Only a certified provider may receive payment from the department for services provided to individuals under the plan under this section.
The department shall pay a certified provider for a service that is covered under the plan under this section an amount that is not less than the amount that is payable for the same service under the Medical Assistance program under subch. IV
, except that the department shall make payments to federally qualified health centers and hospital outlier payments in an amount that is no higher than the amount that is payable under the Medical Assistance program under subch. IV
. A certified provider that provides a covered service to an individual with coverage under the plan under this section shall accept the department's payment as payment in full and, subject to subd. 2.
, may not bill the individual to whom the service was provided for any amount other than any cost sharing required under sub. (4)
A certified provider that provides to an individual with coverage under the plan under this section inpatient or nonemergency outpatient hospital services to which a deductible under sub. (4) (b)
applies may not charge for those services an amount that is higher than the amount that would be payable to the provider under subd. 1.
for those services.
May not exceed benefits under other plan.
The benefits covered under the plan under this section may not exceed the benefits covered under the health care benefit plan under s. 49.45 (23)
Benefits under the plan under this section shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care coverage, Medicare, or any other governmental program, except as otherwise provided by law. If an individual who has coverage under the plan under this section also has coverage under the plan under subch. II of ch. 149
, benefits under the plan under this section are secondary to the benefits provided under the plan under subch. II of ch. 149
The department is subrogated to the rights of an individual with coverage under the plan under this section to recover special damages for illness or injury to the individual caused by the act of a 3rd person to the extent that benefits are provided under the plan.
The department may recover a payment made incorrectly for benefits provided under this section on behalf of an individual if the incorrect payment was made as a result of any of the following:
At the time the individual obtained coverage under the plan under this section, the individual was on the waiting list established for the health care benefit plan under s. 49.45 (23)
because of a misstatement or omission of fact by the individual.
The individual's coverage under the plan under this section was continued because of a misstatement or omission of fact by the individual.
The department's right of recovery is against the individual with coverage under the plan under this section on whose behalf the incorrect payment was made. The extent of the recovery is limited to the amount of the benefits actually paid.
(6m) Disclosure of benefits and cost sharing.
When an individual applies for coverage under the plan under this section, the department shall provide to the individual written disclosure of the benefits provided under the plan and the premiums, deductibles, copayments, and any other cost sharing required under the plan.
(7) Review of coverage denial or discontinuation.
Any individual who is denied enrollment in the plan under this section or whose coverage is discontinued may request that the department review the action by filing with the department a written request that includes the reasons why the individual disagrees with the denial or discontinuation of coverage. The written request must be filed within 60 days after the coverage denial or discontinuation. An individual must exhaust the process under this subsection before commencing any action in court relating to the coverage denial or discontinuation.
(8) Inapplicable provisions.
All of the following apply to the plan under this section:
(9) Reports to joint committee on finance.
The department shall on a quarterly basis submit a report to the joint committee on finance that includes information on the solvency of the plan under this section and that describes any changes that have been made under the plan since the last report was submitted to premiums, benefits, or provider payment rates.
(9g) Reports to joint committee on finance.
The department shall on a quarterly basis submit a report to the joint committee on finance that includes, relevant to the period since the last report, all of the following concerning the plan under this section:
Information about solvency, including claims paid, premium collected, and condition of reserves.
A description of any changes to premiums, benefits, enrollee cost sharing, or provider payment rates.
Demographic information about applicants and enrollees, including age, gender, residence, health status, employment, income, health insurance history, and claims history under the plan under this section.
A description of the department's process for verifying eligibility of applicants and enrollees and information about the number of applicants and enrollees found to be eligible and the number of applicants and enrollees found to be ineligible under the plan's eligibility criteria.
(9m) Termination of plan.
The plan under this section shall terminate on January 1, 2014. The department shall not pay any claim under this section for services provided after December 31, 2013, to an individual with coverage under the plan under this section.
Aid for treatment of kidney disease. 49.68(1)
Declaration of policy.
The legislature finds that effective means of treating kidney failure are available, including dialysis or artificial kidney treatment or transplants. It further finds that kidney disease treatment is prohibitively expensive for the overwhelming portion of the state's citizens. It further finds that public and private insurance coverage is inadequate in many cases to cover the cost of adequate treatment at the proper time in modern facilities. The legislature finds, in addition, that the incidence of the disease in the state is not so great that public aid may not be provided to alleviate this serious problem for a relatively modest investment. Therefore, it is declared to be the policy of this state to assure that all persons are protected from the destructive cost of kidney disease treatment by one means or another.
