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.
*
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.
