49.45(29r)(b)1.c. c. Outpatient primary care services.
49.45(29r)(b)1.d. d. Inpatient psychiatric services.
49.45(29r)(b)1.e. e. General inpatient hospital services.
49.45(29r)(b)1.f. f. Services of a care coordinator or navigator for each individual in the pilot project.
49.45(29r)(b)2. 2. The health care provider provides, directly or through an affiliated entity or contracted entity, the coordination of social services fostering the individual's recovery following an inpatient psychiatric discharge.
49.45(29r)(c) (c) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot projects under par. (b) beginning no earlier than January 1, 2016.
49.45(29r)(d) (d) Subject to par. (c), the department shall allocate a total state share amount of $600,000 plus any federal matching moneys as funding for all 3-year pilot projects under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot projects under this subsection.
49.45(29u) (29u)Psychiatric consultation reimbursement pilot project.
49.45(29u)(a)(a) In this subsection, "health care provider" does not include a health maintenance organization.
49.45(29u)(b) (b) Subject to par. (e), the department shall develop and award a pilot project lasting up to 3 years to test a new Medical Assistance payment model for adult recipients of Medical Assistance that is designed to encourage the provision of psychiatric consultations by psychiatrists to health care providers treating primary care issues and to selected specialty health care providers to help those providers manage and treat adults with mild to moderate mental illness and physical health needs. An applicant for the pilot project under this subsection shall submit a strategy to use the pilot project funding to improve mental health access in the applicant's service area and to reduce overall Medical Assistance costs. The department shall require the health care provider that is awarded the pilot project to submit to the department interim and final reports analyzing the differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports.
49.45(29u)(c) (c) The department shall award a pilot project only to a health care provider that is an organization that provides outpatient psychiatric services and primary and specialty care outpatient services for physical health conditions. The department shall allocate funding to the health care provider that is awarded a pilot project or to individual psychiatrists providing care within the organization of the health care provider that is awarded a pilot project. The department shall allocate a total state share amount of $200,000 plus any federal matching moneys as funding for the 3-year pilot project under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot project under this subsection.
49.45(29u)(d) (d) The department may limit a pilot project awarded to a health care provider described under par. (c) to specific providers or clinics within the multispecialty outpatient clinic organization.
49.45(29u)(e) (e) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot project under par. (b) beginning no earlier than January 1, 2016.
49.45(29w) (29w)Mental health services.
49.45(29w)(a)(a) In providing mental health benefits under this subchapter, the department shall do all of the following:
49.45(29w)(a)1. 1. Allow a severely emotionally disturbed child, as defined in sub. (25) (a), to access in-home therapy without having to show a failure to succeed in outpatient therapy.
49.45(29w)(a)2. 2. Allow qualifying families to participate in in-home therapy even if a child in that family is enrolled in a day treatment program.
49.45(29w)(b)1.1. In this paragraph:
49.45(29w)(b)1.a. a. "Mental health service" means a service that is covered under one of the Medical Assistance mental health or substance abuse benefits under s. 49.46 (2) of outpatient mental health, outpatient substance abuse, pharmacologic management, mental health day treatment, substance abuse day treatment, crisis intervention, service provided by a community support program or community based-psychosocial service program, community recovery services, psychotherapy and alcohol and other drug abuse services, child or adolescent day treatment services, or any other mental health or substance abuse benefit described in s. 49.46 (2).
49.45(29w)(b)1.b. b. "Telehealth" is a service provided from a remote location using a combination of interactive video, audio, and externally acquired images through a networking environment between an individual at an originating site and a provider at a remote location with the service being of sufficient audio and visual fidelity and clarity as to be functionally equivalent to face-to-face contact. "Telehealth" does not include telephone conversations or Internet-based communications between providers or between providers and individuals.
49.45(29w)(b)2. 2. Mental health services provided through telehealth are reimbursable by the Medical Assistance program under this subchapter if the provider of the service through telehealth satisfies all of the following criteria:
49.45(29w)(b)2.a. a. The provider is a certified provider of mental health services under Medical Assistance in this state and is an agency that is certified by the department as an emergency mental health service program, a comprehensive community services program, a mental health day treatment services program for children, a program organized under s. 46.23, 51.42, or 51.437, an outpatient psychotherapy clinic, or a community support program or that is certified by the department to perform a community substance abuse prevention and treatment service, except for narcotic treatment service for opiate addiction.
