(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.
SECTION 1444. 49.496 (2) (title) of the statutes is amended to read:
49.496 (2) (title) LIENS ON THE HOMES OF NURSING HOME RESIDENTS AND INPATIENTS AT HOSPITALS.
SECTION 1445. 49.496 (2) (a) of the statutes is amended to read:
49.496 (2) (a) Except as provided in par. (b), the department may obtain a lien on a recipient's home if the recipient resides in a nursing home, or if the recipient resides in a hospital and is required to contribute to the cost of care, and the recipient cannot reasonably be expected to be discharged from the nursing home or hospital and return home. The lien is for the amount of medical assistance paid on behalf of the recipient while the recipient resides in a nursing home that is recoverable under sub. (3) (a).
SECTION 1446. 49.496 (2) (b) 3. of the statutes is amended to read:
49.496 (2) (b) 3. The recipient's sibling who has an ownership interest in the home and who has lived in the home continuously beginning at least 12 months before the recipient was admitted to the nursing home or hospital.
SECTION 1447. 49.496 (2) (c) 1. of the statutes is amended to read:
49.496 (2) (c) 1. Notify the recipient in writing of its determination that the recipient cannot reasonably be expected to be discharged from the nursing home or hospital, its intent to impose a lien on the recipient's home and the recipient's right to a hearing on whether the requirements for the imposition of a lien are satisfied.
SECTION 1448. 49.496 (2) (f) 3. of the statutes is amended to read:
49.496 (2) (f) 3. A child of any age who resides in the home, if that child resided in the home for at least 24 months before the recipient was admitted to the nursing home or hospital and provided care to the recipient that delayed the recipient's admission to the nursing home or hospital.
SECTION 1449. 49.496 (2) (f) 4. of the statutes is amended to read:
49.496 (2) (f) 4. A sibling who resides in the home, if the sibling resided in the home for at least 12 months before the recipient was admitted to the nursing home or hospital.
SECTION 1450. 49.496 (2) (h) of the statutes is amended to read:
49.496 (2) (h) The department shall file a release of a lien imposed under this subsection if the recipient is discharged from the nursing home or hospital and returns to live in the home.
SECTION 1451. 49.496 (3) (a) (intro.) of the statutes is amended to read:
49.496 (3) (a) (intro.) Except as provided in par. (b), the department shall file a claim against the estate of a recipient or against the estate of the surviving spouse of a recipient for all of the following unless already recovered by the department under this section:
SECTION 1452. 49.496 (3) (a) 1. of the statutes is amended to read:
49.496 (3) (a) 1. The amount of medical assistance paid on behalf of the recipient while the recipient resided in a nursing home or while the recipient was an inpatient in a medical institution hospital and was required to contribute to the cost of care.
SECTION 1453. 49.496 (3) (a) 2. a. of the statutes is amended to read:
49.496 (3) (a) 2. a. Home-based or community-based services under 42 USC 1396d (a) (7) and (8) and under any waiver granted under 42 USC 1396n (c) (4) (B) or 42 USC 1396u.
SECTION 1454. 49.496 (3) (a) 2. d. of the statutes is created to read:
49.496 (3) (a) 2. d. Personal care services under s. 49.46 (2) (b) 6. j.
SECTION 1455. 49.496 (3) (am) (intro.) of the statutes is amended to read:
49.496 (3) (am) (intro.) The court shall reduce the amount of a claim under par. (a) by up to $3,000 the amount specified in s. 861.33 (2) if necessary to allow the recipient's heirs or the beneficiaries of the recipient's will to retain the following personal property:
SECTION 1456. 49.496 (3) (am) 3. of the statutes is amended to read:
49.496 (3) (am) 3. Other tangible personal property not used in trade, agriculture or other business, not to exceed $1,000 in value the amount specified in s. 861.33 (1) (a) 4.
SECTION 1457. 49.496 (3) (b) of the statutes is amended to read:
49.496 (3) (b) A claim under par. (a) is not allowable if while the decedent has a surviving child who is under age 21 or disabled or a surviving spouse.
SECTION 1458. 49.496 (3) (c) of the statutes is renumbered 49.496 (3) (c) 1. and amended to read:
49.496 (3) (c) 1. If the department's claim is not allowable because of par. (b) and the estate includes an interest in a home, the court exercising probate jurisdiction shall, in the final judgment or summary findings and order, assign the interest in the home subject to a lien in favor of the department for the amount described in par. (a). The personal representative or petitioner for summary settlement or summary assignment of the estate shall record the final judgment as provided in s. 863.29, 867.01 (3) (h) or 867.02 (2) (h).
SECTION 1459. 49.496 (3) (c) 2. of the statutes is created to read:
49.496 (3) (c) 2. If the department's claim is not allowable because of par. (b), the estate includes an interest in a home and the personal representative closes the estate by sworn statement under s. 865.16, the personal representative shall stipulate in the statement that the home is assigned subject to a lien in favor of the department for the amount described in par. (a). The personal representative shall record the statement in the same manner as described in s. 863.29, as if the statement were a final judgment.
SECTION 1460. 49.496 (3) (f) of the statutes is created to read:
49.496 (3) (f) The department may contract with or employ an attorney to probate estates to recover under this subsection the costs of care.
SECTION 1461. 49.496 (5) of the statutes is amended to read:
