49.43(2)
(2) "Cost" means the reasonable cost of services, care or commodities as determined by the principles of reimbursement used under
42 USC 1395 to
1395rr, in effect on April 30, 1980.
49.43(2m)
(2m) "Cost-effective" has the meaning given in
P.L. 101-508, section 4402 (a) (2).
49.43(3)
(3) "Dentist" means a person licensed to practice dentistry.
49.43(3e)
(3e) "Department" means the department of health and family services.
49.43(3r)
(3r) "Group health plan" has the meaning given in
P.L. 101-508, section 4402 (a) (2).
49.43(5)
(5) "Hospital" means an institution, approved by the appropriate state agency, providing 24-hour continuous nursing service to patients confined therein; which provides standard dietary, nursing, diagnostic and therapeutic facilities; and whose professional staff is composed only of physicians and surgeons, or of physicians and surgeons and doctors of dental surgery.
49.43(6)
(6) "Inpatient psychiatric hospital services for individuals 21 years of age or for individuals under 22 years of age who are receiving such service immediately prior to reaching age 21" has the same meaning as provided in section 1905 (h) of the federal social security act.
49.43(7)
(7) "Intermediate care facility" means either of the following:
49.43(7)(a)
(a) An institution or distinct part thereof, which is:
49.43(7)(a)1.
1. Licensed or approved under state law to provide, on a regular basis, health related care and services to individuals who do not require the degree of care and treatment which a hospital or skilled nursing home is designated to provide but who because of their mental or physical condition require care and services above the level of room and board, which can be made available to them only through institutional facilities; and
49.43(7)(a)2.
2. Qualifies as an "intermediate care facility" within the meaning of Title XIX of the social security act.
49.43(7)(b)
(b) A public institution, or distinct part thereof, which is:
49.43(7)(b)1.
1. Licensed or approved under state law for the mentally retarded or persons with related conditions, the primary purpose of which is to provide health or rehabilitative services for mentally retarded individuals according to rules promulgated by the department; and
49.43(7)(b)2.
2. Qualifies as an "intermediate care facility" within the meaning of Title XIX of the social security act.
49.43(8)
(8) "Medical assistance" means any services or items under
ss. 49.45 to
49.47 and
49.49 to
49.497, or any payment or reimbursement made for such services or items.
49.43(9)
(9) "Physician" means a person licensed to practice medicine and surgery, and includes graduates of osteopathic colleges holding an unlimited license to practice medicine and surgery.
49.43(10)
(10) "Provider" means a person, corporation, limited liability company, partnership, unincorporated business or professional association and any agent or employe thereof who provides medical assistance.
49.43(10m)
(10m) "Public medical institution" has the meaning designated in Title XIX of the federal social security act.
49.43(10s)
(10s) "Secretary" means the secretary of health and family services.
49.43(11)
(11) "Skilled nursing home" means a facility or distinct part thereof, which:
49.43(11)(a)
(a) Is licensed or approved under state law for the accommodation of convalescents or other persons who are not acutely ill and not in need of hospital care;
49.43(11)(b)
(b) Employs sufficient registered nursing practitioners for supervision of those giving nursing care to patients; and
49.43(11)(c)
(c) Qualifies as a "skilled nursing facility" within the meaning of Title XIX of the social security act.
49.43(12)
(12) "Spouse" means the legal husband or wife of the beneficiary, whether or not eligible for medical assistance.
49.45
49.45
Medical assistance; administration. 49.45(1)
(1)
Purpose. To provide appropriate health care for eligible persons and obtain the most benefits available under Title XIX of the federal social security act, the department shall administer medical assistance, rehabilitative and other services to help eligible individuals and families attain or retain capability for independence or self-care as hereinafter provided.
49.45(2)(a)1.
1. Exercise responsibility relating to fiscal matters, the eligibility for benefits under standards set forth in
ss. 49.46 to
49.47 and general supervision of the medical assistance program.
49.45(2)(a)2.
2. Employ necessary personnel under the classified service for the efficient and economical performance of the program and shall supply residents of this state with information concerning the program and procedures.
49.45(2)(a)3.
3. Determine the eligibility of persons for medical assistance, rehabilitative and social services under
ss. 49.46,
49.468 and
49.47 and rules and policies adopted by the department and may designate this function to the county department under
s. 46.215,
46.22 or
46.23 or, to the extent permitted by federal law or a waiver from federal secretary of health and human services, to a Wisconsin works agency.
