The department shall accept from any person a verified complaint concerning any violation of this subsection. The department shall forward to the accused within 10 days a copy of such complaint. The department, upon such investigation as it deems necessary, may dismiss the complaint or may find probable cause to believe that a violation of this subsection has occurred.
If the department finds probable cause to believe that a violation of this subsection has occurred, it may assess a forfeiture of not less than $25 nor more than $500 for each occurrence, and in addition may order that any amount illegally charged against a resident's account be restored. The department shall immediately inform the complainant and respondent of any such decision and the amount of forfeiture or repayment, if any. If the department is not notified in writing that a party wishes to contest a decision within 15 working days after the parties are informed of such decision, the department's determination shall be deemed final and may not be appealed to a court.
The department shall inform the nursing home administrators examining board of all decisions made under this paragraph.
The department's determination of serious misconduct under this subsection shall be cause for terminating the facility's participation in the state-funded portion of the medical assistance program under this subchapter.
Nursing homes shall adopt a uniform accounting system prescribed by the department for purposes of managing residents personal fund accounts.
(8) Per-visit limits on home health services reimbursement. 49.45(8)(a)4.
“Patient care visit" means a personal contact with a patient in a patient's home that is made by a registered nurse, licensed practical nurse, nurse aide, physical therapist, occupational therapist, or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under s. 49.46
, or 49.471
. “Patient care visit" does not include time spent by a nurse, therapist, or nurse aide on case management, care coordination, travel, record keeping, or supervision that is related to the patient care visit.
“Speech-language pathologist" means an individual engaged in the practice of speech-language pathology, as regulated under ch. 459
Reimbursement under s. 20.435 (4) (b)
, and (w)
for home health services provided by a certified home health agency or independent nurse shall be made at the home health agency's or nurse's usual and customary fee per patient care visit, subject to a maximum allowable fee per patient care visit that is established under par. (c)
The department shall establish a maximum statewide allowable fee per patient care visit, for each type of visit with respect to provider, that may be no greater than the cost per patient care visit, as determined by the department from cost reports of home health agencies, adjusted for costs related to case management, care coordination, travel, record keeping and supervision.
(8r) Payment for certain obstetric and gynecological care.
The rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in s. 36.60 (1) (cm)
, or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125 percent of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.
(8v) Incentive-based pharmacy payment system.
The department shall establish a system of payment to pharmacies for legend and over-the-counter drugs provided to recipients of medical assistance that has financial incentives for pharmacists who perform services that result in savings to the medical assistance program. Under this system, the department shall establish a schedule of fees that is designed to ensure that any incentive payments made are equal to or less than the documented savings. The department may discontinue the system established under this subsection if the department determines, after performance of a study, that payments to pharmacists under the system exceed the documented savings under the system.
(9) Free choice.
Any person eligible for medical assistance under s. 49.46
, or 49.471
may use the physician, chiropractor, dentist, pharmacist, podiatrist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, podiatrist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, podiatrist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist, podiatrist, or dentist may be required to practice exclusively in the medical assistance program.
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.
(9r) Complex rehabilitation technology. 49.45(9r)(a)1.
“Complex needs patient" means an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation.
“Complex rehabilitation technology" means items classified within Medicare as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. “Complex rehabilitation technology” includes complex rehabilitation manual and power wheelchairs, adaptive seating and positioning items, and other specialized equipment such as standing frames and gait trainers, as well as options and accessories related to any of these items.
“Individually configured" means having a combination of sizes, features, adjustments, or modifications that a qualified complex rehabilitation technology supplier can customize to the specific individual by measuring, fitting, programming, adjusting, or adapting as appropriate so that the device operates in accordance with an assessment or evaluation of the individual by a qualified health care professional and is consistent with the individual's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
“Medicare" means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395
“Qualified complex rehabilitation technology professional" means an individual who is certified as an assistive technology professional by the Rehabilitation Engineering and Assistive Technology Society of North America.
“Qualified complex rehabilitation technology supplier" means a company or entity that meets all of the following criteria:
Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology.
Is an employer of at least one qualified complex rehabilitation technology professional to analyze the needs and capacities of the complex needs patient in consultation with qualified health care professionals, to participate in the selection of appropriate complex rehabilitation technology for those needs and capacities of the complex needs patient, and to provide training in the proper use of the complex rehabilitation technology.
Requires a qualified complex rehabilitation technology professional to be physically present for the evaluation and determination of appropriate complex rehabilitation technology for a complex needs patient.
Has the capability to provide service and repair by qualified technicians for all complex rehabilitation technology it sells.
Provides written information at the time of delivery of the complex rehabilitation technology to the complex needs patient stating how the complex needs patient may receive service and repair for the complex rehabilitation technology.
“Qualified health care professional" means any of the following:
The department shall promulgate rules and other policies for use of complex rehabilitation technology by recipients of Medical Assistance. The department shall include in the rules all of the following:
Designation of billing codes as complex rehabilitation technology including creation of new billing codes or modification of existing billing codes. The department shall include provisions allowing quarterly updates to the designations under this subdivision.
Establishment of specific supplier standards for companies or entities that provide complex rehabilitation technology and limiting reimbursement only to suppliers that are qualified complex rehabilitation technology suppliers.
A requirement that Medical Assistance recipients who need a complex rehabilitation manual wheelchair, complex rehabilitation power wheelchair, or other complex rehabilitation seating component to be evaluated by all of the following:
A qualified health care professional who does not have a financial relationship with a qualified complex rehabilitation technology supplier.
Establishment and maintenance of payment rates for complex rehabilitation technology that are adequate to ensure complex needs patients have access to complex rehabilitation technology, taking into account the significant resources, infrastructure, and staff needed to appropriately provide complex rehabilitation technology to meet the unique needs of complex needs patients.
A requirement for contracts with the department that managed care plans providing services to Medical Assistance recipients comply with this subsection and the rules promulgated under this subsection.
Protection of access to complex rehabilitation technology for complex needs patients.
This subsection is not intended to affect coverage of speech generating devices, including healthcare common procedure coding system codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, and E2599, under the Medical Assistance program.
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.