49.45(6c)
(6c) Preadmission screening and resident review. 49.45(6c)(a)1.
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.
49.45(6c)(a)2.
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.
49.45(6c)(a)4.
4. "Developmental disability" means any of the following:
49.45(6c)(a)4.a.
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.
49.45(6c)(a)6.
6. "Facility care" means services provided in a facility that are in conformity with
42 USC 1396r and that are payable under
sub. (6m).
49.45(6c)(b)
(b)
Preadmission screening. Except as provided in
par. (e), beginning on August 9, 1989, 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. Beginning on August 9, 1989, 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.
49.45(6c)(c)
(c)
Resident review. Except as provided in
par. (e), by April 1, 1990, and at least annually thereafter, 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 to determine if any of the following applies:
49.45(6c)(c)2.
2. The resident requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(d)1.1. 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 or
49.47, 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.
49.45(6c)(d)2.
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 or
49.47 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.
49.45(6c)(e)1.1. 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.
49.45(6c)(e)2.
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:
49.45(6c)(e)2.a.
a. It is determined that the individual needs facility care and requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)2.b.
b. The individual chooses not to participate in active treatment.
49.45(6c)(f)
(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.
49.45(6c)(g)
(g)
Rule making. The department shall promulgate all of the following rules:
49.45(6c)(g)1.
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.
49.45(6h)
(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.
49.45(6j)
(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.
49.45(6m)(a)2.
2. "Cost center" means a group of similar facility expenses.
49.45(6m)(a)3.
3. "Facility" means a nursing home as defined under
s. 50.01 (3) 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.
49.45(6m)(a)4.
4. "Net property tax" means property tax from which the Wisconsin state property tax credit has been deducted.
49.45(6m)(ag)
(ag) Payment for care provided in a facility under this subsection made under
s. 20.435 (1) (b),
(o) or
(p) 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 which are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities in order to provide care in conformity with this section, with federal regulations authorized under
42 USC 1396a (a) (13) (A),
1396a (a) (30),
1396b (i) (3),
1396L and
1396r (e) and with quality and safety standards established under
subch. II of ch. 50 and
ch. 150. In administering this payment system, the department shall allow costs it determines are necessary and proper for providing patient care. The payment system shall reflect all of the following:
49.45(6m)(ag)1.
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.
49.45(6m)(ag)2.
2. Standards established by the department for costs of economically and efficiently operated facilities 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.
49.45(6m)(ag)3m.
3m. For state fiscal year 1995-96, rates that shall be set by the department based on information from cost reports for the 1994 fiscal year of the facility and for state fiscal year 1996-97, rates that shall be set by the department based on information from cost reports for the 1995 fiscal year of the facility.
49.45(6m)(ag)6.
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.
49.45(6m)(ag)7.
7. Assurance of an acceptable quality of care for all medical assistance recipients provided nursing home care.
49.45(6m)(ag)8.
8. Calculation of total payments and supplementary payments to facilities that permits an increase in funds allocated under
s. 20.435 (1) (b) and
(o) for nursing home care provided medical assistance recipients over that paid for services provided in state fiscal year 1994-95 of no more than 4.25% during state fiscal year 1995-96 and over that paid for services provided in state fiscal year 1995-96 of no more than 3.5% during state fiscal year 1996-97, excluding increases in total payments attributable to increases in recipient utilization of facility care, payments for the provision of active treatment to facility residents with developmental disability or chronic mental illness and payments for preadmission screening of facility applicants and annual reviews of facility residents required under
42 USC 1396r (e).
49.45(6m)(am)
(am) In determining payments for a facility under the payment system in
par. (ag), the department shall consider all of the following cost centers:
49.45(6m)(am)1.
1. Allowable direct care costs, including, if provided, any of the following:
49.45(6m)(am)1.d.
d. Services of facility medical personnel that are not separately billable under medical assistance requirements.
49.45(6m)(am)1.e.
e. Nonbillable services of a registered nurse, licensed practical nurse, nursing assistant, 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.
49.45(6m)(am)2.
2. Allowable support service costs, including the following allowable facility expenses:
49.45(6m)(am)2.a.
a. Dietary service for the provision of meals to facility residents.
49.45(6m)(am)2.b.
b. Environmental service for the provision of maintenance, housekeeping, laundry and security service.
49.45(6m)(am)3.
3. Allowable fuel and utility costs, including the facility expenses that the department determines are allowable for the provision of:
49.45(6m)(am)4.
4. Net property tax or allowable municipal service costs incurred by the owner of the facility for the facility.
49.45(6m)(am)5.
5. 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.
49.45(6m)(am)5m.
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.
49.45(6m)(am)6.
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.
