49.45(19)(c)
(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.
49.45(20)
(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.
49.45(21)
(21) Taking over provider's operation; repayments required. 49.45(21)(ag)(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:
49.45(21)(ag)1.
1. Ownership of the provider's business or all or substantially all of the assets of the business.
49.45(21)(ag)4.
4. The right to contact and offer services to patients, clients, or residents served by the provider.
49.45(21)(ag)5.
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.
49.45(21)(ag)6.
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.
49.45(21)(ag)7.
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.
49.45(21)(ar)
(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.
49.45(21)(b)
(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.
49.45(21)(c)
(c) The department may enforce this subsection within 4 years following a transfer.
49.45(21)(e)
(e) The department shall promulgate rules to implement this subsection.
49.45(22)
(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.
49.45(23)
(23) Assistance for childless adults demonstration project. 49.45(23)(a)(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 for basic primary and preventive care to adults who are under the age of 65, who have family incomes not to exceed 200 percent of the poverty line, 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.
49.45(23)(b)
(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. 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 January 1, 2009, or on the effective date of the waiver, whichever is later.
49.45(24)
(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.
49.45(24m)
(24m) Home health care and personal care pilot program. From the appropriation accounts under
s. 20.435 (4) (b),
(gp),
(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:
49.45(24m)(a)
(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.
49.45(24m)(b)
(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.
49.45(24r)
(24r) Family planning demonstration project. 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 family planning, as defined in
s. 253.07 (1) (a), under medical assistance to any woman between the ages of 15 and 44 whose family income does not exceed 200% of the poverty line for a family the size of the woman's family. The department shall implement any waiver granted.
49.45(25)(a)(a) In this subsection, "severely emotionally disturbed child" means an individual under 21 years of age who has emotional and behavioral problems that:
49.45(25)(a)3.
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
49.45(25)(a)4.
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.
49.45(25)(am)
(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:
49.45(25)(am)9.
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.
49.45(25)(am)14.
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.
49.45(25)(b)
(b) A county, city, village, town or, in a county having a population of 500,000 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 500,000 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.
49.45(25)(be)
(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 under
s. 20.435 (5) (am).
49.45(25)(bg)
(bg) An independent living center, as defined in
s. 46.96 (1) (ah), that is a certified case management provider 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.
49.45(25)(bj)
(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),
(4m), or
(4n), or
938.357 (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).
49.45(25)(bm)
(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:
49.45(25)(bm)1.
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.
49.45(25)(c)
(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.
49.45(26)
(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.
49.45(27)
(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).
49.45(29)
(29) Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under
ss. 49.46,
49.47, and
49.471.
49.45(30)
(30) Services provided by community support programs. 49.45(30)(b)
(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.
49.45(30e)
(30e) Community-based psychosocial service programs. 49.45(30e)(a)(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:
49.45(30e)(a)1.
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.
49.45(30e)(a)2.
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.
49.45(30e)(a)3.
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.
49.45(30e)(a)4.
4. The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under
par. (b) 3.
49.45(30e)(b)
(b)
Rules. The department shall promulgate rules regarding all of the following:
49.45(30e)(b)3.
3. Requirements for certification of community-based psychosocial service programs.
49.45(30e)(b)4.
4. Any other conditions for coverage of community-based psychosocial services under the Medical Assistance Program.
49.45(30e)(c)
(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.
49.45 Cross-reference
Cross Reference: See also ch.
DHS 36, Wis. adm. code.
49.45(30m)
(30m) Certain services for developmentally disabled. 49.45(30m)(a)(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:
49.45(30m)(a)2.
2. Services in an intermediate care facility for persons with mental retardation, as defined in
s. 46.278 (1m) (am), other than a state center for the developmentally disabled.
49.45(30m)(am)
(am) 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).
49.45(30m)(b)
(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).
49.45(30m)(c)
(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:
49.45(30m)(c)1.
1. Any placement or admission that is made after April 30, 2005, complied with the requirements of
s. 46.279.
49.45(31)
(31) Long-Term Care Partnership Program. 49.45(31)(a)(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:
49.45(31)(a)1.
1. The individual's resources for purposes of determining the individual's eligibility for medical assistance.
49.45(31)(a)2.
2. The amount to be recovered from the individual's estate if the individual receives medical assistance.
