49.45(25g)(b)2.h. h. Systematic tracking of referrals using a paper or electronic system.
49.45(25g)(b)2.i. i. Measuring the quality of the performance of the provider and of individuals who perform services on behalf of the provider, including with respect to provision of clinical services, patient outcomes, and patient safety.
49.45(25g)(b)2.j. j. Reporting to employees and contractors of the provider and to other persons on the quality of the performance of the provider and of individuals who perform services on behalf of the provider.
49.45(25g)(c) (c) The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), 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. (b) 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 January 1, 2011.
Effective date note NOTE: Par. (c) is shown as repealed and recreated eff. 1-1-15 by 2013 Wis. Act 20. Prior to 1-1-15 it reads:
Effective date text (c) The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), 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. (b) 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 January 1, 2011. If the department creates a policy under sub. (2m) (c) 4., this paragraph does not apply to the extent it conflicts with the policy.
49.45(25g)(d) (d) 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 under par. (b) beginning January 1, 2011.
49.45(25g)(e) (e) A provider may not seek medical assistance reimbursement under this subsection and sub. (25) (be) for the same services.
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), unless otherwise provided by the department by a policy created under sub. (2m) (c).
Effective date note NOTE: Sub. (27) is amended eff. 1-1-15 by 2011 Wis. Act 32 to read:
Effective date text (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(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(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(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).
49.45(31)(c)3. 3. The training under this paragraph shall cover at a minimum long-term care insurance, long-term care services, qualified partnerships, and the relationship between qualified partnerships and other public and private coverage of long-term care costs.
49.45(31)(d) (d) An insurer that issues a long-term care insurance policy described in par. (b) shall be required to submit reports to the secretary of the federal department of health and human services, in accordance with regulations developed by the secretary, that include notice of when benefits are paid under the policy, the amount of the benefits, notice of the termination of the policy, and any other information required by the secretary.
49.45(31)(e)1.1. Notwithstanding par. (b) (intro.), the department, when making a determination under par. (a) 1. or 2. with respect to an individual, shall disregard an amount equal to the insurance benefit payments that are made to or on behalf of the individual under a qualified long-term care insurance policy under 26 USC 7702B (b) that was purchased in a state that had a state plan amendment that provided for a qualified state long-term care partnership, as defined in 42 USC 1396p (b) (1) (C) (iii), at the time of the purchase of the policy.
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2011-12 Wisconsin Statutes updated through 2013 Wis. Act 380 and all Supreme Court Orders entered before Oct. 4, 2014. Published and certified under s. 35.18. Changes effective after Oct. 4, 2014 are designated by NOTES. (Published 10-4-14)