Health and social services
Public assistance
Transfer of functions from the department of health and social services
Under current law, the department of health and social services (DHSS) provides state administration of a range of economic support and work programs. These programs include: the aid to families with dependent children (AFDC) program; the job opportunities and basic skills (JOBS) program, which requires certain AFDC recipients to participate in employment and training programs; the work experience and job training program for certain noncustodial parents, commonly referred to as the children-first program; the food stamp program, under which certain low-income families are provided with food coupons; the general relief program; the relief of needy Indian persons program (RNIP); the medical assistance or medicaid program, which provides certain medical services to certain low-income individuals and recipients of certain other forms of public assistance; the program for providing state supplements to recipients under the federal supplemental security income (SSI) program, which provides cash payments to certain aged and disabled individuals; the low-income energy assistance program; and the program for paying funeral expenses of certain public assistance recipients. DHSS annually contracts with county departments of social services and human services for county income maintenance administration of RNIP, AFDC and medical assistance. Under these contracts, DHSS reimburses counties for certain administrative expenses and for payments to recipients and providers of services. Among other duties, DHSS submits to the federal authorities state plans for the administration of AFDC and medical assistance, promulgates rules that establish standards for eligibility for the programs, supervises cost accounting and management information systems that monitor utilization of services by public assistance recipients, recovers overpayments under these programs and conducts activities to reduce payment errors.
This bill transfers from DHSS to the department of industry, labor and human relations (DILHR), effective July 1, 1996, the powers and duties of state agency supervision for the administration of AFDC, JOBS, and all of the AFDC and JOBS pilot programs including learnfare, work-not-welfare and the parental responsibility pilot program. The learnfare pilot program requires certain children in families receiving AFDC to attend school as a condition of receiving AFDC benefits; the work-not-welfare pilot program sets time limits on AFDC benefits and requires AFDC recipients subject to the program to meet certain employment and training requirements; and the parental responsibility pilot program limits AFDC benefit increases for certain additional children born to AFDC recipients and requires AFDC recipients to participate in certain training and parental education programs. The bill also transfers from DHSS to DILHR administration of the food stamps program and the employment and training program for food stamp recipients; the children-first program; and the program for payment of funeral expenses for recipients of certain public assistance programs. The bill also transfers from DHSS to DILHR the responsibility for state supervision of income maintenance administration by county departments of social services and human services for medical assistance and RNIP. This includes supervision of county efforts to reduce recipient fraud under medical assistance and RNIP. However, DHSS retains responsibility for administering all aspects of medical assistance other than supervision of county income maintenance administration. DHSS also retains responsibility for administering general relief and RNIP which, as discussed below, are combined into an emergency medical relief program, and the state SSI supplement. Administration of the low-income energy assistance program is transferred under the bill from DHSS to the department of administration (DOA).
General relief and RNIP
Under current law, a county is required to provide general relief to all eligible dependent persons within the county. A similar program provides relief to needy Indian persons residing on tax-free land. This bill combines the general relief and RNIP programs into a single program called emergency medical relief, under which benefits are limited to emergency medical services. Participation by counties and tribal governing bodies in the program is optional. Under the bill, counties and tribal governing bodies may establish their own relief programs that are more comprehensive than emergency medical relief; however, partial state reimbursement is provided only to counties that elect to provide emergency medical relief and only with respect to eligible emergency medical relief costs. In particular, the bill makes the following changes:
1. Eligibility. Under current law, eligibility for general relief is determined primarily in accordance with written criteria, established by counties, to determine dependency. However, state law provides that certain people who have recently moved to the state are ineligible for general relief until they have resided in the state for at least 60 consecutive days. State law also provides that no person is eligible for general relief if the person is eligible for benefits under the AFDC or SSI programs, if the person fails to comply with general relief work requirements, if the person is removed from certain other public assistance programs as a result of sanctions or if the person is ineligible for AFDC because of provisions under the work-not-welfare pilot program, which provides AFDC benefits only for a limited time period. Similarly, current law provides that a person is not eligible for general relief medical benefits if the person is ineligible for medical assistance because the person has divested resources.
Eligibility for RNIP is currently determined under state law. A person is eligible if the person is an American Indian residing on tax-free land or is the spouse or child of such a person residing in the same household, if the person is ineligible for SSI, AFDC or medical assistance, if the person complies with RNIP work requirements and if the person meets the financial eligibility criteria under the AFDC program. A person is ineligible for RNIP if the person is ineligible for AFDC because of provisions under the work-not-welfare program.
Under this bill, eligibility for the emergency medical relief program is similar to eligibility under the current general relief program. A person is eligible for medical relief if the person resides in a county or on tribal land that elects to provide emergency medical relief and if the person qualifies under written criteria of dependency established by the emergency medical relief agency in that county or on that tribal land. The same state residency requirements which currently exist under the general relief program apply to emergency medical relief, as do the provisions requiring ineligibility of persons who receive other forms of public assistance or who have divested themselves of resources. However, unlike the eligibility criteria under the general relief program, persons who have been sanctioned under other public assistance programs or who have become ineligible for AFDC under the work-not-welfare program continue to be eligible for emergency medical relief.
2. Benefits. Currently, both the general relief and RNIP programs provide eligible recipients with cash benefits or in-kind relief for nonmedical support. These benefits are eliminated under this bill, as are nonemergency medical benefits. Under the emergency medical relief program, recipients may receive only emergency hospitalization and care when, in the reasonable professional judgment of a physician, emergency medical treatment or hospitalization is necessary because severe physical or psychological damage to the recipient will occur if the treatment or hospitalization is withheld. DHSS is required to promulgate rules establishing standards to be used by physicians in making this judgment.
