services.
(a)
By November 1 annually, the department shall provide to the department of revenue information concerning the estimated amounts of supplements payable from the appropriation accounts under s. 20.435 (4) (b) and (gm) to specific local governmental units for the provision of transportation for medical care, as specified under s. 49.46 (2) (b) 3., during the fiscal year. Beginning November 1, 2004, the information that the department provides under this paragraph shall include any adjustments necessary to reflect actual claims submitted by service providers in the previous fiscal year.
(b)
On the date that is the 3rd Monday in November, the department shall annually pay to specific local governmental units the estimated net amounts specified in par. (a).
NOTE: Sub. (51) is repealed eff. 7-1-24 by 2023 Wis. Act 12.
(52)
Payment adjustments; federal funding for certain services.
(a)
1.
If the department provides the notice under par. (c) selecting the payment procedure in this paragraph, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payment adjustments to county departments under s. 46.215, 46.22, 46.23, 51.42, or 51.437 or to local health departments, as defined in s. 250.01 (4), as appropriate, for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16., except for services specified under s. 49.46 (2) (b) 6. b. and c. provided to children participating in the early intervention program under s. 51.44. Payment adjustments under this paragraph shall include the state share of the payments. The total of any payment adjustments under this paragraph and Medical Assistance payments made from appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), may not exceed applicable limitations on payments under 42 USC 1396a (a) (30) (A).
2.
The department may require a county department or local health department to submit a certified cost report that meets the requirements of the federal department of health and human services for covered services described in subd. 1.
(b)
If the department provides the notice under par. (c) selecting the payment procedure in this paragraph, all of the following apply:
1.
Annually, a county department under s. 46.215, 46.22, 46.23, 51.42, or 51.437 shall submit a certified cost report that meets the requirements of the federal department of health and human services for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16., except for services specified under s. 49.46 (2) (b) 6. b. and c. provided to children participating in the early intervention program under s. 51.44.
2.
For services described under subd. 1., the department shall base the amount of a claim for federal medical assistance funds on certified cost reports submitted by county departments under subd. 1. to the extent the reports comply with federal requirements.
3.
The department shall pay county departments a percentage of the federal funds claimed under subd. 2. for services described under subd. 1., which percentage is established in the most recent biennial budget.
4.
The department may pay a local health department, as defined in s. 250.01 (4), that submits certified cost reports for services described under subd. 1. a percentage of the federal funds claimed for those services, which percentage is established in the most recent biennial budget.
(c)
The department shall select a payment procedure under either par. (a) or (b) and may change which procedure under par. (a) or (b) is selected. The department shall notify each county department and local health department, as applicable, of the selected payment procedure before the date on which payment for services is made under that selected or newly selected procedure.
(53)
Payments for certain services. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under ss. 49.46 (2) (a) 4. d. and (b) 6. j. and m. and 49.471 (11) (f) that are provided before January 1, 2012.
(53m)
Coverage program for institutions for mental disease. Subject to any necessary waiver approval of the federal department of health and human services, or as otherwise permitted under federal law, the department may, if federal funding participation is available, provide Medical Assistance coverage of services provided in an institution for mental disease to persons ages 21 to 64.
(54)
Therapy for children participating in the birth to 3 program.
(a)
Federal share for county expenditures. If a county certifies to the department that the amount the county expended to provide services specified under s. 49.46 (2) (b) 6. b. and c. to children participating in the early intervention program under s. 51.44 exceeds the amount the county received as reimbursement under this section, based on reimbursement rates established by the department for those services, and the federal government pays the state the federal share of Medical Assistance for the amount by which the county expenditures exceed the reimbursement, the department may disburse the federal share to the county. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under s. 51.44 or for services under the disabled children's long-term support program, as defined in s. 46.011 (1g).
