49.45(47)(a)(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.
49.45(47)(b) (b) No person may receive reimbursement under s. 46.27 (11) 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.
49.45(47)(c) (c) The biennial fee for the certification required under par. (b) of an adult day care center is $100. Fees collected under this paragraph shall be credited to the appropriation account under s. 20.435 (6) (jm).
49.45(47)(d) (d) The department, by rule, may increase any fee specified in par. (c).
49.45(48) (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.
49.45(49) (49)Prescription drug prior authorization.
49.45(49)(a)(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:
49.45(49)(a)1. 1. Two physicians, as defined in s. 448.01 (5), who are currently in practice.
49.45(49)(a)2. 2. Two pharmacists, as defined in s. 450.01 (15).
49.45(49)(a)3. 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.
49.45(49)(b) (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.
49.45(49m) (49m)Prescription drug cost controls; purchasing agreements.
49.45(49m)(a)(a) In this section:
49.45(49m)(a)1. 1. "Brand name" has the meaning given in s. 450.12 (1) (a).
49.45(49m)(a)2. 2. "Generic name" has the meaning given in s. 450.12 (1) (b).
49.45(49m)(a)3. 3. "Prescription drug" has the meaning given in s. 450.01 (20).
49.45(49m)(b) (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.
49.45(49m)(c) (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:
49.45(49m)(c)1. 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.
49.45(49m)(c)2. 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).
49.45(49m)(c)3. 3. Utilization management and fraud and abuse controls.
49.45(49m)(c)4. 4. Any other activity to reduce the cost of or expenditures for prescription drugs and maintain high quality in prescription drug therapies.
49.45(49m)(d) (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.
49.45(50) (50)Disease management.
49.45(50)(a)(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:
49.45(50)(a)1. 1. Best practices.
49.45(50)(a)2. 2. Prevention strategies.
49.45(50)(a)3. 3. Clinical practice improvement.
49.45(50)(a)4. 4. Clinical interventions and protocols.
49.45(50)(a)5. 5. Outcomes research, information, and technology.
49.45(50)(a)6. 6. Other tools and resources to reduce overall costs and improve measurable outcomes.
49.45(50)(b) (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.
49.45(51) (51)Medical care transportation services.
49.45(51)(a)(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 under s. 20.435 (4) (b) 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.
49.45(51)(b) (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).
49.45(52) (52)Payment adjustments. Beginning on January 1, 2003, 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, or 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. Payment adjustments under this subsection shall include the state share of the payments. The total of any payment adjustments under this subsection and Medical Assistance payments made from appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w) may not exceed applicable limitations on payments under 42 USC 1396a (a) (30) (A).
49.45(53) (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).
49.45(56) (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:
49.45(56)(a) (a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
49.45(56)(b) (b) Educating health care providers on health care process improvement by developing best practice models.
49.45(56)(c) (c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
49.45(56)(d) (d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
49.45(56)(e) (e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
49.45(57) (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.
49.45(58) (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.
49.45 Cross-reference Cross Reference: See also chs. HA 3 and DHS 101, 102, 103, 104, 105, 106, 107, and 108, Wis. adm. code.
49.45 Annotation 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).
49.45 Annotation 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 3rd party. Ellsworth v. Schelbrock, 2000 WI 63, 235 Wis. 2d 678, 611 N.W.2d 764, 98-0294.
49.45 Annotation 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 received funds from the 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.
49.45 Annotation Medical assistance eligibility is not a default position that the department 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 MA 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.
49.45 Annotation Sub. (2) (a) 9. does not direct the department 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 was a condition of reimbursement, not an administrative rule requiring promulgation. Meda-Care Vans of Waukesha, Inc. v. Division of Hearings and Appeals, 2007 WI App 140, 302 Wis. 2d 499, 736 N.W.2d 147, 05-2979.
49.45 Annotation Medicaid reimbursement is governed by the "Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates" adopted by the department under sub. (6m). Sub. (6m) (e) requires the department to establish an appeals mechanism within the department 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. The department does not have the authority to grant an increased reimbursement rate absent appeals board approval. Park Manor, Ltd. v. Department of Health and Family Services, 2007 WI App 176, 304 Wis. 2d 512, 737 N.W.2d 88, 06-2311.
49.45 Annotation 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.
49.45 Annotation 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. Medical assistance discussed. Harris v. McRae, 448 U.S. 297 (1980).