3. Administration. Currently, there are a number of requirements that must be followed by counties in administering general relief, including procedures that must be followed by hospitals and counties that provide emergency medical treatment or hospitalization and provisions granting applicants for, and recipients of, general relief a number of procedural rights. These administrative provisions are largely eliminated in this bill. Instead, like the RNIP program under current law, many requirements concerning the administration of the emergency medical relief program are left to DHSS to specify in rules. The bill requires DHSS to promulgate rules regarding the administration of emergency medical relief, including procedures for making eligibility determinations, procedures for counties and tribal governing bodies to follow in obtaining partial reimbursement for emergency medical relief expenses and procedures for appealing eligibility determinations.
4. State reimbursement. Under current law, the state reimburses a county for up to 37.5% of eligible cash benefit costs under the general relief program. The state also reimburses up to 40% of eligible medical costs incurred by the county for a recipient that are not more than $10,000 and up to 70% of eligible medical costs over that amount, except in a county that enrolls its recipients in a prepaid health plan and meets certain additional criteria, in which case the state reimburses the county for 60% of the enrollment costs. If there are not enough funds appropriated to pay the maximum percentages permitted under current law, DHSS prorates the available funds among the counties claiming reimbursement. Current law also requires a county to accept, as payment of a claim for reimbursement of general relief costs, certain payments made to county hospitals and county mental health complexes under the medical assistance program. There is no reimbursement by the state for administrative costs relating to general relief. Under current law, the state reimburses elected tribal governing bodies for 100% of RNIP benefits and for 100% of RNIP administrative costs.
Under this bill, reimbursement is provided only for eligible emergency medical costs. For counties, the reimbursement percentages are the same as under current law, except that if a county operates a comprehensive medical relief program and enrolls its participants in a prepaid health plan, the state reimburses the county for 60% of the portion of the enrollment costs for all recipients that are attributable to emergency medical services. Under the bill, DHSS is required to promulgate rules for determining the portion of the enrollment costs that are attributable to emergency care. Counties are required to treat certain payments to county hospitals and county mental health complexes under the medical assistance program as reimbursement for emergency medical relief. If there are insufficient funds appropriated to pay counties the maximum reimbursement percentages, proration among the counties is required. For tribal governing bodies, the state reimburses 100% of eligible emergency medical costs, but no longer reimburses tribal governing bodies for any administrative costs. As under current law, reimbursement is made to counties on a yearly basis and reimbursement is made to tribal governing bodies in accordance with DHSS rules.
5. Repeal of general relief and RNIP work programs. Under current law, recipients of general relief and RNIP may be required to participate in work or grant diversion programs. Under the general relief grant diversion program, counties may use a recipient's general relief grant to pay up to 50% of the wages that an employer pays to the recipient for a period of up to 6 months. If the employer fails to retain the individual as an employe for at least 3 months after the wage subsidization has ended and the employe was not dismissed for cause, the employer must pay back the wage subsidization that it received. As part of general relief work programs, the general relief agency may require participation in educational or other programs that, in the judgment of the general relief agency, can assist the recipient in achieving financial independence. Current law provides for similar RNIP work relief and grant diversion programs, as well as for tribal economic development projects. This bill repeals these work and grant diversion programs. The bill authorizes counties to operate their own county-funded relief programs and permits counties to include work components in these relief programs.
6. Other changes. This bill makes a number of other changes related to the elimination of general relief and relief of needy Indian persons and the establishment of emergency medical relief programs and optional county-funded relief programs. The bill repeals provisions governing recovery of cash overpayments and repeals provisions that allow these amounts to be recovered by withholding any state income tax refunds due the recipient. Currently, the Wisconsin conservation corps and the Wisconsin service corps programs are required to attempt to hire 50% of their corps members from among recipients of specified types of public assistance. The bill changes these specified types of public assistance to eliminate general relief and RNIP and to include optional county-funded relief programs. The bill also amends a number of provisions exempting general relief and RNIP benefits from attachment and garnishment to exempt optional county-funded relief programs instead. Similarly, the exemption of general relief benefits from income, for purposes of the Wisconsin individual income tax, is replaced with an exemption for cash benefits provided under optional county-funded relief programs.
Under current law, the state provides funding to counties to provide certain types of mental health and alcohol and other drug abuse treatment services through what is commonly referred to as "community aids". Under the general relief program, the state also reimburses counties for a portion of counties' general relief medical costs. This bill provides that counties are not required to provide mental health and alcohol and other drug abuse treatment services under the general relief program or, after January 1, 1996, under the emergency medical relief program, and prohibits state reimbursement for these services under these programs.
Aid to families with dependent children
Under this bill, DHSS is required to conduct a demonstration project, pursuant to a waiver from the secretary of the federal department of health and human services, that would permit DHSS to limit increases in an AFDC grant for certain additional children. Under the demonstration project, in determining the amount of the AFDC grant, DHSS would not consider a child born into a family more than 10 months after the date on which the family was first determined to be eligible for AFDC, subject to certain exceptions. The demonstration project does not apply to certain children who are conceived as a result of sexual assault or incest. It also does not apply to a child who is born into a family that did not receive AFDC benefits for 6 months, other than as a result of being sanctioned, and who is born during that time or not more than 10 months after the family resumed receiving AFDC benefits. In addition, it does not apply to a child who does not reside with his or her biological parents. If the waiver is granted, DHSS may award grants to counties to provide family planning education services to persons covered by the waiver. The waiver does not apply to persons subject to the parental responsibility pilot program. DHSS may request that the waiver apply to all AFDC recipients or to a test group determined by DHSS. If the waiver is granted and in effect, the bill requires DHSS to implement the waiver.
