SECTION 1429. 49.45 (47) of the statutes is created to read:
49.45 (47) ADULT DAY CARE CENTERS. (a) In this subsection, "adult day care center" means an entity that provides services for part of a day in a group setting to adults who need an enriched health-supportive or social experience and who may need assistance with activities of daily living, supervision or protection.
(b) No person may receive reimbursement under s. 46.27 (11) for the provision of services to clients in an adult day care center unless the adult day care center is certified by the department under sub. (2) (a) 11. as a provider of medical assistance.
(c) The biennial fee for the certification required under par. (b) of an adult day care center is $100, plus a biennial fee of $20 per client, based on the number of clients that the adult day care center is certified to serve. Fees collected under this paragraph shall be credited to the appropriation account under s. 20.435 (6) (jm).
(d) The department, by rule, may increase any fee specified in par. (c).
SECTION 1430. 49.453 (4) (title) of the statutes is amended to read:
49.453 (4) (title) IRREVOCABLE ANNUITIES, PROMISSORY NOTES AND SIMILAR TRANSFERS.
SECTION 1431. 49.453 (4) (a) of the statutes is renumbered 49.453 (4) (a) (intro.) and amended to read:
49.453 (4) (a) (intro.) For the purposes of sub. (2), whenever a covered individual or his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transfers assets to an irrevocable annuity, or transfers assets by promissory note or similar instrument, in an amount that exceeds the expected value of the benefit, the covered individual or his or her spouse transfers assets for less than fair market value. A transfer to an annuity, or a transfer by promissory note or similar instrument, is not in excess of the expected value only if all of the following are true:
SECTION 1432. 49.453 (4) (a) 1. and 2. of the statutes are created to read:
49.453 (4) (a) 1. The periodic payments back to the transferor include principal and interest that, at the time that the transfer is made, is at least at the prime lending rate as reported by the federal reserve board in federal statistical release H. 15.
2. The terms of the instrument provide for a payment schedule that includes equal periodic payments, except that payments may be unequal if the interest payments are tied to the prime lending rate, as reported by the federal reserve board in federal statistical release H. 15., and the inequality is caused exclusively by fluctuations in that rate.
SECTION 1433. 49.453 (4) (c) of the statutes is amended to read:
49.453 (4) (c) The department shall promulgate rules specifying the method to be used in calculating the expected value of the benefit, based on 26 CFR 1.72-1 to 1.72-18, and specifying the criteria for adjusting the expected value of the benefit based on a medical condition diagnosed by a physician before the assets were transferred to the annuity, or transferred by promissory note or similar instrument.
SECTION 1434. 49.46 (1p) of the statutes is created to read:
49.46 (1p) DEMONSTRATION PROJECT FOR PERSONS WITH HIV. The department shall request a waiver from the secretary of the federal department of health and human services to allow the department to provide under this section coverage of services specified under sub. (2) (b) 17. for persons who have HIV infection, as defined in s. 252.01 (2). If a waiver is granted and in effect, the department shall provide coverage for the services specified under sub. (2) (b) 17. for persons who qualify under the terms of the waiver.
SECTION 1435. 49.46 (2) (b) 8. of the statutes is amended to read:
49.46 (2) (b) 8. Home or community-based services, if provided under s. 46.27 (11), 46.275, 46.277 or 46.278 or under the family care benefit if a waiver is in effect under s. 46.281 (1) (c).
SECTION 1436. 49.46 (2) (b) 17. of the statutes is created to read:
49.46 (2) (b) 17. If a waiver under sub. (1p) is granted and in effect, clinical evaluation services, as defined by the department, for persons who qualify for coverage under sub. (1p), not to exceed $500 per year per person.
SECTION 1437. 49.46 (2) (b) 18. of the statutes is created to read:
49.46 (2) (b) 18. Alcohol or other drug abuse residential treatment services of no more than 45 days per treatment episode, under s. 49.45 (46). This subdivision does not apply after July 1, 2003.
SECTION 1438. 49.47 (4) (as) 1. of the statutes is amended to read:
49.47 (4) (as) 1. The person would meet the financial and other eligibility requirements for home or community-based services under s. 46.27 (11) or 46.277 or under the family care benefit if a waiver is in effect under s. 46.281 (1) (c) but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3).
SECTION 1439. 49.47 (4) (as) 3. of the statutes is amended to read:
49.47 (4) (as) 3. Funding is available for the person under s. 46.27 (11) or 46.277 or under the family care benefit if a waiver is in effect under s. 46.281 (1) (c).
SECTION 1440. 49.472 of the statutes is created to read:
49.472 Medical assistance purchase plan. (1) DEFINITIONS. In this section:
(a) "Earned income" has the meaning given in 42 USC 1382a (a) (1).
(am) "Family" means an individual, the individual's spouse and any dependent child, as defined in s. 49.141 (1) (c), of the individual.
(b) "Health insurance" means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.
(c) "Independence account" means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date that an individual began receiving medical assistance under this section.
(d) "Medical assistance purchase plan" means medical assistance, eligibility for which is determined under this section.
(e) "Unearned income" has the meaning given in 42 USC 1382a (a) (2).
(2) WAIVERS AND AMENDMENTS. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.
(3) ELIGIBILITY. Except as provided in sub. (6) (a), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:
(a) The individual's net income, including income that would be deemed to the individual under 20 CFR 416.1160, is less than 250% of the poverty line for a family the size of the individual's family. In calculating the net income, the department shall disregard the income specified under 42 USC 1382a (b).
(b) The individual's assets do not exceed $20,000. In determining assets, the department may not include assets that are excluded from the resource calculation under 42 USC 1382b (a) or assets accumulated in an independence account. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.
(c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income in excess of the limit established under 42 USC 1396d (q) (2) (B) and unearned income that is disregarded under sub. (4) (a) 2.
(e) The individual is legally able to work in all employment settings without a permit under s. 103.70.
(f) The individual maintains premium payments calculated by the department in accordance with sub. (4), unless the individual is exempted from premium payments under sub. (4) (b) or (c) or (5).
(g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals.
(h) The individual meets all other requirements established by the department by rule.
(4) PREMIUMS. (a) Except as provided in par. (b) and sub. (5), an individual who is eligible for medical assistance under sub. (3) and receives medical assistance shall pay a monthly premium to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:
1. The premium for any individual may not exceed the sum of the following:
a. Three and one-half percent of the individual's earned income.
b. One hundred percent of the individual's unearned income after the deductions specified in subd. 2.
2. In determining an individual's unearned income under subd. 1., the department shall disregard all of the following:
a. A maintenance allowance established by the department by rule. The maintenance allowance may not be less than the sum of $20, the federal supplemental security income payment level determined under 42 USC 1382 (b) and the state supplemental payment determined under s. 49.77 (2m).
b. Medical and remedial expenses and impairment-related work expenses.
3. The department may reduce the premium by 25% for an individual who is covered by private health insurance.
(b) The department may waive monthly premiums that are calculated to be below $10 per month.
(c) The department shall assess a one-time entry premium based on a sliding scale established by the department by rule and according to an individual's gross income. In calculating an individual's gross income, the department may treat earned and unearned income differently. The department may waive all or part of the entry premium, or extend the time period for payment of the entry premium, for an individual if the department determines that any of the following is true:
1. Assessment of the premium would impose an undue hardship on the individual and, would fail to remove barriers to employment for the individual or would fail to increase access to health care for the individual.
2. Assessment of the premium would reduce the cost-effectiveness of the medical assistance purchase plan.
(5) COMMUNITY OPTIONS PARTICIPANTS. From the appropriation under s. 20.435 (7) (bd), the department shall pay the entry premium established under sub. (4) (c) for a person who is a participant in the community options program under s. 46.27 (7), and may pay the entry premium calculated under sub. (4) (c) or the monthly premium calculated under sub. (4) (a), for an individual who is a participant in the community options program under s. 46.27 (11). No individual who is a participant in the community options program under s. 46.27 (11) may be required to pay a monthly premium calculated under sub. (4) (a) if the individual pays the amount calculated under s. 46.27 (6u) (c) 2.
(6) INSURED PERSONS. (a) Notwithstanding sub. (4) (a) 3., from the appropriation under s. 20.435 (4) (b), the department shall, on the part of an individual who is eligible for medical assistance under sub. (3), pay premiums for or purchase individual coverage offered by the individual's employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.
(b) If federal financial participation is available, from the appropriation under s. 20.435 (4) (b), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under sub. (3).
