This bill requires DWD and DHFS, jointly, to contract with county departments
to reimburse the county departments for the reasonable costs of determining the
eligibility of individuals for MA. Under the bill, only DWD makes the payments for
reimbursement to the county departments but the payments are funded, in part, by
an appropriation to DHFS. The bill requires DHFS to establish its own program to
investigate possible fraud on the part of MA recipients and to reduce errors in the
payments of MA or, in the alternative, to contract with DWD to conduct these
activities.
Under current federal medicaid law, nonfederal public funds transferred to the
state and expended for MA purposes may be considered as the state's share for the
purpose of claiming federal financial participation.
This bill creates an MA trust fund. The fund consists of 1) moneys received as
federal financial participation to match public moneys transferred to the state or
certified by DHFS as the state share of financial participation for MA payments
related to nursing homes; and 2) public moneys transferred to the state or certified
by DHFS as the state and federal share of financial participation for MA payments
related to nursing homes. The moneys in the MA trust fund are appropriated to
DHFS to meet the costs of MA and the administrative costs associated with
augmenting federal financial participation.
Under current law, in each fiscal year DHFS may distribute up to $38,600,000
received as federal financial participation to supplement MA payments to reduce the
operating deficits of county, city, village, or town nursing homes. DHFS must also
distribute for this purpose additional moneys received as federal financial
participation that were not anticipated before enactment of the biennial budget act
or before enactment of other legislation that affects the appropriation of such federal
moneys.
As of July 1, 2000, this bill retroactively eliminates the requirement that DHFS
distribute for this purpose additional, unanticipated moneys received as federal
financial participation and increases, to up to $40,100,000, the amount of federal
financial participation that may be distributed.
Under current law, DHFS administers the Badger Care Health Care Program
(BadgerCare) under a waiver from the federal department of health and human
services. BadgerCare provides health care coverage to certain low-income families
and to certain low-income children who do not reside with a parent. As a condition
of eligibility for BadgerCare, a family or child must be without access to
employer-subsidized health care coverage for a period specified by DHFS by rule.
This bill requires DHFS to request a waiver from the federal department to
extend the period a family or child is required to be without access to
employer-subsidized health care coverage to be eligible for BadgerCare to six
months except under certain circumstances. The bill also requires DHFS to request
a second waiver to permit DHFS, prior to enrolling a family or child in BadgerCare,
to verify whether the family or child has had access to employer-subsidized health
care.
Under current law, DHFS certifies persons that meet certain criteria as MA
providers and pays for services and items that MA recipients receive from the
providers. Currently, DHFS is authorized or required to enforce numerous
sanctions, including decertification or suspension from MA, against providers who
fail to comply with MA requirements or to whom MA payments have been improperly
or erroneously made or overpayments have been made. To implement these
sanctions, DHFS must provide written notice, a fair hearing, and a written decision.
Currently, fraud in applications for, rights to, and conversion of MA benefits or
payments is prohibited. These prohibitions are punishable by fines and
imprisonment. Also under current law, if a provider who is liable for repayment of
improper or erroneous MA payments or overpayments sells or otherwise transfers
ownership of his or her business, the seller and transferee are each liable for the
repayment. The transferee must contact DHFS and ascertain whether the seller has
an outstanding amount owing. DHFS may bring an action to compel payment
against either the seller or transferee if a sale or other transfer occurs, and the
amount has not been repaid.
This bill authorizes DHFS, after providing reasonable notice and the
opportunity for a hearing, to charge a fee to an MA provider that has repeatedly been
subject to recoveries of MA payments because of the provider's failure to follow
billing procedures or to follow other MA requirements. The fee must be used to
defray the costs of audits and investigations by DHFS of federal medicaid or MA
violations and to verify that services have been provided and the appropriateness
and accuracy of reimbursement claims. The fee may not exceed $1,000 or 200% of
the amount of any recovery, whichever is greater. The bill permits DHFS to recover
any part of such a fee that is not timely paid by offsetting the fee against any MA
payment owed to the provider. Failure to timely pay a fee is grounds for MA
decertification.
The bill authorizes DHFS to require certain MA providers, as a condition of
certification, to file with DHFS a surety bond, payable to DHFS, that would
reasonably pay the amount of a recovery and DHFS's costs to pursue recovery of
overpayments or to investigate and pursue allegations of false claims or statements.