49.45(29w)(b)2.ag. ag. The provider and the individual providing the service comply with all Medical Assistance coverage policies and standards established by the department, rules, and federal statutes and regulations for each particular mental health service provided.
49.45(29w)(b)2.ar. ar. The provider is certified for telehealth by the department.
49.45(29w)(b)2.b. b. The individual who is providing the service is currently licensed, certified, or registered in his or her profession in this state and is in good standing with the applicable examining board in this state for that individual's profession.
49.45(29w)(b)2.c. c. The provider is located in the United States. The provider is not required to be located in this state.
49.45(30) (30)Services provided by community support programs.
49.45(30)(a)(a) A county shall provide the portion of the cost of services under s. 49.46 (2) (b) 6. L. that is not provided by the federal government.
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(30c) (30c)Licensed treatment professionals. To the extent allowable by the federal department of health and human services, the department shall certify and reimburse under the Medical Assistance program under this subchapter licensed treatment professionals, as defined in s. 51.03 (6) (a), for mental health services provided at a school regardless of whether the school site is designated as a clinic office and regardless of whether the licensed treatment professional is employed by, a contractor of, or affiliated with a clinic. The department shall seek any approval necessary from the federal department of health and human services to provide reimbursement to licensed treatment professionals under this subsection.
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)(a)5. 5. Any other condition required by rule under par. (b) 4. is satisfied.
49.45(30e)(b) (b) Rules. The department shall promulgate rules regarding all of the following:
49.45(30e)(b)1. 1. Standards for determining whether an individual is eligible under par. (a) 3.
49.45(30e)(b)2. 2. The scope of psychosocial services that may be provided under s. 49.46 (2) (b) 6. Lm.
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(30e)(d) (d) Provision of services on regional basis. Notwithstanding par. (c) and subject to par. (e), in counties that elect to deliver the services under s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to criteria established by the department, the department shall reimburse a provider of the services for the amount of the allowable charges for those services under the Medical Assistance program that is provided by the federal government and for the amount of the allowable charges that is not provided by the federal government.
49.45(30e)(e) (e) Report; release of funds.
49.45(30e)(e)1.1. Prior to implementing, and receiving funding for implementing, the regional basis provision of services under par. (d), the department shall submit to the joint committee on finance, no later than March 1, 2014, a request for the release of funds and a report on its proposal for implementation that includes all of the following:
49.45(30e)(e)1.a. a. A description of the criteria that the department will apply in its regionalization model.
49.45(30e)(e)1.b. b. A description of how the regions will be established and the degree of county participation in that process.
49.45(30e)(e)1.c. c. An updated list of the counties that have indicated, by the date of the report, that they will offer the services under s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to the criteria established by the department.
49.45(30e)(e)1.d. d. An evaluation of the estimated long-term costs of the proposed regional model.
49.45(30e)(e)2. 2. If the cochairpersons of the committee do not notify the department within 14 working days after the date that the department submits the report and the funding request that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released and the department may implement its proposal for the regional basis provision of services on July 1, 2014. If, within 14 working days after the date that the department submits the report and the funding request, the cochairpersons notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released, and the department may implement its proposal for the regional basis provision of services, only upon approval of the committee.
49.45(30f) (30f)Psychotherapy and alcohol and other drug abuse services. The department shall include licensed mental health professionals, as defined in s. 632.89 (1) (dm), and licensed psychologists, as defined in s. 455.01 (4), as providers of psychotherapy and of alcohol and other drug abuse services. Except for services provided under sub. (30e), the department may not require that licensed mental health professionals or licensed psychologists be supervised; may not require that clinical psychotherapy or alcohol and other drug abuse services be provided under a certified program; and, notwithstanding subs. (9) and (9m), may not require that a physician or other health care provider first prescribe psychotherapy or alcohol and other drug abuse services to be provided by a licensed mental health professional or licensed psychologist before the professional or psychologist may provide the services to the recipient. This subsection does not affect the department's powers under ch. 50 or 51 to establish requirements for facilities that are licensed, certified, or operated by the department.
49.45(30g) (30g)Community recovery services.
49.45(30g)(a)(a) When services are reimbursable. Community recovery services under s. 49.46 (2) (b) 6. Lo. provided to an individual are reimbursable under the Medical Assistance program only if all of the following conditions are met:
49.45(30g)(a)1. 1. An approved amendment to the state medical assistance plan permits reimbursement for the services under s. 49.46 (2) (b) 6. Lo. in the manner provided under this subsection.
49.45(30g)(a)2. 2. The county in which the individual resides elects to provide the community recovery services under s. 49.46 (2) (b) 6. Lo. through the Medical Assistance program.
49.45(30g)(a)3. 3. The individual, the community recovery services, and the community recovery services provider meet any condition set forth in the approved amendment to the medical assistance plan.
49.45(30g)(b) (b) Limit on the amount of reimbursement. If community recovery services are reimbursable under par. (a), the department shall reimburse each participating county for the portion of the federal share of allowable charges for the community recovery services provided by the county that exceeds that county's proportionate share of $600,000 in fiscal year 2010-2011 and for 95 percent of the federal share of allowable charges for the community recovery services provided by the county in each fiscal year thereafter. The portion of the federal share of allowable charges not reimbursed to counties shall be transferred to the appropriation account under s. 20.435 (5) (kx).
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)1. 1. Services under s. 51.06 (1m) (d).
49.45(30m)(a)2. 2. Services in an intermediate care facility for persons with an intellectual disability, as defined in s. 46.278 (1m) (am), other than a state center for the developmentally disabled.
49.45(30m)(a)3. 3. Services for which payment is permitted under sub. (6c) (d) 2. that are provided in a nursing facility, as defined in s. 46.279 (1) (c).
49.45(30m)(am)1.1. 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)(am)2. 2. For individuals receiving the family care benefit under s. 46.286, the care management organization that manages the family care benefit for the recipient shall pay the portion of the payment that is not covered by the federal government for services that are described under par. (a) 1. and are covered services under the family care benefit; the department shall pay the remainder of the portion of the payment that is not covered by the federal government.
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(30m)(c)2. 2. For an individual who was provided protective placement under ch. 55 at any time, any annual review that is conducted under s. 55.18 (1) (a) (intro.) after April 30, 2005, complies with the requirements of s. 55.18 (1) (ar).
49.45(30r) (30r)Services in a mental health institute. A county shall provide the portion of payment that is not provided by the federal government for services under s. 49.46 (2) (b) 6. e. in a mental health institute under s. 51.05.
49.45(30x) (30x)Licensed midwife services.
49.45(30x)(a)(a) Provider reimbursement. Beginning January 1, 2016, services under s. 49.46 (2) (b) 12t. provided to an individual are reimbursable under the Medical Assistance program if an amendment to the state medical assistance plan approved by the federal department of health and human services permits reimbursement under s. 49.46 (2) (b) 12t.
49.45(30x)(b) (b) Plan amendment. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of par. (a). The department may not pay reimbursement under par. (a) unless the amendment to the state plan allowing reimbursement under s. 49.46 (2) (b) 12t. is approved and in effect.
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.
49.45(31)(b) (b) To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:
49.45(31)(b)1. 1. The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.
49.45(31)(b)2. 2. The policy meets the definition of a qualified long-term care insurance policy under 26 USC 7702B (b).
49.45(31)(b)3. 3. The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in 42 USC 1396p (b) (5).
49.45(31)(b)4. 4. The policy includes the applicable inflation protection specified in 42 USC 1396p (b) (1) (C) (iii) (IV).
49.45(31)(b)5. 5. The commissioner of insurance certifies to the department that the policy meets the criteria under subds. 2. to 4.
49.45(31)(c)1.1. The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.
49.45(31)(c)2. 2. The training program approved under this paragraph shall include initial training that is not less than 8 hours long and ongoing training sessions that are not less than 4 hours long per session. Individuals who sell long-term care insurance policies shall be required to attend an ongoing training session every 24 months after the initial training. The commissioner may approve the initial and ongoing training sessions for continuing education requirements under s. 628.04 (3).
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2013-14 Wisconsin Statutes updated through 2015 Wis. Act 392 and all Supreme Court Orders entered before April 21, 2016. Published and certified under s. 35.18. Changes effective after April 21, 2016 are designated by NOTES. (Published 4-29-16)