Under the JOBS program, AFDC recipients who are not exempt are required to participate in certain jobs-related activities. DHSS has received a waiver from the federal government to permit the state to require participation in the JOBS program of certain parents and other caretakers of children who would otherwise be exempt from participation under federal law and regulations. Current state law requires participation of parents and other caretakers of children who have attained 2 years of age. Current federal law now grants states the option of requiring parents and other caretakers of children who have attained one year of age to participate in the JOBS program. This bill eliminates the current provision regarding the waiver and takes advantage of the federal law option to require JOBS participation of parents and other caretakers of children who have attained one year of age.
In addition, the bill requires DHSS to request a waiver from the federal department of health and human services to permit DHSS to require AFDC applicants to provide verification of compliance with certain orientation and job search activities before providing aid under the AFDC program. Under the waiver, DHSS may require attendance at one or more orientation sessions during the 30-day period beginning on the date that the applicant applied for AFDC. In addition, DHSS may require participation in not more than 30 days of job search activities by an AFDC applicant who is subject to the JOBS program. Exceptions to the mandatory orientation and job search requirements may be made if a determination is made that the AFDC applicant would not benefit from application of the requirement. In addition, DHSS may not require participation in orientation or job search activities for certain AFDC recipients who are subject to certain school attendance requirements under the learnfare program, if the orientation or job search activity would conflict with school attendance.
The bill also requires DHSS to request a waiver from the federal department of health and human services relating to the AFDC and JOBS programs. Currently, under the JOBS program, an AFDC recipient who is not exempt and who does not participate may be removed from AFDC grant eligibility for a specified period.
The waiver requested under this bill would allow DHSS, in certain circumstances, to reduce the amount of an AFDC grant based on the level of participation in the JOBS program. The waiver would apply to an AFDC recipient who is not exempt if: 1) the AFDC recipient is required to participate in a JOBS activity for a regularly scheduled number of hours in a month; 2) the activity is expected to continue for more than one month; and 3) the recipient fails to participate in the activity for the required number of hours in that month without good cause, as defined by DHSS by rule. If these criteria are met, for every hour that an AFDC recipient is required to participate in a JOBS activity, does not participate and does not have good cause for not participating, an amount equal to the federal minimum wage is subtracted from the AFDC grant for the recipient's family for a subsequent month.
Under current state law and the terms of a waiver from the federal department of health and human services, certain AFDC recipients between the ages of 6 and 19 are required to attend school under the learnfare program. The school attendance standard, which must be maintained in order for persons subject to the learnfare program to avoid sanctions, is currently set by administrative rule. This bill provides that an individual who is subject to the learnfare program fails to meet the school attendance requirement if the individual is a habitual truant. "Habitual truant" is defined as an individual who is absent from school without an acceptable excuse for part or all of 5 or more days out of 10 consecutive days on which school is held during a school semester or for part or all of 10 or more days on which school is held during a school semester. Under current law, a school board must establish a written attendance policy specifying the reasons for which pupils may be permitted to be absent from a public school. Whether or not an individual has an acceptable excuse is determined under this written attendance policy.
Current law permits DHSS to recover overpayments of AFDC benefits by reducing the amount of a family's monthly AFDC allowance by a specified percentage of the maximum monthly payment allowance for a family of that size. The percentage is 10% for overpayments resulting from an intentional AFDC program violation by a member of the family, and is 7% in all other cases. This bill eliminates this distinction and provides for a recoupment percentage of 10% in all cases.
Currently, the state pays for certain burial, funeral and cemetery expenses of AFDC recipients. This bill requires DHSS to amend the state AFDC plan to treat these payments as special-needs items under federal AFDC regulations, thus allowing the state to receive federal financial participation for these payments under the AFDC program.
Under current law, certain pregnant women are eligible for certain benefits under the AFDC program. These benefits begin on the first day of the month in which the 7th month of pregnancy begins or on the first day of the first month after the pregnant woman notifies the county department of health or county department of social services of the pregnancy, whichever is later. If the pregnant woman was receiving AFDC prior to the notification, the woman is eligible for a maternity benefit in addition to her current AFDC grant. If the pregnant woman was not receiving AFDC but would be eligible to receive AFDC but for the fact that she has no children, the pregnant women is eligible for the maternity benefit and an AFDC grant based on a family size of one. Eligibility for all of these benefits continues through the month of the child's birth. This bill provides that these benefits do not begin until the first day of the month in which the 8th month of pregnancy begins or on the first day of the first month after the pregnant woman notifies the county department of the pregnancy, whichever is later.
The work-not-welfare program is currently a pilot program under the AFDC program. In general, persons who are subject to the pilot program receive a combined AFDC and food stamps benefit that is paid in cash. The benefits are payable only for a limited time period, generally 24 months, and must be used within a specified benefit period. After the benefits are exhausted or the benefit period has expired, persons subject to the work-not-welfare program are generally ineligible for AFDC, general relief and RNIP for a 3-year period. This bill makes a number of changes to the work-not-welfare program:
1. Under the work-not-welfare program, the monthly benefit amount is equal to the AFDC and food stamp benefit that would have been paid to the recipient if the recipient were not subject to the work-not-welfare program, with certain adjustments and exceptions. This benefit amount is calculated based on the average income of the work-not-welfare group, estimated prospectively for a 6-month period, except that, for the first 2 months of participation in the program, the benefit amount is based on the estimated average income for those first 2 months. This bill provides that, for the first 2 months of participation in the program, the benefit amount is based on the estimated income for those first 2 months.