The bill also authorizes DHFS to limit the number of providers of particular services
that may receive MA certification or limit the amount of resources, including
employees and equipment, that a certified provider may use to provide MA services
and items.
The bill changes numerous provisions relating to procedures for the recovery
by DHFS of MA overpayments or improper or erroneous payments, including all of
the following:
1. Hearing requirements are eliminated and, instead, a provider has the
opportunity to present information and argument to DHFS staff.
2. A deadline for the payment of recoveries is established, and payment of
interest on delinquent amounts is required.
The bill eliminates DHFS's general authority to suspend a provider, but instead
authorizes DHFS, if certain criteria are met, to suspend certification for a provider
pending a hearing on whether the provider must be decertified for violation of federal
or state laws.
The bill requires providers to allow DHFS access to provider records and
specifies that a provider's failure to provide access constitutes grounds for
decertification.
With respect to liability for repayment of improper or erroneous payments or
overpayments of a provider who sells or transfers ownership of his or her business,
the bill eliminates provisions that confer liability on both the transferor and the
transferee. Under the bill, before a person may take over the operation of an MA
provider, the person must obtain MA certification with respect to the provider's
operation, regardless of whether the person is currently certified. Also, before a
person may take over the operation of an MA provider that is liable for repayment
of improper or erroneous MA payments or overpayments, full repayment must be
made. Upon request, DHFS must notify the person or provider as to whether the
provider is liable. If, notwithstanding the prohibition, the person takes over the
provider's operation, and the outstanding repayment is not made, DHFS may
withhold certification from the person and may proceed against the provider or
person. If the repayment is not paid in full within 30 days after DHFS provides notice
to the certified provider, DHFS may bring an action to compel payment, to decertify
a provider, or to do both.
Under current law, DHFS receives federal funding to conduct a breast and
cervical cancer early detection program. This program provides individuals with
breast and cervical cancer screening, referrals, education, and outreach. This bill
expands MA to provide MA to women who are under the age of 65, who require
treatment for breast or cervical cancer, who have been screened for breast or cervical
cancer under the breast and cervical cancer early detection program, and who are not
otherwise eligible for MA or any other health care coverage.
Currently, the long-term support Community Options Program (COP)
provides functionality assessments of, and home and community-based care to,
among others, elderly and disabled persons as an alternative to institutionalized
care. One part of COP (often referred to as COP-Regular) is funded by state general
purpose revenues and the other part (often referred to as COP-Waiver) is funded
jointly by federal medicaid and state MA moneys under a waiver of federal medicaid
laws. Also under MA under a waiver of federal medicaid laws, a Community
Integration Program (often referred to as CIP II) provides home and
community-based services and continuity of care for persons relocated from
institutions, other than the state centers for the developmentally disabled, and for
persons who meet requirements for MA reimbursement in nursing homes.
Currently, funds under COP-Waiver and CIP II may not be used to provide
services in a C-BRF that has more than four beds unless the C-BRF has five to eight
beds and DHFS approves the C-BRF. This bill changes restrictions on the use of
COP-Waiver and CIP II funds for providing services in a C-BRF to permit use of the
funds in a C-BRF that has five to 20 beds if DHFS approves.
Currently, DHFS operates three Community Integration Programs (CIPs) as
part of MA. These programs provide home and community-based services to
individuals who are relocated from institutions such as state centers for the
developmentally disabled or nursing homes, or who meet the criteria for
reimbursement under MA for nursing home care. DHFS also administers the Family
Support Program, which provides assistance, including home and community-based
services, to families with a disabled child, and a program that provides early
intervention services to certain eligible children. These two programs are not part
of MA and are funded with GPR.
This bill requires DHFS to request a waiver of federal medicaid laws from the
federal department of health and human services to provide to disabled individuals
who are under 24 years of age, under one program, with unified administration and
service delivery, the services offered under COP-Waiver, CIPs, the Family Support
Program, and the Early Intervention Program. If DHFS receives the waiver, DHFS
must seek enactment of legislation to implement the waiver within the limits of
available federal, state, and county funds.
