49.45(18)(ac)(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.
49.45(18)(ag)
(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:
49.45(18)(am)1.1. Except as provided in
subd. 2., no person is liable under this subsection for services provided through prepayment contracts.
49.45(18)(am)2.
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.
49.45(18)(b)
(b) The following services are not subject to recipient cost sharing under this subsection:
49.45(18)(b)1.
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.
49.45(18)(b)2.
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.
49.45(18)(b)3.
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.
49.45(18)(b)6.
6. Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under
s. 46.215 or
46.22.
49.45(18)(b)7.
7. Home health services or, if a home health agency is unavailable, nursing services.
49.45(18)(c)
(c) The department may limit any medical assistance recipient's liability under this subsection for services it designates.
49.45(18)(d)
(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.
49.45(19)
(19) Establishing paternity and assigning support rights. 49.45(19)(a)(a) As a condition of eligibility for medical assistance, a person shall:
49.45(19)(a)1.
1. Fully cooperate in good faith with efforts directed at establishing the paternity of a nonmarital child and obtaining support payments or any other payments or property to which the person and the dependent child or children may have rights. This cooperation shall be in accordance with federal law and regulations applying to paternity establishment and collection of support payments and may not be required if the person has good cause for refusing to cooperate, as determined by the department in accordance with federal law and regulations.
49.45(19)(a)2.
2. 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.
49.45(19)(b)
(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.
49.45(19)(bm)
(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.
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. 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 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(24g)
(24g) Physician practice payment pilot. 49.45(24g)(a)(a) The department shall develop a proposal to increase medical assistance reimbursement to providers to which at least one of the following applies:
49.45(24g)(a)1.
1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
49.45(24g)(a)2.
2. The secretary determines that the provider performs well with respect to all of the following aspects of care:
49.45(24g)(a)2.a.
a. Adoption of written standards for patient access and patient communication.
49.45(24g)(a)2.b.
b. Use of data to show that standards for patient access and patient communication are satisfied.
49.45(24g)(a)2.c.
c. Use of paper or electronic charting tools to organize clinical information.
49.45(24g)(a)2.d.
d. Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
49.45(24g)(a)2.e.
e. Adoption and implementation of guidelines that are based on evidence for treatment and management of at least 3 chronic conditions.
49.45(24g)(a)2.g.
g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.
49.45(24g)(a)2.h.
h. Systematic tracking of referrals using a paper or electronic system.
49.45(24g)(a)2.i.
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.
49.45(24g)(a)2.j.
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.
49.45(24g)(c)
(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.
49.45(24g)(d)
(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.
49.45(24g)(e)
(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.
49.45(24m)
(24m) From the appropriation accounts under
s. 20.435 (4) (b),
(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. 49.45(24r)(a)(a) The department shall implement any waiver granted by 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.
49.45(24r)(b)
(b) The department may request an amended waiver from the secretary to permit the department to conduct a demonstration project to provide family planning to any man 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 man's family. If the amended waiver is granted, the department may implement the waiver.
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.