2. Under current law, the benefit amount is generally readjusted only at regularly scheduled redeterminations, unless there is a "significant change in circumstances". Current law provides a list of the events that constitute a "significant change in circumstances". For example, under current law, it is a "significant change in circumstances" if the combined equity value of all of a work-not-welfare group's assets exceeds the asset limit for AFDC eligibility. This bill clarifies that this provision does not apply to an AFDC recipient who is also subject to the vehicle asset demonstration project or the education and employability account demonstration project. The vehicle asset demonstration project allows owners of vehicles with a total equity value of not more than $2,500 to qualify for AFDC and the education and employability account demonstration project allows AFDC receipts to accumulate $10,000 in an account, the balance of which may be used only for certain purposes, without losing AFDC eligibility. In addition, this bill includes, as a "significant change in circumstance": a) an increase or decrease in unsubsidized employment of 10 or more hours per week; b) a change in child care expenses of more than $50 per month; and c) a change in the maximum allowable child care disregard.
Under current law, a work-not-welfare group receives an additional month of benefits and a one-month extension in the group's benefit period for each month that a person in the group receives benefits under the SSI program. This bill amends this provision to also cover months in which a person has been determined to be eligible for, but does not receive, benefits under the SSI program.
Current law provides for a demonstration project under which DHSS provides certain persons who are eligible for AFDC and who have not previously resided in this state for at least 6 months, with an AFDC benefit for the first 6 months that they reside in this state that is based on the AFDC benefit levels in their previous state of residence. This project is commonly referred to as the "2-tier demonstration project". Under current law, this project does not apply to any person who has previously resided in this state for at least 6 months. Under this bill, this provision is changed to require that this 6 months of residence in the state be consecutive. In addition, current law requires DHSS to promulgate a rule, which it must update annually, establishing the AFDC benefits that will be paid under the 2-tier demonstration project. This bill modifies this requirement so that DHSS is required to promulgate a rule establishing the methods and identifying the factors that it will use to determine the benefit amounts under the project. This rule is also required to establish the initial benefit table to be used in determining benefits under the project. Changes to this initial benefit table must be published in the Wisconsin Administrative Register.
Medical assistance eligibility
Under current law, the eligibility provisions under the medical assistance program allow the spouse of a person who is institutionalized in a medical institution or a nursing facility to retain certain income and resources without having the institutionalized spouse lose eligibility for medical assistance. The "minimum monthly maintenance needs allowance" allows the community spouse to retain a minimum amount of income each month without causing the institutionalized spouse to lose medical assistance eligibility. This minimum monthly maintenance needs allowance is $1,500, increased by the rate of inflation between 1988 and the year before the year in which the calculation is made. This bill reduces the allowance, for 1996 and 1997 only, to 200% of the monthly amount of the federal poverty line for a family of 2 plus an allowance for high housing costs, except that the allowance may not exceed $1,500, increased by the rate of inflation between 1988 and the year before the year in which the calculation is made.
Current law also protects certain assets of the spouse of an institutionalized medical assistance recipient. The amount that is protected is commonly referred to as the "community spouse resource allowance". Under current law, this allowance is $60,000, increased by the rate of inflation between 1988 and the year in which the calculation is made, unless a greater amount is set at a hearing or is transferred to the community spouse by court order. This bill sets a new amount for the community spouse resource allowance, for 1996 and 1997 only, unless a greater amount is set at a hearing or is transferred to the community spouse by a court order. Under the bill, this new amount is equal to the greater of $12,000, increased by the rate of inflation between 1988 and the year in which the calculation is made, and the "spousal share of community assets", except that the amount may not exceed $60,000 increased by the rate of inflation between 1988 and the year in which the calculation is made. The "spousal share of community assets" is equal to 50% of the total value of all resources owned by the community spouse and the institutionalized spouse at the time that the institutionalized spouse was first institutionalized for a continuous period.
Under current law, there are 2 types of eligibility for medical assistance -- eligibility based on receipt of some other kind of public assistance, generally referred to as categorically needy eligibility, and eligibility based on financial need, generally referred to as medically needy eligibility. In order to qualify for medical assistance as medically needy, an individual must meet certain income limitations. Currently, an individual generally meets this income limitation if the individual's income does not exceed 133 1/3% of the greater of the maximum AFDC payment for the individual's family size or the combined benefit amount available under the federal SSI program and the state supplement to it. A separate provision of current law states that, except for persons covered under the "healthy start" program, which allows certain low-income pregnant women and children to qualify for medical assistance, no one is eligible for medical assistance if their income exceeds the maximum income levels that the federal department of health and human services sets for federal participation. This bill repeals this provision.