(c)
Special services. From the appropriations under s. 20.435 (4) (b) and (o) and (7) (bt), the department may pay the costs of services provided under the early intervention program under s. 51.44 that are included in program participant's individualized family service plan and that were not authorized for payment under the state Medicaid plan or a department policy before July 1, 2017, including any services under the early intervention program under s. 51.44 that are delivered by a type of provider that becomes certified to provide Medical Assistance service on July 1, 2017, or after.
(56)
Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57), the department shall develop and implement, for Medical Assistance recipients, disease management programs. These programs shall have at least the following characteristics:
(a)
The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
(b)
Educating health care providers on health care process improvement by developing best practice models.
(c)
The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
(d)
Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
(e)
Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
(57)
Physical health risk assessment. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.
(58)
Program for all-inclusive care for the elderly. The department may administer the program of all-inclusive care for the elderly under 42 USC 1396u-4.
(59)
Health maintenance organization payments to hospitals.
(a)
The department shall, from the appropriation accounts under s. 20.435 (4) (xc) and (xe), pay each health maintenance organization with which it contracts to provide medical assistance a monthly amount that the health maintenance organization shall use to make payments to hospitals under par. (b).
(b)
Health maintenance organizations shall pay all of the moneys they receive under par. (a) to eligible hospitals, as defined in s. 50.38 (1), within 15 days after receiving the moneys. The department shall specify in contracts with health maintenance organizations to provide medical assistance a method that health maintenance organizations shall use to allocate the amounts received under par. (a) among eligible hospitals based on the number of discharges from inpatient stays and the number of outpatient visits for which the health maintenance organization paid such a hospital in the previous month for enrollees who are recipients of medical assistance. Payments under this paragraph shall be in addition to any amount that a health maintenance organization is required by agreement between the health maintenance organization and a hospital to pay the hospital for providing services to the health maintenance organization's enrollees.
(c)
Each health maintenance organization that provides medical assistance shall report to the department each month the amount it paid each hospital under par. (b) and the percentage of the total payments it made under par. (b) that it paid to each hospital.
(d)
Each health maintenance organization that provides medical assistance shall report monthly to each hospital to which the health maintenance organization makes payments under par. (b) such information regarding the payments that the department specifies in its contract with the health maintenance organization to provide medical assistance.
(e)
1.
If the department determines that a health maintenance organization has not complied with a requirement under pars. (b) to (d), the department shall order the health maintenance organization to comply with the requirement within 15 days after the department's determination of noncompliance.
2.
The department may terminate a contract with a health maintenance organization to provide medical assistance if the health maintenance organization fails to comply with a requirement under pars. (b) to (d).
3.
The department may audit a health maintenance organization to determine whether the health maintenance organization has complied with the requirements under pars. (b) to (d).
(f)
The department shall specify in contracts with health maintenance organizations to provide medical assistance the method for adjusting payments under par. (b) to correct a health maintenance organization's inaccurate counting of inpatient discharges or outpatient visits in calculating a monthly payment to a hospital under par. (b).
(g)
If a health maintenance organization and hospital do not agree on the amount of a monthly payment that the health maintenance organization is required to pay the hospital under par. (b), either the health maintenance organization or the hospital, within 6 months after the first day of the month in which the payment is due, may request that the department determine the amount of the payment. The department shall determine the amount of the payment within 60 days after the request for a determination is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under ch. 227 on the department's determination.
(60)
Savings account program. The department shall submit to the federal department of health and human services a request for a waiver of federal Medicaid law to establish and implement a savings account program that is similar in function and operation to health savings accounts in the Medical Assistance program under this subchapter. The department shall exclude from any requirement to have a Medical Assistance savings account under the waiver request under this subsection any individual who is elderly, blind, or disabled and any child.
(61)
Services provided through telehealth and communications technology.
(a)
In this subsection:
1.
“Asynchronous telehealth service” is telehealth that is used to transmit medical data about a patient to a provider when the transmission is not a 2-way, real-time, interactive communication.
2.