Under current law, an individual who meets the requirements under one of the
following categories is eligible for MA:
1. AFDC-MA. This category includes individuals who meet the income, asset,
and non-financial requirements for the federal Aid to Families with Dependent
Children (AFDC) Program that were in effect on July 16, 1996. Generally,
individuals who meet the AFDC requirements are certain children under 19 years
of age, their caretaker relatives, and pregnant women in the eighth or ninth month
of pregnancy.
2. AFDC-related MA. This category includes individuals who meet the income
and asset requirements of the AFDC program that were in effect on July 16, 1996,
but who would not have received an AFDC payment and who are either children
under 19 years of age, their caretaker relatives, or pregnant. Also eligible under this
category are children under the age of 18 and pregnant women whose incomes do not
exceed 133.33% of the maximum payment under the AFDC program, and whose
assets do not exceed certain asset limits.
This bill eliminates the asset requirements for the AFDC-MA and
AFDC-related MA categories so that an individual who meets the other
requirements under one of those categories is eligible for MA.
Under current law, DHFS excludes certain assets when determining whether
certain individuals meet the specific asset limits to qualify for MA. One of the assets
that is excluded is up to $2,500 in an irrevocable burial trust. This bill increases the
amount of such assets that are excluded to $3,300 on January 1, 2003.
Currently, DHFS is required to recover the following from the estate of an MA
recipient who is not survived by a spouse or a child who is under 21 or disabled:
1. The amount of MA paid on behalf of the recipient while the recipient resided
in a hospital and was required to contribute to the cost of care or resided in a nursing
home.
2. The amount of MA paid on behalf of a recipient after the recipient reached
age 55 for home-based or community-based services, community-supported living,
personal care services, or hospital and prescription drug services.
This bill expands the types of services that are subject to the Estate Recovery
Program to include all health care services for which MA was paid on behalf of a
recipient after the recipient reached age 55. The bill requires that, if these health
care services were provided by a managed care organization, under the Program of
All-Inclusive Care for the Elderly (PACE) that provides health and social services
to low-income elderly individuals at home, or under the Wisconsin Partnership
Program, which provides health care and long-term care services to low-income
elderly and disabled individuals, DHFS must calculate the amount of MA as the
capitation rate that was paid on behalf of the recipient. If the health care services
were provided under the Family Care Program, DHFS must calculate the amount
of MA as the cost of the health care services that were paid for with MA. For all other
services provided, DHFS is required to calculate the amount of MA on a
fee-for-service basis.
Under current law, to recover the amount of MA paid on behalf of MA recipients,
DHFS may place a lien on the home of a recipient under certain circumstances. This
bill authorizes DHFS to place a lien on any other real property in which an MA
recipient has an interest if DHFS may currently place a lien on the recipient's home.
Under current law, medicare part A and part B beneficiaries who are MA
recipients with incomes at or below 100% of the federal poverty line or who are
elderly or disabled persons with low incomes and resources receive payment for
medicare deductible and coinsurance amounts, monthly medicare premiums, and,
if applicable, late enrollment penalties for medicare part A premiums. (Medicare
part A provides inpatient hospital coverage for persons who are aged 65 or disabled,
and medicare part B provides coverage for outpatient services for those persons.) MA
recipients whose incomes are above 100% of the federal poverty line receive MA
payment of medicare deductible and coinsurance amounts; if they are beneficiaries
of only medicare part A or part B, they receive MA payment of the applicable
medicare part A or part B deductible and coinsurance amounts. However, for all of
these MA recipients, MA payment for the coinsurance for a service under medicare
part B may not exceed the allowable charge for the service under MA minus the
medicare payment amount.
Under this bill, MA recipients and elderly or disabled persons with low incomes
and resources may receive MA payments for their coinsurance for medicare part B
outpatient hospital services that exceed the MA allowable charge for the services.
The bill requires that DHFS include in the state plan for MA a methodology for
payment of the medicare part B outpatient hospital services coinsurance amounts.
Currently, one of the factors that determines the amounts paid to nursing
homes for care provided to MA recipients is the variation in regional labor costs. This
bill eliminates that factor.
Under current law, beginning July 1, 2000, DHFS must distribute state GPR
and federal medicaid moneys as a supplemental payment to a hospital for which MA
revenues were at least 8% of the hospital's total revenues in the most recent year
before the year of distribution. This bill eliminates these supplemental payments.