Currently, under the state medical assistance plan, DHSS provides medical assistance to certain persons whose income exceeds the 133 1/3% limit. DHSS currently provides medically needy medical assistance to individuals who are 65 years of age or older, blind or totally and permanently disabled, who require certain care by nursing homes or other medical institutions, who meet the medically needy resource limitations and whose incomes do not exceed 300% of the federal benefit rate under the SSI program. This bill amends the statutory medical assistance eligibility criteria to cover these individuals, except that the percentage test is lowered to 225% from 300%, effective January 1, 1996. The bill also requires that DHSS request a waiver to continue to provide medical assistance to persons who are receiving skilled nursing care services or intermediate care services as a resident of a nursing home or community-based residential facility (C-BRF) on January 1, 1996, who would lose eligibility as a result of decreasing the percentage limit from 300% to 225%. If the waiver is granted and in effect, these persons continue to be eligible for medical assistance.
This bill expands eligibility for medical assistance to cover certain individuals infected with tuberculosis who meet the income and resource eligibility requirements for the federal SSI program, but do not meet the nonfinancial SSI eligibility requirements. Individuals eligible for medical assistance under this provision are eligible only for certain tuberculosis-related services. These include prescription drugs, physician services, laboratory and X-ray services, clinic services, case-management services and certain services designed to encourage individuals to take their medications. Case-management services are available only from or through a certified case management provider in a county, city, village or town that elects to pay the portion of the costs that are not covered by the federal government.
This bill requires DHSS to seek a waiver from the secretary of the federal department of health and human services to apply special eligibility criteria to migrant workers and their dependents in determining their eligibility for medical assistance benefits. Under the bill, "migrant worker" means any person who temporarily leaves a principal place of residence outside of this state and comes to this state for not more than 10 months in a year to accept certain types of seasonal agricultural employment. "Migrant worker" does not include certain students or any person who is employed by certain of the person's relatives. DHSS is permitted to establish, by rule, additional exceptions from the definition of migrant worker.
If the waiver is granted and in effect, a migrant worker and his or her dependents are eligible for medical assistance in this state if the migrant worker and his or her dependents have a valid medical assistance identification card issued in another state and if the migrant worker completes a Wisconsin medical assistance application. This eligibility continues for the period specified on the identification card issued in the other state. DHSS is required to notify the other state that the migrant worker and his or her dependents are eligible for medical assistance in Wisconsin. In addition, if the waiver is granted and in effect, DHSS must determine medical assistance eligibility for a migrant worker and his or her dependents by using an income-averaging method, if the migrant worker and his or her dependents are not eligible for medical assistance using prospective budgeting.
Medical assistance benefits
As of January 1, 1996, this bill eliminates skilled nursing home services and intermediate care facility services, except those in an institution for mental diseases, as benefits for persons who are eligible as medically needy under the medical assistance program. A component of these benefits ("active treatment" for persons with mental illness or developmental disability) is also eliminated, under the bill, as of January 1, 1996. The bill also eliminates services that are substituted for skilled nursing or intermediate care services, to persons eligible as medically needy, under the community options program, and under the community integration programs for relocated residents of state centers for the developmentally disabled and certain other institutions. The bill provides for continuation of skilled nursing services and intermediate care facility services (including "active treatment") to persons who are, as of January 1, 1996, receiving the services as medically needy eligibles under the medical assistance program, under the community options program, and under the community integration programs, if the federal department of health and human services grants waivers of federal medicaid laws to do so.
Under current law, home and community-based personal care services are provided as a benefit under the medical assistance program for eligible persons. This bill eliminates personal care services as a benefit under the medical assistance program.
This bill requires DHSS to promulgate rules, with the approval of DOA, that define "supportive, personal and nursing services" that are permitted, under the bill, to be provided in an assisted living facility. These services may, under the bill, be reimbursed with medical assistance funds under the community options program and the community integration program for medical assistance-eligible persons who meet certain reimbursable levels of care. Reimbursement must be at 85% of the statewide nursing home medical assistance reimbursement rate. DHSS must establish this rate by July 1 annually.
Currently, under a waiver of federal medicaid laws, state general purpose revenues and federal medicaid moneys fund home or community-based care for persons who are eligible for medical assistance. These persons are either relocated into the community from certain institutions or have physical conditions that meet requirements for medical assistance reimbursement for their care in certain nursing facilities. The program funding this care is commonly known as "CIP II".
Current federal medicaid law prohibits funding, under this state's medical assistance program, of mentally ill persons aged 22 to 64 who receive services in a facility that the federal health care financing administration finds is an institution for mental diseases.
This bill prohibits use of funds under the "CIP II" program for the home or community-based care of a person who is aged 21 to 64, who has a primary diagnosis of mental illness, who is relocated to the community from a facility that is found to be an institution for mental diseases and for which DHSS has reduced the licensed bed capacity.
Currently, medical assistance provides certain dentists' services that are not required by federal law to be covered by a state's medical assistance program. Under current law, these services are limited to basic services within the following categories: diagnostic services, preventive services, restorative services, endodontic services, periodontic services, oral and maxillofacial surgery services, emergency treatment of dental pain, removable prosthodontic services and fixed prosthodontic services. This bill eliminates the coverage of basic dentists' services that are not within the categories of emergency treatment of dental pain, removable prosthodontic services or fixed prosthodontic services, unless the services are found to be necessary as a result of early and periodic screening and diagnostic services provided under the medical assistance program.
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This bill permits school districts to receive federal medical assistance funds for certain health care services provided in schools to children who are eligible for medical assistance. The bill covers those health care services that are appropriate to a school setting under rules promulgated by DHSS. The bill covers all public schools, including charter schools, and includes early childhood programs for developmentally delayed and disabled 4-year-old and 5-year-old children. If a school district elects to provide school medical services and meets all certification and reporting requirements established by DHSS, DHSS must reimburse a school district for the federal share of allowable charges for the school medical services that the school district provides and for allowable administrative costs. The bill requires DHSS to promulgate rules establishing a methodology for making these reimbursements. All other expenses for school medical services must be paid for by the school district with public funds received from state or local taxes. The bill also requires the school district to comply with all requirements of the federal department of health and human services for receiving federal financial participation.
Under current law, mental health crisis intervention services are not a covered benefit under the medical assistance program. This bill allows a county, city, village or town to elect to provide mental health crisis intervention services to medical assistance recipients as a medical assistance benefit. If a county, city, village or town elects to provide these services as a medical assistance benefit, the county, city, village or town is required to reimburse the provider of the mental health crisis intervention services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. DHSS is required to reimburse the provider for the amount that is provided by the federal government.
Under current law, medical assistance covers nurse-midwifery services only if prescribed by a physician. This bill changes this provision to cover all nurse-midwifery services regardless of whether they are prescribed by a physician.
Under current law, medical assistance provides reimbursement only for certain case management services. Generally, in order for medical assistance to provide reimbursement, the services must be provided by or through a certified case management provider in a county, city, village or town that elects to reimburse the case management provider for the portion of the costs that are not reimbursed by the federal government. In addition, the case management services must be provided to recipients with certain specified diseases or disabilities. Under current law, case management services reimbursement may generally be provided for severely emotionally disturbed children and for persons with a developmental disability, a chronic mental illness, Alzheimer's disease, alcoholism or drug dependency, a physical disability or HIV infection. This bill also permits reimbursement of case management services for a family who has a child at risk of physical, mental or emotional dysfunction, as defined by DHSS.
Currently, counties provide early intervention services, funded by state and federal moneys, to certain very young children with certain documented physical or mental conditions and their families under what is known as the "birth to 3" program. This bill expands eligibility for case management services to include children who are otherwise eligible for medical assistance who receive early intervention services under the "birth to 3" program.
Under current law, the medical assistance program covers alcohol and other drug abuse day treatment services. This benefit expires on June 30, 1995, or on the day after publication of the 1995-97 biennial budget act, whichever is later. This bill removes this expiration date.
Medical assistance provider reimbursement and funding
Under current law, there are a number of provisions that govern the amount that a nursing home is reimbursed for providing care to medical assistance recipients. This bill makes the following changes to the nursing home reimbursement provisions:
1. Under current law, a nursing home's reimbursement rate may not fall below the rate that was in effect for the nursing home during the previous fiscal year. This bill provides that the nursing home's reimbursement rate may not fall below the rate that was in effect for the nursing home on June 30, 1994.
2. Under current law, DHSS is permitted to distribute supplemental payments to nursing homes to cover the costs of caring for emotionally disturbed residents. This bill eliminates supplemental payments for emotionally disturbed residents effective July 1, 1997.
3. This bill requires DHSS to use interest and investment income of a nursing home and affiliated entities, to the extent required under the state's approved medical assistance plan, to offset allowable interest expenses in determining the nursing home's reimbursement rate. It also requires, as a condition of receiving reimbursement under the medical assistance program, that nursing homes provide information to DHSS, upon request, that DHSS considers necessary to determine allowable interest expenses of the nursing home and of affiliated entities.
4. Under current law, the "capital" component of a nursing home's reimbursement rate is based on the replacement value of a nursing home facility, as determined by a commercial estimator who is paid and contracted for by DHSS. This provision is changed to require the nursing home to pay for a commercial estimator contracted for by DHSS.
5. This bill permits an increase in total payments to nursing home facilities for state fiscal year 1995-96 of no more than 4.25% over that paid for services in state fiscal year 1994-95 and for state fiscal year 1996-97 of no more than 5% over that paid for services in state fiscal year 1995-96.
Under current law, DHSS may reimburse the 3 state centers for the developmentally disabled for the cost of services provided by the centers. This reimbursement is made from state revenues under the medical assistance program and from federal matching funds. The reimbursement is reduced by a specified amount following each placement made under the community reintegration program that involves a relocation from one of the state centers. Under current law, the specified reduction amount for the central Wisconsin center for the developmentally disabled is $55.77 per day; the amount for the northern Wisconsin center for the developmentally disabled is $49.06 per day; and the amount from the southern Wisconsin center for the developmentally disabled is $48.37 per day. This bill changes these amounts, beginning in fiscal year 1995-96, to $232, $225 and $173, respectively.
This bill permits DHSS to impose certain requirements on certain providers of medical assistance services relating to the amount that the provider may claim from DHSS as reimbursement for medical assistance services. DHSS may impose these requirements with respect to all medical assistance services except certain hospital services, skilled nursing facility and intermediate care facility services, and home and community-based services. The bill allows DHSS to require that the providers of these services charge DHSS the lesser of the provider's "best price" for the service or the provider's actual cost for the service, unless a different price is determined by a contract. The bill defines "best price" for a service to mean the lowest price that a provider has accepted or agreed to accept as payment, from any 3rd-party payer, including self-insured plans, the medicare program and insurers, for a like service provided to a customer during the same month that the service is provided. If DHSS requires that a provider charge a particular price for a service, DHSS may not reimburse the provider for more than that amount.
This bill provides that medical assistance reimbursement for home health and private-duty nursing services provided to a medical assistance recipient in a month may not exceed the average monthly cost of nursing home care, as determined by DHSS. The monthly limit does not apply to a medical assistance recipient under the age of 22, to a ventilator-dependent individual or to any other individual if DHSS determines that the cost of providing that individual with nursing home care would exceed the cost of providing the individual with the home health and private-duty nursing services.
This bill provides up to $4,500,000 in federal medical assistance moneys in each fiscal year as a match to costs of a county department of social services or human services that exceed medical assistance reimbursement for home health services, medical day treatment services, mental health services and alcohol and other drug abuse services. Under the bill, county departments that have operating deficits resulting from these costs may apply to DHSS for federal matching funds. DHSS must develop a method, using criteria specified in the bill, to distribute the federal moneys to individual county departments of social services or human services.
Under current law, DHSS must annually submit to the joint committee on finance (JCF) a report on nursing home bed use by medical assistance recipients for the immediate prior 2 fiscal years. If the report indicates a decrease in the number of beds used in the most recent fiscal year from the previous fiscal year, DHSS must calculate the difference in costs between the 2 fiscal years for the provision of the care. The DHSS report to JCF must include a proposal to transfer an amount equal to the difference from the appropriation for medical assistance to the appropriation for the community options program. If within 14 working days after submission of the report JFC does not schedule a meeting to review the action, the secretary of health and social services must transfer the funds.
This bill eliminates the requirements that DHSS annually submit a report to JCF concerning medical assistance-funded bed utilization in nursing homes; that, if the bed utilization has decreased, DHSS calculate a figure that is the difference in costs for the provision of this care; and that, if JCF fails to schedule a meeting to review the issue, funds be transferred from the medical assistance program to the community options program.
This bill requires DHSS to conduct a study of the feasibility of contracting out the operation of the medical assistance program. DHSS is required to report its findings to the governor and to the appropriate standing committees of the legislature before July 1, 1996.
Under current law, DHSS distributes certain supplemental funding under the medical assistance program to county hospitals and county mental health complexes, as determined by DHSS, for inpatient hospital services that are not in excess of the hospitals' customary charges for the services, subject to certain limitations under federal law. This bill allows DHSS to distribute this supplemental funding to county hospitals and county mental health complexes for all hospital services, not just inpatient services.
Other public assistance
Under current law, the state makes payments to certain individuals who meet the resource limitations and the nonfinancial eligibility requirements of the federal SSI program, including needy persons or couples residing in this state who receive benefits under the federal SSI program or whose income, after deducting income excludable under the federal SSI program, is less than the combined benefit level available under the federal SSI program and the state supplement. This bill changes these eligibility criteria. First, the bill eliminates eligibility for the state supplement for those needy persons and couples whose income, after deducting income excludable under the federal SSI program, is less than the combined benefit level available under the federal SSI program and the state supplement. Second, the bill allows DHSS to make certain needy persons or couples residing in this state who receive benefits under the federal SSI program ineligible for the state supplement if DHSS and the secretary of administration approve the change in eligibility and the change is not disapproved by the JCF or the governor. This procedure for changing eligibility criteria is virtually identical to the procedure under current law that allows DHSS to adjust state supplement benefit levels.
Current law allows DHSS the option of administering the state supplement directly or under a contract with the federal government. However, the appropriation from which state supplement administrative expenses are paid authorizes expenditures only for the payment of fees charged by the federal government for administration of the state supplement. This bill allows moneys to be expended from the appropriation to administer the state supplement, either directly or under a contract with the federal government.
Under current law, DHSS supplements the provision of supplemental foods, nutrition education and other services to individuals who meet the eligibility criteria under the federal special supplemental food program for women, infants and children (WIC). This bill eliminates the state supplement to the WIC program.
Under current law, DHSS may distribute funds to nonprofit organizations for certain food stamp outreach projects. The projects must inform individuals with low incomes about the availability, eligibility requirements, application procedures and benefits of the food stamp program and must meet federal requirements to allow federal reimbursement of 50% of the project costs. This bill repeals the provisions that allow DHSS to distribute funds for these outreach projects.
Under current law, if a recipient of certain types of public assistance dies and the recipient's estate is insufficient to pay the cemetery, funeral and burial expenses, the county or the applicable tribal governing body, or other organization responsible for the burial of the recipient, is required to pay certain cemetery, funeral and burial expenses. In particular, the county or tribal governing body or organization is required to pay all of the deceased recipient's cemetery expenses and the lesser of $1,000 or the amount of funeral and burial expenses that are not paid by the deceased recipient's estate or by other persons. Current law also requires DHSS to reimburse the county or tribal governing body or organization for all cemetery expenses that it pays and for those funeral and burial expenses that it is required to pay under the provision. If DHSS approves the reimbursement due to unusual circumstances, DHSS may reimburse a county or applicable tribal governing body or organization for funeral and burial expenses that it pays for the deceased, even if these expenses exceed the amount that the county or tribal governing body or organization is required to pay under the provision.
Under this bill, the county or tribal governing body or organization is required to pay the lesser of $1,000 or the amount of cemetery expenses that are not paid by the estate of the deceased and other persons. For funeral and burial expenses, the county or tribal governing body or organization is required to pay the lesser of the amount of funeral and burial expenses that are not paid by the deceased recipient's estate and other persons or the following: 1) if the total funeral and burial expenses are $1,000 or less, the amount of these expenses; 2) if the total funeral and burial expenses are more than $1,000 but not more than $2,000, 50% of the total funeral and burial expenses; and 3) if the total funeral and burial expenses are more than $2,000, $0. DHSS is required to reimburse a county or applicable tribal governing body for any cemetery, funeral or burial expenses that it is required to pay under these provisions and, if DHSS approves the reimbursement due to unusual circumstances, for any additional expenses.
