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:
49.496 (5) USE OF FUNDS. From the appropriation under s. 20.435 (5) (4) (im), the department shall pay the amount of the payments under sub. (4) that is not paid from federal funds, shall pay to the federal government the amount of the funds recovered under this section equal to the amount of federal funds used to pay the benefits recovered under this section and shall spend the remainder of the funds recovered under this section for medical assistance benefits under this subchapter.
SECTION 1462. 49.499 (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, is renumbered 49.499 (1) (intro.).
SECTION 1463. 49.499 (1) to (3) of the statutes are renumbered 49.499 (1) (a) to (c).
SECTION 1464. 49.499 (2m) of the statutes is created to read:
49.499 (2m) From the appropriation under s. 20.435 (6) (g), the department may distribute funds for innovative projects designed to protect the health and property of a resident in a nursing facility, as defined in s. 49.498 (1) (i).
SECTION 1465. 49.665 (1) (a) of the statutes is renumbered 49.665 (1) (e) and amended to read:
49.665 (1) (e) "Custodial parent Parent" has the meaning given in s. 49.141 (1) (b) (j).
SECTION 1466. 49.665 (1) (b) of the statutes is repealed and recreated to read:
49.665 (1) (b) "Child" means a person who is under the age of 19.
SECTION 1467. 49.665 (1) (d) of the statutes is amended to read:
49.665 (1) (d) "Family" means a unit that consists of at least one dependent child and his or her custodial parent or parents, all of whom reside in the same household. "Family" includes the spouse of an individual who is a custodial parent if the spouse resides in the same household as the individual.
SECTION 1468. 49.665 (1) (f) of the statutes is created to read:
49.665 (1) (f) "State plan" means the state child health plan under 42 USC 1397aa (b).
SECTION 1469. 49.665 (3) of the statutes is amended to read:
49.665 (3) ADMINISTRATION. The department shall administer a program to provide the health services and benefits described in s. 49.46 (2) to families persons that meet the eligibility requirements specified in sub. (4). The department shall promulgate rules setting forth the application procedures and appeal and grievance procedures. The department may promulgate rules limiting access to the program under this section to defined enrollment periods. The department may also promulgate rules establishing a method by which the department may purchase family coverage offered by the employer of a member of an eligible family or by a member of a child's household under circumstances in which the department determines that purchasing that coverage would not be more costly than providing the coverage under this section.
SECTION 1470. 49.665 (4) (a) 1. of the statutes is amended to read:
49.665 (4) (a) 1. The family's income does not exceed 185% of the poverty line, except as provided in par. (at) and except that a family that is already receiving health care coverage under this section may have an income that does not exceed 200% of the poverty line. The department shall establish by rule the criteria to be used to determine income.
SECTION 1471. 49.665 (4) (am) of the statutes is created to read:
49.665 (4) (am) A child who does not reside with his or her parent is eligible for health care coverage under this section if the child meets all of the following requirements:
1. The child's income does not exceed 185% of the poverty line, except as provided in par. (at) and except that a child that is already receiving health care coverage under this section may have an income that does not exceed 200% of the poverty line. The department shall use the criteria established under par. (a) 1. to determine income under this subdivision.
2. The child does not have access to employer-subsidized health care coverage.
3. The child has not had access to employer-subsidized health care coverage within the time period established by the department under par. (a) 3. The department may establish exceptions to this subdivision.
4. The child meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements.
SECTION 1472. 49.665 (4) (at) of the statutes is created to read:
49.665 (4) (at) 1. The department shall establish by state plan amendment a lower maximum income level for the initial eligibility determination if funding under s. 20.435 (4) (bc), (jz) and (p) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding.
2. If, after the department has established a lower maximum income level under subd. 1., projections indicate that funding under s. 20.435 (4) (bc), (jz) and (p) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185% of the poverty line.