49.45(2)(a)4.
4. To the extent funds are available under
s. 20.435 (1) (bm), certify all proper charges and claims for administrative services to the department of administration for payment and the department of administration shall draw its warrant forthwith.
49.45(2)(a)5.
5. Cooperate with the division for learning support, equity and advocacy in the department of public instruction to carry out the provisions of Title XIX.
49.45(2)(a)6.
6. Appoint such advisory committees as are necessary and proper.
49.45(2)(a)7.
7. Cooperate with the federal authorities for the purpose of providing the assistance and services available under Title XIX to obtain the best financial reimbursement available to the state from federal funds.
49.45(2)(a)8.
8. Periodically report to the joint committee on finance concerning projected expenditures and alternative reimbursement and cost control policies in the medical assistance program.
49.45(2)(a)9.
9. Periodically set forth conditions of participation and reimbursement in a contract with provider of service under this section.
49.45(2)(a)10.
10. After reasonable notice and opportunity for hearing, recover money improperly or erroneously paid, or overpayments to a provider either by offsetting or adjusting amounts owed the provider under the program, crediting against a provider's future claims for reimbursement for other services or items furnished by the provider under the program, or by requiring the provider to make direct payment to the department or its fiscal intermediary.
49.45(2)(a)11.
11. Establish criteria for the certification of eligible providers of services under Title XIX of the social security act and, except as provided in
s. 49.48, certify such eligible providers.
49.45(2)(a)12.
12. Decertify or suspend under this subdivision a provider from the medical assistance program, if after giving reasonable notice and opportunity for hearing, the department finds that the provider has violated federal or state law or administrative rule and such violations are by law, regulation or rule grounds for decertification or suspension. No payment may be made under the medical assistance program with respect to any service or item furnished by the provider subsequent to decertification or during the period of suspension.
49.45(2)(a)12r.
12r. Notify the medical examining board, or any affiliated credentialing board attached to the medical examining board, of any decertification or suspension of a person holding a license granted by the board or the affiliated credentialing board if the grounds for the decertification or suspension include fraud or a quality of care issue.
49.45(2)(a)13.
13. Impose additional sanctions for noncompliance with the terms of provider agreements under
subd. 9. or certification criteria established under
subd. 11.
49.45(2)(a)14.
14. Assure due process in implementing
subds. 12. and
13. by providing written notice, a fair hearing and a written decision.
49.45(2)(a)15.
15. Routinely provide notification to persons eligible for medical assistance, or such persons' guardians, of the department's access to provider records.
49.45(2)(a)16.
16. Notify the joint committee on finance and appropriate standing committees in each house of the legislature prior to renewing, extending or amending the claims processing contract under the medical assistance program.
49.45(2)(a)17.
17. Notify the governor, the joint committee on legislative organization, the joint committee on finance and appropriate standing committees, as determined by the presiding officer of each house, if the appropriation under
s. 20.435 (5) (b) is insufficient to provide the state share of medical assistance.
49.45(2)(a)18.
18. Conduct outreach for the early and periodic screening, diagnosis and treatment program as required under
42 CFR 441. This activity is limited to persons under 21 years of age who have been determined to be eligible for medical assistance.
49.45(2)(a)20.
20. Submit a report, by May 1, 1991, and annually thereafter, to the joint committee on finance on the participation rates of children in the early and periodic screening and diagnosis program.
49.45(2)(a)22.
22. After consulting with counties, independent living centers, consumer organizations and home health agencies, periodically identify those barriers to the provision of personal care services under
s. 49.46 (2) (b) 6. j. which lead to a failure to respond to the needs and preferences of individuals who are eligible for these services and act to remove the barriers to the extent possible.
49.45(2)(a)23.
23. Promulgate rules that define "supportive services", "personal services" and "nursing services" provided in a certified residential care apartment complex, as defined under
s. 50.01 (1d), for purposes of reimbursement under
ss. 46.27 (11) (c) 7. and
46.277 (5) (e).
49.45(2)(a)24.
24. In consultation with hospitals, health maintenance organizations, county departments of social services and of human services and other interested parties, develop and, not later than January 1, 1999, implement a process for expediting medical assistance eligibility determinations for persons in urgent medical situations. The department shall promulgate any rules necessary for the implementation of that process.
49.45(2)(b)1.
1. Direct a county department under
s. 46.215,
46.22 or
46.23 to perform other functions, responsibilities and services, including any functions related to health maintenance organizations, limited service health organizations and preferred provider plans.