“Interactive telehealth” means telehealth delivered using multimedia communication technology that permits 2-way, real-time, interactive communications between a certified provider of Medical Assistance at a distant site and the Medical Assistance recipient or the recipient's provider.
3.
“Remote patient monitoring” is telehealth in which a patient's medical data is transmitted to a provider for monitoring and response if necessary.
4.
“Telehealth” means a practice of health care delivery, diagnosis, consultation, treatment, or transfer of medically relevant data by means of audio, video, or data communications that are used either during a patient visit or a consultation or are used to transfer medically relevant data about a patient. “Telehealth” does not include communications delivered solely by audio-only telephone, facsimile machine, or electronic mail unless the department specifies otherwise by rule.
(b)
Subject to par. (e), the department shall provide reimbursement under the Medical Assistance program for any benefit that is a covered benefit under s. 49.46 (2) and that is delivered by a certified provider for Medical Assistance through interactive telehealth.
(c)
Subject to par. (e), the department shall provide reimbursement under the Medical Assistance program for all of the following:
1.
Except as provided by the department by rule, a consultation pertaining to a Medical Assistance recipient conducted through interactive telehealth between a certified provider of Medical Assistance and the Medical Assistance recipient's treating provider that is certified under Medical Assistance.
2.
Except as provided by the department by rule, remote patient monitoring of a Medical Assistance recipient and asynchronous telehealth service in which the medical data pertains to a Medical Assistance recipient.
3.
Except as provided by the department by rule and subject to par. (e) 4., services that are covered under the Medicare program under 42 USC 1395 et seq. for which the federal department of health and human services provides Medical Assistance federal financial participation and that are any of the following:
a.
Telehealth services, as defined under 42 USC 1395m (m) (4) (F).
b.
Remote physiologic monitoring.
c.
Remote evaluation of prerecorded patient information.
d.
Brief communication technology-based services.
e.
Care management services delivered through telehealth.
f.
Any other telehealth or communication technology-based services.
4.
Any service that is not specified in subds. 1. to 3. or par. (b) that is provided through telehealth and that the department specifies by rule under par. (d) is a covered and reimbursable service under the Medical Assistance program.
(d)
The department shall promulgate rules specifying any services under par. (c) 4. that are reimbursable under Medical Assistance. The department may promulgate rules excluding services under par. (c) 1. to 3. from reimbursement under Medical Assistance. The department may promulgate rules specifying any telehealth service under par. (b) or (c) 1. or 2. that is provided solely by audio-only telephone, facsimile machine, or electronic mail as reimbursable under Medical Assistance.
(e)
2.
The department may not require a certified provider of Medical Assistance that provides a reimbursable service under par. (b) or (c) to obtain an additional certification or meet additional requirements solely because the service was delivered through telehealth, except that the department may require, by rule, that the transmission of information through telehealth be of sufficient quality to be functionally equivalent to face-to-face contact. The department may apply any requirement that is applicable to a covered service that is not provided through telehealth to any service provided under par. (b) or (c).
3.
The department may not limit coverage or reimbursement of a service provided under par. (b) or (c) based on the location of the Medical Assistance recipient when the service is provided.
4.
The department may not cover or provide reimbursement under Medical Assistance for a service described under par. (c) 3. that is first covered under the Medicare program under 42 USC 1395 et seq. after July 1, 2019, until the date that is one year after the date the service is covered under the Medicare program or the date the secretary explicitly approves the service as a Medical Assistance covered service, whichever is earlier.
