49.46(2)(a)6.
6. Premiums, deductibles and coinsurance and other cost-sharing obligations for items and services otherwise paid under this subsection that are required for enrollment in a group health plan, as specified in
sub. (1) (m), except that, if enrollment in the group health plan requires enrollment of family members who are not eligible under this subsection, the department shall pay, if it is cost-effective, for an ineligible family member only the premium that is required for enrollment in the group health plan.
49.46(2)(b)
(b) Except as provided in
par. (be), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services:
49.46(2)(b)1.
1. Dentists' services, limited to basic services within each of the following categories:
49.46(2)(b)3.
3. Transportation by emergency medical vehicle to obtain emergency medical care, transportation by specialized medical vehicle to obtain medical care including the unloaded travel of the specialized medical vehicle necessary to provide that transportation or, if authorized in advance by the county department under
s. 46.215 or
46.22, transportation by common carrier or private motor vehicle to obtain medical care.
49.46(2)(b)6.
6. The following services if prescribed by a physician:
49.46(2)(b)6.a.
a. Intermediate care facility services other than in an institution for mental diseases.
49.46(2)(b)6.e.
e. Inpatient hospital, skilled nursing facility and intermediate care facility services for patients of any institution for mental diseases who are under 21 years of age, are under 22 years of age and who were receiving these services immediately prior to reaching age 21, or are 65 years of age or older.
49.46(2)(b)6.f.
f. Medical day treatment services, mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist.
49.46(2)(b)6.g.
g. Nursing services, including services performed by a nurse practitioner, as defined in rules that the department shall promulgate.
49.46(2)(b)6.h.
h. Legend drugs, as listed in the Wisconsin medical assistance drug index.
49.46(2)(b)6.i.
i. Over-the-counter drugs listed by the department in the Wisconsin medical assistance drug index.
49.46(2)(b)6.L.
L. Mental health and psychosocial rehabilitative services, including case management services, provided by the staff of a community support program certified under
s. 49.45 (2) (a) 11.
49.46(2)(b)6.m.
m. Respiratory care services for ventilator-dependent individuals.
49.46(2)(b)12.
12. Care coordination for women with high-risk pregnancies.
49.46(2)(b)13.
13. Care coordination and follow-up of persons having lead poisoning or lead exposure, as defined in
s. 254.11 (9), including lead inspections.
49.46(2)(b)16.
16. Case management services for recipients with high-cost chronic health conditions or high-cost catastrophic health conditions, if the department operates a program under
s. 49.45 (43).
49.46(2)(be)
(be) Benefits for an individual eligible under
sub. (1) (a) 9. are limited to those services under
par. (a) or
(b) that are related to pregnancy, including postpartum and family planning services, or related to other conditions which may complicate pregnancy.
49.46(2)(bm)
(bm) Benefits for an individual who is eligible for medical assistance only under
sub. (1) (a) 15. are limited to those services related to tuberculosis that are described in
42 USC 1396a (z) (2).
49.46(2)(c)2.
2. For an individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare, meets the eligibility criteria under
sub. (1) and meets the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums payable under
42 USC 1395v; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.46(2)(c)3.
3. For an individual who is only entitled to coverage under part A of medicare, meets the eligibility criteria under
sub. (1) and meets the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which are not paid under
42 USC 1395 to
1395i, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare.
49.46(2)(c)4.
4. For an individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare and meets the eligibility criteria for medical assistance under
sub. (1), but does not meet the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.46(2)(c)5.
5. For an individual who is only entitled to coverage under part A of medicare and meets the eligibility criteria for medical assistance under
sub. (1), but does not meet the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which are not paid under
42 USC 1395 to
1395i, including those medicare services that are not included in the approved state plan for services under
42 USC 1396.
49.46(2)(c)5m.
5m. For an individual who is only entitled to coverage under part B of medicare and meets the eligibility criteria under
sub. (1), but does not meet the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395j to
1395w, including those medicare services that are not included in the approved state plan for services under
42 USC 1396. Payment of coinsurance for a service under part B of medicare may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.46(2)(c)6.
6. The income limitation under this paragraph is income that is equal to or less than 100% of the poverty line, as established under
42 USC 9902 (2).
49.46(2)(cm)1.1. Beginning on January 1, 1993, for an individual who is entitled to coverage under part A of medicare, is entitled to coverage under part B of medicare, meets the eligibility criteria under
sub. (1) and meets the limitation on income under
subd. 2., medical assistance shall pay the monthly premiums under
42 USC 1395r.
49.46(2)(cm)2.
2. Benefits under
subd. 1. are available for an individual whose income is greater than 100% of the poverty line but less than 120% of the poverty line.
49.46(2)(d)
(d) Benefits authorized under this subsection may not include payment for that part of any service payable through 3rd party liability or any federal, state, county, municipal or private benefit system to which the beneficiary is entitled. "Benefit system" does not include any public assistance program such as, but not limited to, Hill-Burton benefits under
42 USC 291c (e), in effect on April 30, 1980, or relief funded by a relief block grant.
49.46(2)(dm)
(dm) Benefits under this section may not include payment for services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this paragraph, the department shall define "convalescent leave" and "conditional release" by rule.
49.46(2)(f)
(f) Benefits under this subsection may not include payment for gastric bypass surgery or gastric stapling surgery unless it is performed because of a medical emergency.