(7) DEPARTMENT DUTIES. The department shall do all of the following:
(a) Determine eligibility, or contract with a county department, as defined in 49.45 (6c) (a) 3., or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with sub. (3).
(b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.
SECTION 1441. 49.475 (5) of the statutes is amended to read:
49.475 (5) REIMBURSEMENT OF COSTS. From the appropriations under s. 20.435 (1) (4) (bm) and (p) (pa), the department shall reimburse an insurer that provides information under this section for the insurer's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of information under this section.
SECTION 1442. 49.475 (6) of the statutes is created to read:
49.475 (6) SHARING INFORMATION. The department may provide to the department of workforce development any information that the department receives under this section. The 2 departments shall agree on procedures and methods to adequately safeguard the confidentiality of the information provided.
SECTION 1443. 49.489 of the statutes is created to read:
49.489 False claims or statements prohibited. (1) In this section:
(a) "Claim" means a request submitted by a provider for payment for services or items furnished by the provider under the medical assistance program.
(b) "Statement" means a representation, certification, affirmation, document, record or accounting or bookkeeping entry made with respect to a claim or to obtain approval or payment of a claim.
(2) No provider may submit a claim or cause a claim to be submitted if the provider knows or should know any of the following:
(a) That the claim is false.
(b) That the claim includes or is supported by a written statement that asserts a material fact that is false.
(c) That the claim includes or is supported by a written statement that omits a material fact that the provider has a duty to include and, by reason of the omission, is false.
(3) No provider may make or cause to be made a written statement that contains or is accompanied by an express certification or affirmation of the truthfulness and accuracy of the statement if the provider knows or should know any of the following:
(a) That the statement asserts a material fact that is false.
(b) That the statement omits a material fact that the provider has a duty to include and, by reason of the omission, is false.
(4) For purposes of subs. (2) and (3), all of the following apply:
(a) Each claim form constitutes a separate claim.
(b) Each representation, certification, affirmation, document, record or accounting or bookkeeping entry constitutes a separate statement.
(c) A claim is subject to this section regardless of whether the claim is actually paid.
(d) A claim is considered to be made when it is received by the fiscal agent.
(e) Except as provided in par. (f), a statement is considered to be made when it is received by the fiscal agent.
(f) A statement that is not submitted to a fiscal agent but is retained by the provider to support a claim is considered to be made when it is entered in the provider's books, files or other records.
(5) Any person who violates sub. (2) or (3) may be required to forfeit not more than $5,000 for each offense.
(6) If the department assesses a forfeiture under sub. (5) for a violation of sub. (2), the department may impose on the violator, in addition to the forfeiture, a false claim surcharge in an amount that is not more than 200% of the amount of the claim in regard to which sub. (2) was found to have been violated.
(7) The department may directly assess a forfeiture provided for in sub. (5). If the department determines that a forfeiture should be assessed for a particular violation, the department shall send a notice of assessment to the alleged violator. The notice shall specify the amount of the forfeiture assessed, the violation and the statute alleged to have been violated and shall inform the alleged violator of the right to a hearing under sub. (8).
(8) An alleged violator may contest an assessment of a forfeiture by sending, within 30 days after receipt of the notice under sub. (7), a written request for hearing under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1). The administrator of the division may designate a hearing examiner to preside over the case and recommend a decision to the administrator under s. 227.46. The decision of the administrator of the division shall be the final administrative decision. The division shall commence the hearing within 30 days after receipt of the request for hearing and shall issue a final decision within 15 days after the close of the hearing. Proceedings before the division are governed by ch. 227. In any petition for judicial review of a decision by the division, the party, other than the petitioner, who was in the proceeding before the division shall be the named respondent.
(9) All forfeitures and false claim surcharges, if any, shall be paid to the department within 10 days after receipt of notice of assessment or, if the forfeiture is contested under sub. (8), within 10 days after receipt of the final decision after exhaustion of administrative review, unless the final decision is appealed. The department shall remit all forfeitures paid to the state treasurer for deposit in the school fund. The department shall credit all false claims surcharges to the appropriation account under s. 20.435 (1) (kx).
(10) The attorney general may bring an action in the name of the state to collect any forfeiture or false claim surcharge imposed under this section if the forfeiture or false claim surcharge has not been paid following the exhaustion of all administrative and judicial reviews. The only issue to be contested in any such action is whether the forfeiture or false claim surcharge has been paid.