In this section, "recombinant human erythropoietin" means a bioengineered glycoprotein that has the same biological effects in stimulating red blood cell production as does the glycoprotein erythropoietin that is produced by the human body.
(2) Duties of department.
The department shall:
Promulgate rules setting standards for operation and certification of dialysis and renal transplantation centers and home dialysis equipment and suppliers.
Promulgate rules setting standards for acceptance and certification of patients into the treatment phase of the program.
Promulgate rules concerning reasonable cost and length of treatment programs.
Aid in preparing educational programs and materials informing the public as to chronic renal disease and the prevention and treatment thereof.
(3) Aid to kidney disease patients. 49.68(3)(a)(a)
Subject to s. 49.687 (1m)
, any permanent resident of this state who suffers from chronic renal disease may be accepted into the dialysis treatment phase of the renal disease control program if the resident meets standards set by rule under sub. (2)
and s. 49.687
From the appropriation accounts under ss. 20.435 (4) (e)
, the state shall pay, at a rate determined by the department under par. (e)
, for medical treatment that is required as a direct result of chronic renal disease of certified patients from the date of certification, including administering recombinant human erythropoietin to appropriate patients, whether the treatment is rendered in an approved facility in the state or in a dialysis or transplantation center that is approved as such by a contiguous state, subject to the conditions specified under par. (d)
. Approved facilities may include a hospital in-center dialysis unit or a nonhospital dialysis center that is closely affiliated with a home dialysis program supervised by an approved facility. Aid shall also be provided for all reasonable expenses incurred by a potential living-related donor, including evaluation, hospitalization, surgical costs, and postoperative follow-up to the extent that these costs are not reimbursable under the federal medicare program or other insurance. In addition, all expenses incurred in the procurement, transportation, and preservation of cadaveric donor kidneys shall be covered to the extent that these costs are not otherwise reimbursable. All donor-related costs are chargeable to the recipient and reimbursable under this subsection.
Disbursement and collection of all funds under this subsection shall be by the department or by a fiscal intermediary, in accordance with a contract with a fiscal intermediary. The costs of the fiscal intermediary under this paragraph shall be paid from the appropriation under s. 20.435 (1) (a)
No aid may be granted under this subsection unless the recipient has no other form of aid available from the federal medicare program, from private health, accident, sickness, medical, and hospital insurance coverage, or from other health care coverage specified by rule under s. 49.687 (1m)
. If insufficient aid is available from other sources and if the recipient has paid an amount equal to the annual medicare deductible amount specified in subd. 2.
, the state shall pay the difference in cost to a qualified recipient. If at any time sufficient federal or private insurance aid or other health care coverage becomes available during the treatment period, state aid under this subsection shall be terminated or appropriately reduced. Any patient who is eligible for the federal medicare program shall register and pay the premium for medicare medical insurance coverage where permitted, and shall pay an amount equal to the annual medicare deductible amounts required under 42 USC 1395e
(b), prior to becoming eligible for state aid under this subsection.
Aid under this subsection is only available after the patient pays an annual amount equal to the annual deductible amount required under the federal medicare program. This subdivision requires an inpatient who seeks aid first to pay an annual deductible amount equal to the annual medicare deductible amount specified under 42 USC 1395e
and requires an outpatient who seeks aid first to pay an annual deductible amount equal to the annual medicare deductible amount specified under 42 USC 1395L
No payment shall be made under this subsection for any portion of medical treatment costs or other expenses that are payable under any state, federal, or other health care coverage program, including a health care coverage program specified by rule under s. 49.687 (1m)
, or under any grant, contract, or other contractual arrangement.
Payment for services provided under this section shall be at a rate determined by the department that does not exceed the allowable charges under the federal Medicare program. In no case shall state rates for individual service elements exceed the federally defined allowable costs. The rate of charges for services not covered by public and private insurance shall not exceed the reasonable charges as established by Medicare fee determination procedures. A person that provides to a patient a service for which aid is provided under this section shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section. The state may not pay for the cost of travel, lodging, or meals for persons who must travel to receive inpatient and outpatient dialysis treatment for kidney disease. This paragraph shall not apply to donor related costs as defined in par. (b)
See also ch. DHS 152
, Wis. adm. code.
Recovery from estates. 49.682(1)(c)
"Home" means property in which a person has an ownership interest consisting of the person's dwelling and the land used and operated in connection with the dwelling.