49.46 History
History: 1971 c. 125,
211,
215;
1973 c. 90,
147;
1975 c. 39;
1977 c. 29 ss.
592m,
1656 (18);
1977 c. 389,
418;
1979 c. 34,
221;
1981 c. 20,
93,
317;
1983 a. 27;
1983 a. 189 s.
329 (5);
1983 a. 245 ss.
10,
15;
1983 a. 538;
1985 a. 29,
120,
176,
253;
1987 a. 27,
307,
339,
399,
413;
1989 a. 9;
1989 a. 31 ss.
1454d to
1460 and
2909g,
2909i;
1989 a. 122,
173,
333,
336,
351;
1991 a. 39,
178,
269,
316;
1993 a. 16,
99,
269,
277,
446,
450,
491;
1995 a. 27,
77,
164,
289,
303,
457; s. 13.93 (2) (c).
49.46 Annotation
Categorically needy person applying for assistance under this section need not comply with divestment of assets provisions under 49.47 (4) (d). Sinclair v. H&SS Department, 77 W (2d) 322, 253 NW (2d) 245.
49.46 Annotation
Sub. (1) (b) and s. 49.47 (6) (d) limit retroactive medical assistance payments to services received not more than three months prior to the date the application was submitted. St. Paul Ramsey Medical Center v. DHSS, 186 W(2d) 37, 519 NW (2d) 706 (Ct. App. 1994).
49.46 Annotation
States need not fund nontherapeutic abortions. Beal v. Doe, 432 US 438.
49.465
49.465
Presumptive medical assistance eligibility. 49.465(1)(1) In this section, "qualified provider" means a provider which satisfies the requirements under
42 USC 1396r-1 (b) (2), as determined by the department.
49.465(2)
(2) A pregnant woman is eligible for medical assistance benefits, as provided under
sub. (3), during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman's family income does not exceed the highest level for eligibility for benefits under
s. 49.46 (1) or
49.47 (4) (am) or
(c) 1. and ending as follows:
49.465(2)(a)
(a) If the woman applies for benefits under
s. 49.46 or
49.47 within the time required under
sub. (4), the day on which the department or the county department under
s. 46.215,
46.22 or
46.23 determines whether the woman is eligible for benefits under
s. 49.46 or
49.47.
49.465(2)(c)
(c) If the woman does not apply for benefits under
s. 49.46 or
49.47 within the time required under
sub. (4), the last day of the month following the month in which the provider makes the determination under this subsection.
49.465(3)
(3) The department shall audit and pay allowable charges to a provider certified under
s. 49.45 (2) (a) 11. for medical assistance on behalf of a recipient under this section only for ambulatory prenatal care covered under
s. 49.46 (2).
49.465(4)
(4) A woman who is determined to be eligible under this section shall apply for benefits under
s. 49.46 or
49.47 on or before the last day of the month following the month in which the qualified provider makes that determination.
49.465(5)
(5) A qualified provider which determines that a woman is eligible under this section shall do all of the following:
49.465(5)(a)
(a) Notify the department of that determination within 5 working days after the day the determination is made.
49.465(6)
(6) The department shall provide qualified providers with application forms for medical assistance under
ss. 49.46 and
49.47 and information on how to assist women in completing the forms.
49.465(7)
(7) This section does not apply beginning on the first day of the 6th month beginning after the date stated in the notice under
s. 49.141 (2) (d).
49.468
49.468
Expanded medicare buy-in. 49.468(1)(b)
(b) For an elderly or disabled individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare and who does not meet the eligibility criteria for medical assistance under
s. 49.46 (1),
49.465 or
49.47 (4) but meets the limitations on income and resources under
par. (d), medical assistance shall pay the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums payable under
42 USC 1395v; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.468(1)(c)
(c) For an elderly or disabled individual who is only entitled to coverage under part A of medicare and who does not meet the eligibility criteria for medical assistance under
s. 49.46 (1),
49.465 or
49.47 (4) but meets the limitations on income and resources under
par. (d), medical assistance shall pay the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which are not paid under
42 USC 1395 to
1395i, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty for premiums under part A of medicare, if applicable.
49.468(1)(d)
(d) Benefits under
par. (b) or
(c) are available for an individual who has resources that are equal to or less than 200% of the allowable resources as determined under
42 USC 1381 to
1385 and income that is equal to or less than 100% of the poverty line.
49.468(1)(e)
(e) In determining under this subsection the income of an individual who is entitled to a monthly social security benefit under
42 USC 401 to
433, the department shall exclude, from December until the month after the month in which the annual revision of the poverty line is published, the amount of the social security benefit attributable to a cost-of-living increase under
42 USC 415 (i).
49.468(1m)(a)(a) Beginning on January 1, 1993, for an elderly or disabled individual who is entitled to coverage under part A of medicare and is entitled to coverage under part B of medicare, does not meet the eligibility criteria for medical assistance under
s. 49.46 (1),
49.465 or
49.47 (4) but meets the limitations on income and resources under
par. (b), medical assistance shall pay the monthly premiums under
42 USC 1395r.
49.468(1m)(b)
(b) Benefits under
par. (a) are available for an individual who has resources that are equal to or less than 200% of the allowable resources determined under
42 USC 1381 to
1385 and income that is greater than 100% of the poverty line but less than 120% of the poverty line.