History:  1971 c. 40 s. 93; 1971 c. 42, 125; 1971 c. 213 s. 5; 1971 c. 215, 217, 307; 1973 c. 62, 90, 147; 1973 c. 333 ss. 106g, 106h, 106j, 201w; 1975 c. 39; 1975 c. 223 s. 28; 1975 c. 224 ss. 54h, 56 to 59m; 1975 c. 383 s. 4; 1975 c. 411; 1977 c. 29, 418; 1979 c. 34 ss. 837f to 838, 2102 (20) (a); 1979 c. 102, 177, 221, 355; 1981 c. 20 ss. 839 to 854, 2202 (20) (r); 1981 c. 93, 317; 1983 a. 27 ss. 1046 to 1062m, 2200 (42); 1983 a. 245, 447, 527; 1985 a. 29 ss. 1026m to 1031d, 3200 (23), (56), 3202 (27); 1985 a. 120, 176, 269; 1985 a. 332 ss. 91, 251 (5), 253; 1985 a. 340; 1987 a. 27 ss. 989r to 1000s, 2247, 3202 (24); 1987 a. 186, 307, 339, 399; 1987 a. 403 s. 256; 1987 a. 413; 1989 a. 6; 1989 a. 31 ss. 1402 to 1452g, 2909g, 2909i; 1989 a. 107, 173, 310, 336, 351, 359; 1991 a. 22, 39, 80, 250, 269, 315, 316; 1993 a. 16 ss. 1362g to 1403, 3883; 1993 a. 27, 107, 112, 183, 212, 246, 269, 335, 356, 437, 446, 469; 1995 a. 20; 1995 a. 27 ss. 2947 to 3002r, 7299, 9126 (19), 9130 (4), 9145 (1); 1995 a. 191, 216, 225, 289, 303, 398, 417, 457; 1997 a. 3, 13, 27, 114, 175, 191, 237, 252, 293; 1999 a. 9, 63, 103, 180, 185; 2001 a. 13, 16, 35, 38, 57, 67, 104, 109; 2003 a. 33, 318, 321; 2005 a. 22; 2005 a. 25 ss. 1120 to 1149f, 2503 to 2510; 2005 a. 107, 165, 253, 254, 264, 301, 340, 386, 441; 2007 a. 20 ss. 1513 to 1559h, 9121 (6) (a); 2007 a. 90, 97, 104, 141, 153; 2009 a. 2, 28, 113, 177, 180, 190, 221, 334, 342; 2011 a. 10, 32, 120, 126, 158, 192, 209, 258; 2011 a. 260 s. 81; 2013 a. 20, 92; 2013 a. 116 ss. 2, 3, 29, 30; 2013 a. 117 ss. 2, 4; 2013 a. 130; 2013 a. 165 s. 114; 2013 a. 226; 2015 a. 55, 152, 153, 172, 294; 2017 a. 34, 59, 138, 185, 262, 268, 271, 279, 306, 344, 370; 2019 a. 8 ss. 15, 71; 2019 a. 9, 56, 88, 100, 105, 122, 186; 2021 a. 22; 2021 a. 23 ss. 8, 9, 71; 2021 a. 58, 88, 123, 131, 228; 2021 a. 238 s. 44; 2021 a. 239 s. 74; 2021 a. 240 ss. 29, 30; 2021 a. 248, 251; 2023 a. 12, 19; s. 13.92 (1) (bm) 2.; s. 13.92 (2) (i).
Wisconsin has no medical assistance plan independent of Medicaid. Non-residence under federal Medicaid regulations is determinative of medical assistance eligibility. Pope v. DHSS, 187 Wis. 2d 207, 522 N.W.2d 22 (Ct. App. 1994).
Section 49.89, not sub. (19) (a) 2., specifically addresses assignment of actions and subrogation of rights by a public assistance recipient who is injured and has a tort claim against a third party. Ellsworth v. Schelbrock, 2000 WI 63, 235 Wis. 2d 678, 611 N.W.2d 764, 98-0294.
Sub. (7) (a) requires that a health care facility resident who is a recipient of certain funds apply those funds toward the cost of care in the health care facility. The agent who receives funds from the federal Social Security Administration on behalf of the resident has an obligation to pay the funds to the health care facility and is subject to an action for conversion. Methodist Manor of Waukesha, Inc. v. Martin, 2002 WI App 130, 255 Wis. 2d 707, 647 N.W.2d 409, 01-2877.
