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 (4) (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 (4) (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)(ag)
(ag) Reimbursement shall be made to each entity contracted with under
s. 46.281 (1) (d) for functional screens performed under s.46.281 (1) (d).
49.45(3)(am)1.1. From the appropriation under
s. 20.435 (4) (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, plus any disproportionate share funding that the hospital is qualified to receive under
42 USC 1396r-4.
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.
49.45(3)(fm)
(fm) The department shall seek, on behalf of dentists who are providers, federal reimbursement for the cost of any equipment that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of the cost of the equipment that is reimbursed by the federal government.
49.45(3)(g)
(g) The secretary may appoint personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of laws, regulations, or rules applicable to Title XIX of the federal social security act or the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees appointed by the secretary under this paragraph shall be issued and shall possess at all times during which they are performing their investigatory or audit functions under this section identification signed by the secretary which specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Pursuant to the request of a designated person and upon presentation of that person's authorization, providers and recipients shall accord such person access to any records, books, recipient medical records, documents or other information needed. Authorized employees shall have authority to hold hearings, administer oaths, take testimony and perform all other duties necessary to bring such matter before the department for final adjudication and determination.
49.45(3)(h)1.1. For purposes of any audit, investigation, examination, analysis, review or other function authorized by law with respect to the medical assistance program, the secretary shall have the power to sign and issue subpoenas to any person requiring the production of any pertinent books, records, medical records or other information. Subpoenas so issued shall be served by anyone authorized by the secretary by delivering a copy thereof to the person named therein, or by registered mail or certified mail addressed to such person at his or her last-known residence or principal place of business. A verified return by the person so serving the subpoena setting forth the manner of service, or, in the event service is by registered or certified mail, the return post-office receipt signed by the person so served shall constitute proof of service.
49.45(3)(h)2.
2. In the event of contumacy or refusal to obey a subpoena issued under this paragraph and duly served upon any person, any judge in a court of record in the county where the person was served may enforce the subpoena in accordance with
s. 885.12.
49.45(3)(h)3.
3. The failure or refusal of a person to purge himself or herself of contempt found under
s. 885.12 and perform the act as required by law shall constitute grounds for decertification or suspension of that person from participation in the medical assistance program and no payment may be made for services rendered by that person subsequent to decertification or during the period of suspension.
49.45(3)(i)
(i) The department may not reimburse a provider for certain elective surgical procedures without a 2nd opinion from another provider. Second opinions are required for selected elective surgical procedures for which 2nd opinions disagree with the original opinions at demonstrably high rates. The department shall notify the providers of the surgical procedures for which a 2nd opinion is required.
49.45(3)(j)
(j) Reimbursement for administrative contract costs under this section is limited to the funds available under
s. 20.435 (4) (bm).
49.45(3)(k)
(k) If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in
s. 448.60 (3), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.
49.45(3)(L)2.
2. The department may not pay a provider for a designated health service that is authorized under this section or
s. 49.46 or
49.47, that is provided as the result of a referral made to the provider by a physician and that, under
42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of
42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under
42 USC 1395nn.
49.45(3)(L)3.
3. A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under
42 USC 1395nn (f), as amended to August 10, 1993.
49.45(3)(L)4.
4. Any person who fails to comply with
subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.
49.45(4)
(4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.
49.45(5)(a)(a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to
par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing.
49.45(5)(b)1.1. Upon receipt of a timely petition under
par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and to the county clerk or, if a Wisconsin works agency is responsible for making the medical assistance determination, the Wisconsin works agency. The county or the Wisconsin works agency may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a certified copy of its decision to the applicant or recipient, the county clerk and to the county officer or the Wisconsin works agency charged with administration of the medical assistance program. The decision of the department shall have the same effect as an order of the county officer or the Wisconsin works agency charged with the administration of the medical assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:
