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.
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
Under current law, with certain exceptions, the 3-member cost containment
commission is responsible for reviewing and approving the following proposed
projects:
1. A capital expenditure in excess of $1,000,000 made by or on behalf of a
hospital.
2. The implementation of new services to a hospital that exceed $500,000 in a
12-month period.
3. An expenditure in excess of $500,000 made by or on behalf of a hospital,
independent practitioner, limited liability company, partnership, unincorporated
medical group or service corporation for clinical medical equipment.
4. The purchase or acquisition of a hospital.
5. The construction or operation of an ambulatory surgery center or a home
health agency.
Current law sets forth criteria that the commission must use in its review of an
application for project approval. These criteria focus on the economic efficiency of
and need for the proposed projects. The first priority of the commission in applying
the criteria must be cost containment.
The cost containment council represents economic, provider, scientific and
consumer viewpoints. It advises the commission, reviews proposed commission
rules and periodically reports on the performance of the commission and its
operations.
This bill eliminates the cost containment commission, the cost containment
council and the capital expenditure review program.