49.45(6m)(ar)
(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):
49.45(6m)(ar)1.a.
a. The department shall establish standards for payment of allowable direct care costs that are at least 110% of the median for direct care costs for facilities that do not primarily serve the developmentally disabled and separate standards for payment of allowable direct care costs that are at least 110% of the median for direct care costs for facilities primarily serving the developmentally disabled. The standards shall be adjusted by the department for regional labor cost variations. The department may decrease the percentage established for the standards only if amounts available under
par. (ag) (intro.) are insufficient to provide total payment under
par. (am), less capital costs under
subd. 6.
49.45(6m)(ar)1.b.
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.
49.45(6m)(ar)1.c.
c. If a facility has an approved program for provision of service to emotionally disturbed or mentally retarded residents, 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.
Effective date note
NOTE: Subd. par. c. is amended eff. 7-1-97 by
1995 Wis. Act 27 to read:
49.45 Note
c. If a facility has an approved program for provision of service to mentally retarded residents, 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.
49.45(6m)(ar)1.cm.
cm. Notwithstanding the limitations under
par. (ag) 8., 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.
49.45(6m)(ar)2.a.
a. The department shall establish one or more standards for the payment of support service costs that are not less than the median of support service costs for a sample of all facilities within the state.
49.45(6m)(ar)2.b.
b. The department shall establish the support service component of the facility rate for each facility by comparing actual allowable support service cost information of that facility, adjusted for inflation, to the applicable standard established under
subd. 2. a.
49.45(6m)(ar)2.d.
d. The department may provide an efficiency incentive payment to a facility whose allowable support service costs are less than the standards set forth under
subd. 2. a. and a cost share payment to a facility whose allowable support service costs are greater than the standards set forth under
subd. 2. a.
49.45(6m)(ar)3.a.
a. The department shall establish standards, adjusted for heating degree day variations in the state, for payment of fuel and utility costs that are not less than the median of heating fuel and utility costs for a sample of all facilities within the state.
49.45(6m)(ar)3.b.
b. The department shall establish the fuel and utility component of the facility rate for each facility by comparing actual allowable fuel and utility cost information of that facility, adjusted for inflation, to the standard established under
subd. 3. a.
49.45(6m)(ar)3.c.
c. The department may provide an efficiency incentive payment to a facility whose allowable heating fuel and utility costs are less than the standard set forth under
subd. 3. a. and a cost share payment to a facility whose allowable heating fuel and utility costs are greater than the standards set forth under
subd. 3. a.
49.45(6m)(ar)4.
4. For net property taxes or municipal services, payment shall be made for those costs that range from the amount of the previous calendar year's tax or the amount of municipal service costs for a period specified by the department to a maximum limit as determined by the department.
49.45(6m)(ar)5.a.
a. The department shall establish one or more standards for the payment of administrative and general costs that are not less than the median of administrative and general costs for a sample of all facilities within the state.
49.45(6m)(ar)5.b.
b. The department shall establish the administrative and general component of the facility rate for each facility by comparing actual allowable administrative and general cost information of that facility, adjusted for inflation, to the applicable standard established under
subd. 5. a.
49.45(6m)(ar)5.c.
c. The department may provide an efficiency incentive payment to a facility whose allowable administrative and general costs are less than the standards set forth under
subd. 5. a.
49.45(6m)(ar)6.
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, except that the department may not reduce final capital payment of a facility by more than $3.50 per patient day.
49.45(6m)(av)1.1. The department shall calculate a payment rate for a facility by applying the criteria set forth under
pars. (ag) 1. to
5.,
7. and
8.,
(am) 1. to
5. and
(ar) 1. to
5. to information from cost reports submitted by the facility.
49.45(6m)(av)2.
2. The department shall compile an average payment rate for each facility based on that facility's rates for cost centers described under
par. (am) 1. to
5. that were in effect on June 30, 1994. The department may develop a method for adjusting the facility's rate for the cost center under
par. (am) 1. in compiling the average payment rate under this subdivision.
49.45(6m)(av)3.
3. The department shall calculate the facility's projected cost per patient day, based on that facility's cost centers under
par. (am) 1. to
5., adjusted for inflation.
49.45(6m)(av)4.
4. If the facility's payment rate under
subd. 1. is a decrease from its average payment rate under
subd. 2., and if the figure calculated under
subd. 3. exceeds the payment rate for the facility under
subd. 1., the facility's average payment rate shall be the greater of its average payment rate under
subd. 2. or its rate under
subd. 1.
49.45(6m)(av)5.
5. If
subd. 4. does not apply, the facility's payment rate shall be the payment rate calculated under
subd. 1.
49.45(6m)(av)5m.
5m. Notwithstanding the limitations under
par. (ag) 8., the rate under
subd. 1.,
4. or
5. may be adjusted by the department to reflect payments for the provision of active treatment to facility residents with a diagnosis of developmental disability.