49.45(2)(b)2.
2. Contract with any organization whether or not organized for profit to administer, in full or in part, the benefits under the medical assistance program including prepaid health care. The department shall accept bids on contracts for administrative services and services evaluating the medical assistance program as provided in
ch. 16, but may accept the contract deemed most advantageous for claims processing services; or contract with any insurer authorized under the insurance code of this state to insure the program in full or in part and on behalf of the department. The department shall submit a report each December 31 to the governor, the joint committee on finance and the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under
s. 13.172 (3), regarding the effectiveness of the management information system for monitoring and analyzing medical assistance expenditures.
49.45(2)(b)3.
3. Audit all claims filed by any contractor making the payment of benefits paid under
ss. 49.46 to
49.47 and make proper fiscal adjustments.
49.45(2)(b)4.
4. Audit claims filed by any provider of medical assistance, and as part of that audit, request of any such provider, and review, medical records of individuals who have received benefits under the medical assistance program.
49.45(2)(b)5.
5. Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.
49.45(3)(a)(a) Reimbursement shall be made to each county department under
ss. 46.215,
46.22 and
46.23 for the administrative services performed in the medical assistance program on the basis of
s. 49.33 (8). For purposes of reimbursement under this paragraph, assessments completed under
s. 46.27 (6) (a) are administrative services performed in the medical assistance program.
49.45(3)(am)1.1. From the appropriation under
s. 20.435 (1) (bm), the department shall make incentive payments to counties to encourage counties to identify medical assistance applicants and recipients who have other health care coverage and the providers of the health care coverage and give that information to the department.
49.45(3)(am)2.
2. The department shall promulgate rules governing the distribution of payments under this paragraph.
49.45(3)(b)1.1. The contractor, if any, administering benefits or providing prepaid health care under
s. 49.46,
49.465,
49.468 or
49.47 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in
sub. (2) (a) 4., but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
49.45(3)(b)2.
2. The contractor, if any, insuring benefits under
s. 49.46,
49.465,
49.468 or
49.47 shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the persons eligible to receive them and for its services as insurer.
49.45(3)(c)
(c) Payment for services provided under this section shall be made directly to the hospital, skilled and intermediate nursing homes, prepaid health care group, other organization or individual providing such services or to an organization which provides such services or arranges for their availability on a prepayment basis.
49.45(3)(d)
(d) No payment may be made for inpatient hospital services, skilled nursing home services, intermediate care facility services, tuberculosis institution services or inpatient mental institution services, unless the facility providing such services has in operation a utilization review program and meets federal regulations governing such utilization review program.
49.45(3)(dm)
(dm) After distribution of computer software has been made under
1993 Wisconsin Act 16, section 9126 (13h), no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under
s. 49.46 or
49.47 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under
42 USC 1395.
49.45(3)(e)1.1. The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital's total reimbursement or payment to that which would be provided to an economically and efficiently operated facility.
49.45(3)(e)2.
2. A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented under
subd. 1. shall annually prepare a report of cost and other data in the manner prescribed by the department.
49.45(3)(e)3.
3. The department may adopt a prospective payment system under
subd. 1. which may include consideration of an average rate per diem, diagnosis-related groups or a hospital-specific prospective rate per discharge.
49.45(3)(e)4.
4. If the department maintains a retrospective reimbursement system under
subd. 1. for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital's fiscal year may not exceed the lower of the hospital's charges for the services or the actual and reasonable allowable costs to the hospital of providing the services.
49.45(3)(e)7.
7. The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, treatment foster home or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under
sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under
42 USC 1320c to
1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
49.45(3)(e)7m.
7m. Notwithstanding
subd. 7., the daily reimbursement or payment rate for services at a hospital established under
s. 45.375 (1) provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to the facility created under
s. 45.365 (1).
49.45(3)(e)8.
8. Reimbursement or payment for outpatient hospital services may not exceed reimbursement or payment for comparable services performed by providers not owned or operated by hospitals.
49.45(3)(e)9.
9. Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital's reimbursement or payment rate under
subd. 1.
49.45(3)(e)10.
10. Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.
49.45(3)(f)1.1. Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.
49.45(3)(f)2.
2. The department may deny any provider claim for reimbursement which cannot be verified under
subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in
s. 49.46 (2). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
49.45(3)(f)2m.
2m. The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under
par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.
49.45(3)(f)3.
3. Contractors under
sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.