Medical assistance eligibility is not a default position that the Department of Health and Family Services must rebut, but a privilege for which the applicant must prove eligibility. An initial determination of eligibility does not preclude a later redetermination of that status. The state has an ongoing duty to ensure that a medical assistance recipient is eligible, and the recipient bears the ongoing burden of proving eligibility. Estate of Gonwa v. DHFS, 2003 WI App 152, 265 Wis. 2d 913, 668 N.W.2d 122, 02-2901.
Sub. (2) (a) 9. does not direct the Department of Health and Family Services to promulgate rules regarding conditions of reimbursement, but instead to include those conditions in a contract with the provider. A department handbook provision requiring odometer readings is a condition of reimbursement, not an administrative rule requiring promulgation. Meda-Care Vans of Waukesha, Inc. v. Division of Hearings & Appeals, 2007 WI App 140, 302 Wis. 2d 499, 736 N.W.2d 147, 05-2979.
Medicaid reimbursement is governed by the “Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates" adopted by the Department of Health and Family Services (DHFS) under sub. (6m). Sub. (6m) (e) requires DHFS to establish an appeals mechanism within DHFS to review petitions for modifications to any payment under sub. (6m). The “Methods" provides that the nursing home appeals board is available for redress in the event a facility has extraordinary fiscal circumstances. DHFS does not have the authority to grant an increased reimbursement rate absent appeals board approval. Park Manor, Ltd. v. DHFS, 2007 WI App 176, 304 Wis. 2d 512, 737 N.W.2d 88, 06-2311.
Sub. (3) (f) gives the Department of Health Services (DHS) the authority to recoup payments made to a Medicaid provider when that provider failed to maintain records as required by DHS for verification of the provider's claims, regardless of whether other records possessed by the provider show that the provider actually rendered the services in question. In this case, the records were not required, so DHS could not recoup payments. Newcap, Inc. v. Department of Health Services, 2018 WI App 40, 383 Wis. 2d 515, 916 N.W.2d 173, 17-1432.
When read together, sub. (3) (f) 1. and 2. make it clear that a provider has an obligation to make the required records available to the Department of Health Services (DHS) at the time of an audit in order to allow DHS to verify the provider's claims, and DHS may recoup payments already made if the provider fails to do so. Newcap, Inc. v. Department of Health Services, 2018 WI App 40, 383 Wis. 2d 515, 916 N.W.2d 173, 17-1432.
The fact that this section does not address testamentary trusts is not an indication the legislature gave consideration to whether payments from testamentary trusts should be included as unearned income for medical assistance eligibility purposes and concluded to the contrary. Tarrant v. Department of Health Services, 2019 WI App 45, 388 Wis. 2d 461, 933 N.W.2d 145, 18-1299.
Under sub. (3) (f) 1. and 2., the Department of Health Services (DHS) may recoup Medicaid payments from service providers only in cases in which DHS cannot verify one of the following: 1) the actual provision of covered services; 2) that the reimbursement claim is appropriate for the service provided; or 3) that the reimbursement claim is accurate for the service provided. A record imperfection alone is not an independent basis for recouping payments. DHS's practice of seeking recoupment of payments simply because a post-payment audit found that records were not perfect exceeded DHS's recoupment authority. Papa v. Department of Health Services, 2020 WI 66, 393 Wis. 2d 1, 946 N.W.2d 17, 16-2082.
A contract between the trustees of a nursing home and a medical clinic for exclusive medical services under the medical assistance act for residents of such home violates public policy of this state. 59 Atty. Gen. 68.
Poverty is not a constitutionally suspect classification. Encouraging childbirth except in the most urgent circumstances is rationally related to the legitimate governmental objective of protecting potential life. Discussing medical assistance. Harris v. McRae, 448 U.S. 297, 100 S. Ct. 2671, 65 L. Ed. 2d 784 (1980).
Medical Assistance & Divestment. Canellos. Wis. Law. Aug. 1991.