49.45 Annotation Medical Assistance & Divestment. Canellos. Wis. Law. Aug. 1991.
49.453 49.453 Divestment of assets.
49.453(1) (1)Definitions. In this section and in s. 49.454:
49.453(1)(a) (a) "Assets" has the meaning given in 42 USC 1396p (h) (1).
49.453(1)(am) (am) "Covered individual" means an individual who is an institutionalized individual or a noninstitutionalized individual.
49.453(1)(ar) (ar) "Community spouse" means the spouse of either the institutionalized person or the noninstitutionalized person.
49.453(1)(b) (b) "Disabled" has the meaning given in 42 USC 1382c (a) (3).
49.453(1)(c) (c) "Expected value of the benefit" means the amount that an irrevocable annuity will pay to the annuitant during his or her expected lifetime as determined under sub. (4) (c).
49.453(1)(d) (d) "Income" has the meaning given in 42 USC 1396p (h) (2).
49.453(1)(e) (e) "Institutionalized individual" has the meaning given in 42 USC 1396p (h) (3).
49.453(1)(f) (f) "Look-back date" means either of the following:
49.453(1)(f)1m. 1m. For transfers made before February 8, 2006, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under s. 49.454 (2) (c) or (3) (b) the date that is 60 months before:
49.453(1)(f)1m.a. a. For a covered individual who is an institutionalized individual, the first date on which the covered individual is both an institutionalized individual and has applied for medical assistance.
49.453(1)(f)1m.b. b. For a covered individual who is a noninstitutionalized individual, the date on which the covered individual applies for medical assistance or, if later, the date on which the covered individual, his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transferred assets for less than fair market value.
49.453(1)(f)2m. 2m. For all transfers made on or after February 8, 2006, the date that is 60 months before the dates specified in subd. 1m. a. and b.
49.453(1)(fm) (fm) "Noninstitutionalized individual" has the meaning given in 42 USC 1396p (h) (4).
49.453(1)(g) (g) "Reasonable compensation" means the prevailing local market rate of compensation for the service or care provided.
49.453(1)(h) (h) "Relative" means an individual who is related to another by blood, marriage or adoption.
49.453(1)(i) (i) "Resources" has the meaning given in 42 USC 1396p (h) (5).
49.453(1)(j) (j) "Trust" has the meaning given in 42 USC 1396p (d) (6).
49.453(2) (2)Ineligibility for medical assistance for certain services.
49.453(2)(a)(a) Institutionalized individuals. Except as provided in sub. (8), if an institutionalized individual or his or her spouse, or another person acting on behalf of the institutionalized individual or his or her spouse, transfers assets for less than fair market value on or after the institutionalized individual's look-back date, the institutionalized individual is ineligible for medical assistance for the following services for the period specified under sub. (3):
49.453(2)(a)1. 1. For nursing facility services.
49.453(2)(a)2. 2. For a level of care in a medical institution equivalent to that of a nursing facility.
49.453(2)(a)3. 3. For services under a waiver under 42 USC 1396n.
49.453(2)(b) (b) Noninstitutionalized individuals. Except as provided in sub. (8), if a noninstitutionalized individual or his or her spouse, or another person acting on behalf of the noninstitutionalized individual or his or her spouse, transfers assets for less than fair market value on or after the noninstitutionalized individual's look-back date, the noninstitutionalized individual is ineligible for medical assistance for the following services for the period specified under sub. (3):
49.453(2)(b)1. 1. Services that are described in 42 USC 1396d (a) (7), (22) or (24).
49.453(2)(b)2. 2. Other long-term care services specified by the department by rule.
49.453(3) (3)Period of ineligibility.
49.453(3)(a)(a) The period of ineligibility under this subsection begins on either of the following:
49.453(3)(a)1. 1. In the case of a transfer of assets made before February 8, 2006, the first day of the first month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value and that does not occur in any other periods of ineligibility under this subsection.
49.453(3)(a)2. 2. In the case of a transfer of assets made on or after February 8, 2006, the first day of a month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance and would otherwise be receiving institutional level care described in sub. (2) (a) 1. to 3. based on an approved application for the care but for the application of the penalty period, whichever is later, and that does not occur during any other period of ineligibility under this subsection.
49.453(3)(b) (b) Subject to par. (bc), the department shall determine the number of months of ineligibility as follows:
49.453(3)(b)1. 1. The department shall determine the total, cumulative uncompensated value of all assets transferred by the covered individual or his or her spouse on or after the look-back date.
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