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. 49.45(9p)(a)(a)
In this subsection, “recipient of medical assistance" means an individual who receives medical assistance under any of the following:
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.
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:
If the repair is to a power wheelchair, the cost of the repair is less than $300.
If the repair is to a manual wheelchair, the cost of the repair is less than $150.
The cost of the repair is a covered benefit under the program of which the individual is a recipient.
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
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
(12) Machine-readable medical assistance cards. 49.45(12)(a)(a)
The department shall assist the commissioner of insurance to conduct the study of health insurance identification cards under s. 601.57 (1)
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)
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.
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.
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.
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.
Except as provided in pars. (am)
, and subject to par. (ag)
, any person eligible for medical assistance under s. 49.46
, or 49.47
, or for the benefits under s. 49.46 (2) (a)
under s. 49.471
shall pay up to the maximum amounts allowable under 42 CFR 447.53
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.
Except as provided in pars. (am)
, and (c)
, and subject to par. (d)
, a recipient specified in par. (ac)
shall pay all of the following:
Except as provided in subd. 2.
, no person is liable under this subsection for services provided through prepayment contracts.
A person who is eligible for the benefits under s. 49.46 (2) (a)
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.
The following services are not subject to recipient cost sharing under this subsection:
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
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)
under s. 49.471
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.
Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under s. 46.215
Home health services or, if a home health agency is unavailable, nursing services.
The department may limit any medical assistance recipient's liability under this subsection for services it designates.
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) Establishing paternity and assigning support rights. 49.45(19)(a)(a)
As a condition of eligibility for medical assistance, a person shall:
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.
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.
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.
The department or the county department under s. 46.215
shall notify applicants of the requirements of this subsection at the time of application.
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. 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:
Ownership of the provider's business or all or substantially all of the assets of the business.
The right to contact and offer services to patients, clients, or residents served by the provider.
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.
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.
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.
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
, 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.
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.
The department may enforce this subsection within 4 years following a transfer.
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. 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 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
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.
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.
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.
The department may provide services to individuals who are eligible under this subsection through a medical home initiative under sub. (24j)
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:
Impose higher premiums for enrollees who engage in behaviors that increase their health risks, as determined by the department.
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.
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.
If the secretary of the federal department of health and human services approves the amendment to the waiver under par. (a)
, in whole or in part, the department shall implement the changes to the demonstration project under this subsection specified in subd. 1. a.
that are approved by the secretary, consistent with the approval.
(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. 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:
The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
The secretary determines that the provider performs well with respect to all of the following aspects of care:
Adoption of written standards for patient access and patient communication.
Use of data to show that standards for patient access and patient communication are satisfied.
Use of paper or electronic charting tools to organize clinical information.
Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
Adoption and implementation of guidelines that are based on evidence for treatment and management of at least 3 chronic conditions.