Except as provided in par. (d)
, the department shall file a claim against the estate of a client or against the estate of the surviving spouse of a client for the amount of aid under s. 49.68
paid to or on behalf of the client.
The affidavit of a person designated by the secretary to administer this subsection is evidence of the amount of the claim.
The court shall reduce the amount of a claim under par. (a)
by up to the amount specified in s. 861.33 (2)
if necessary to allow the client's heirs or the beneficiaries of the client's will to retain the following personal property:
The decedent's wearing apparel and jewelry held for personal use.
Other tangible personal property not used in trade, agriculture or other business, not to exceed in value the amount specified in s. 861.33 (1) (a) 4.
A claim under par. (a)
is not allowable if the decedent has a surviving child who is under age 21 or disabled or a surviving spouse.
If the department's claim is not allowable because of par. (d)
and the estate includes an interest in a home, the court exercising probate jurisdiction shall, in the final judgment or summary findings and order, assign the interest in the home subject to a lien in favor of the department for the amount described in par. (a)
. The personal representative or petitioner for summary settlement or summary assignment of the estate shall record the final judgment as provided in s. 863.29
, 867.01 (3) (h)
or 867.02 (2) (h)
If the department's claim is not allowable because of par. (d)
, the estate includes an interest in a home and the personal representative closes the estate by sworn statement under s. 865.16
, the personal representative shall stipulate in the statement that the home is assigned subject to a lien in favor of the department for the amount described in par. (a)
. The personal representative shall record the statement in the same manner as described in s. 863.29
, as if the statement were a final judgment.
The department may not enforce the lien under par. (e)
as long as any of the following survive the decedent:
The department may enforce a lien under par. (e)
by foreclosure in the same manner as a mortgage on real property.
The department shall administer the program under this section and may contract with an entity to administer all or a portion of the program, including gathering and providing the department with information needed to recover payment of aid provided under s. 49.68
. All funds received under this subsection, net of any amount claimed under s. 867.035 (3)
, shall be remitted for deposit in the general fund.
The department may recover amounts under this section for the provision of aid provided under s. 49.68
paid on and after September 1, 1995.
The department may file a claim under sub. (2)
only with respect to a client who dies after September 1, 1995.
The department shall promulgate rules establishing standards for determining whether the application of this section would work an undue hardship in individual cases. If the department determines that the application of this section would work an undue hardship in a particular case, the department shall waive application of this section in that case.
The department may contract with or employ an attorney to probate estates to recover under this section the costs of care.
History: 1995 a. 27
; Stats. 1995 s. 49.682; 1995 a. 225
; 1999 a. 9
Cystic fibrosis aids. 49.683(1)
Subject to s. 49.687 (1m)
, the department may provide financial assistance for costs of medical care of persons over the age of 18 years with the diagnosis of cystic fibrosis who meet financial requirements established by the department by rule under s. 49.687 (1)
No payment shall be made under this section for any portion of medical care costs that are payable under any state, federal, or other health care coverage program, including a health care coverage program specified by rule under s. 49.687 (1m)
, or under any grant, contract, or other contractual arrangement.
History: 1973 c. 300
; Stats. 1973 s. 146.35; 1973 c. 336
; Stats. 1973 s. 146.36; 1975 c. 39
; 1979 c. 34
s. 2102 (43) (a)
; 1983 a. 27
; Stats. 1983 s. 49.483; 1993 a. 16
; 1995 a. 27
; Stats. 1995 s. 49.683; 1997 a. 27
; 1999 a. 9
; 2001 a. 16
; 2003 a. 33
See also ch. DHS 154
, Wis. adm. code.
Hemophilia treatment services. 49.685(1)(a)
"Comprehensive hemophilia treatment center" means a center, and its satellite facilities, approved by the department, which provide services, including development of the maintenance program, to persons with hemophilia and other related congenital bleeding disorders.
"Hemophilia" means a bleeding disorder resulting from a genetically determined clotting factor abnormality or deficiency.
"Home care" means the self-infusion of a clotting factor on an outpatient basis by the patient or the infusion of a clotting factor to a patient on an outpatient basis by a person trained in such procedures.
"Maintenance program" means the individual's therapeutic and treatment regimen, including medical, dental, social and vocational rehabilitation including home health care.
"Net worth" means the sum of the value of liquid assets, real property, after excluding the first $10,000 of the full value of the home derived by dividing the assessed value by the assessment ratio of the taxation district.
"Physician director" means the medical director of the comprehensive hemophilia treatment center which is directly responsible for an individual's maintenance program.