Under current law, counties and tribal governing bodies are authorized to recover overpayments under the food stamp, AFDC and medical assistance programs; they are also authorized to retain a percentage of the amount recovered. Current law also authorizes DHSS to certify certain overpayments under these programs to the department of revenue (DOR) for offset against any tax refunds due the recipient of the overpayment. This bill allows DHSS to charge counties and tribal governing bodies for the administrative costs that are incurred by DOR and that are related to certification of these amounts. Recovered administrative costs may be used by DHSS for reducing error and fraud in the food stamp, AFDC and medical assistance programs.
Under current law, overpayments under the food stamp, AFDC and medical assistance programs are often recovered under a recovery plan. This bill authorizes a county or tribal governing body to assess persons who fail to comply with the terms of a recovery plan a fee in an amount not to exceed 10% of the amount remaining to be recovered at the time of the noncompliance. The fee may not be assessed more than once with respect to the same overpayment and may be assessed only if a person is no longer eligible for the type of benefits, such as food stamps, AFDC or medical assistance, that were overpaid. The fee may be retained by the county or the tribal governing body.
Under current law, DHSS may contract with a county to administer a work experience and job training program for noncustodial parents who fail to pay child support or to meet their children's needs for support as a result of unemployment or underemployment. This program is commonly referred to as the "children-first program". A judge may order, in certain child support actions, a noncustodial parent to participate in the children-first program if the noncustodial parent lives in the county in which the court action occurs and that county has a children-first program. This bill permits a judge to order a noncustodial parent to participate in a children-first program regardless of whether the noncustodial parent resides in the county in which the court action occurs. However, if the parent resides in a county other than the county in which the court action occurs, the judge may order the parent to participate in a children-first program only if the parent's county of residence has a children-first program and that county agrees to enroll the parent in that program.
Under current law, DHSS, a county or an elected tribal governing body that provides certain types of public assistance as the result of an injury, sickness or death that results in a possible recovery of an indemnity from a 3rd party, including an insurer, may require an assignment of the right to the indemnity from the public assistance recipient. Under this bill, this assignment is automatic upon the application for public assistance.
Current law provides for subrogation of certain claims against a 3rd party by a public assistance recipient, if the public assistance is provided as a result of the occurrence of an injury, sickness or death that creates a claim or cause of action against the 3rd party. This bill establishes certain notice requirements for claims assigned or subrogated under these provisions. The notice requirements generally apply to the attorney retained to represent the public assistance recipient, or his or her estate, in asserting the claim. If no attorney is retained, the notice requirements apply to the public assistance recipient or his or her guardian or, if the recipient is deceased, to the personal representative of the recipient's estate. A person who is subject to the notice requirements is required to provide notice by certified mail to DHSS as soon as practicable after the filing of the action asserting the claim; the intervention in, or consolidation of, the action; or the settlement of all or part of the claim.
Current law provides that the provision of medical benefits under the general relief program or the RNIP program or under medical assistance constitutes an assignment to DHSS, or to a county providing medical assistance or benefits, to the extent of the medical benefits or assistance provided and for benefits to which the recipient would be entitled under any policy of health and disability insurance. A similar provision assigns rights under uninsured health plans, for example, self-insured employer health plans, although this provision covers only medical assistance. Separate provisions also prohibit the imposition of requirements on DHSS, as an assignee, that are different from those imposed on any other agent or assignee of a person covered under the health and disability insurance policy or under the uninsured health plan.
This bill makes several changes to these provisions. The bill amends the provision covering assignments by uninsured health plans to cover medical benefits under the general relief and RNIP programs, or, after January 1, 1996, the emergency medical relief program, as well as medical assistance. Under current law, only the provision regarding assignment of rights under health and disability policies applies to counties providing medical assistance or benefits, as well as to DHSS. Under this bill, all of the provisions require assignment not only to DHSS, but also to counties providing medical assistance or benefits and to health maintenance organizations with which DHSS has contracted to provide medical assistance or benefits.
This bill requires DHSS to seek a waiver from the secretary of the federal department of agriculture to apply certain special eligibility criteria to migrant workers and their dependents in determining eligibility for benefits under the food stamp program. The bill uses the definition of migrant worker that is used for the waiver that the bill requires DHSS to request for migrant workers under the medical assistance program. If the waiver is granted and in effect, DHSS must determine food stamp eligibility for a migrant worker and his or her dependents using an income-averaging method, if the migrant worker and his or her dependents are not eligible for food stamps using prospective budgeting.
Under current law, DHSS has an appropriation for employment and training programs, which include the JOBS program and the food stamp employment and training project. Under this appropriation, funds that are not encumbered by December 31 of each year lapse to the general fund on the next January 1 unless transferred to the next calendar year by JCF.
This bill allows DHSS to carry forward for a county funds that are committed to the county under a performance-based contract for a specific calendar year and that are earned by the county in that year to the following calendar year, if the carry-forward is approved by the secretary of administration, without approval of JCF. The funds carried forward do not affect a county's base allocation.
The low-income energy assistance program (LIEAP) is a federal block grant program designed to support energy costs incurred by low-income households. Current law requires that $2,400,000 of LIEAP block grant funds be allocated to the payment of crisis assistance benefits to meet weather-related or fuel supply shortage emergencies. This bill eliminates this requirement and allows DHSS or, after July 1, 1996, DOA to determine the amount of the allocation.
Health