Health
Under current law, DHFS licenses, certifies, approves, or registers, and
otherwise regulates numerous health care services providers, including hospitals,
nursing homes, C-BRFs, adult family homes, residential care apartment complexes,
rural medical centers, home health agencies, and hospices. Currently, the sanctions
that DHFS may bring against those facilities or services that violate applicable
standards of care or provisions of licensure, certification, approval, or registration
include denial of licensure, issuance of departmental orders, required submittal of
a plan of correction, assessment of forfeitures (civil penalties), suspension of
admissions, imposition of conditional licensure, and suspension or revocation of
licensure. Facilities or services on which sanctions are imposed may appeal the
sanctions in hearings conducted by DOA. Decisions that result from these hearings
are subject to judicial review.
With certain exceptions, this bill makes uniform the sanctions that DHFS may
impose on hospitals, nursing homes, C-BRFs, licensed adult family homes,
residential care apartment complexes, rural medical centers, home health agencies,
and hospices that violate conditions of licensure, certification, approval, or
registration or applicable standards of care. The bill specifies procedures for
requesting a hearing to contest imposition of a sanction. The bill eliminates DHFS's
authority to suspend a license, certification, approval, or registration. Under the bill,
if DHFS provides a C-BRF, hospital, or home health agency with written notice of
the grounds for a sanction, an explanation of the types of sanctions that DHFS may
impose, and an explanation of the appeal process, DHFS may order that the C-BRF,
hospital, or home health agency do any of the following: 1) if operating without a
license or approval, cease operation; 2) terminate the employment of any person who
operated or permitted operation of a C-BRF, hospital, or home health agency for
which a license or approval was revoked; 3) stop violating a provision of licensure or
approval; 4) for a C-BRF only, submit a plan of correction for violation of a provision
of licensure or approval; 5) for a C-BRF only, implement and comply with a plan of
correction that is approved or developed by DHFS; 6) for a nursing home, C-BRF, or
hospital only, suspend new admissions until all violations are corrected; or 7) provide
training in one or more specific areas for staff members. In addition, if DHFS
provides the same type of written notice, DHFS may impose any of the following:
1. Except for nursing homes, a daily forfeiture of not less than $10 nor more
than $2,000 for each violation, with each day of violation being a separate offense;
the amount of the forfeiture and payment deadlines are specified by DHFS by rule.
2. Under specified circumstances, for all facilities or services, revocation of
licensure, certification, approval, or registration.
The bill requires that licensed nursing homes, C-BRFs, and hospices, if they
are in substantial noncompliance, as defined by DHFS by rule, with respect to
applicable state or federal requirements, demonstrate that they are fit and qualified
to operate.
Under current law, DHFS may, after meeting certain procedural requirements,
issue a conditional license for up to one year to a nursing home and may revoke any
outstanding license of the nursing home for certain violations of standards of care.
This bill authorizes DHFS to issue a conditional license, certification, approval, or
registration that is similar to a conditional approval of a nursing home, to any health
care facility or service that violates standards of care or provisions of licensure.
Under current law, DHFS may issue provisional licenses for home health
agencies, rural medical centers, and hospices that have not previously been licensed,
that are not in operation at the time the application for licensure is made, or that are
temporarily unable to comply with standards of care. DHFS also may issue
probationary licenses for nursing homes and C-BRFs that have not previously been
licensed and are not operating at the time the license application is made. This bill
eliminates provisions relating to provisional licenses for rural medical centers, and,
for home health agencies and hospices, changes the term "provisional" to
"probationary." In addition, the bill decreases from 24 months to 12 months the
period of validity of a hospice probationary license.
Currently, DHFS distributes funds to provide various services for persons with
or at risk of contracting acquired immunodeficiency syndrome (AIDS). This bill also
requires that DHFS provide funds for testing for and prevention of infections related
to AIDS, including hepatitis C virus infection, on behalf of the persons who receive
AIDS services.
Under current law, the governor may enter into an agreement with the federal
Nuclear Regulatory Commission to discontinue certain federal licensing and related
regulatory authority with respect to by-product material (certain radioactive
material and the tailings or waste from ores processed for uranium or thorium),
source material (any material except special nuclear material that contains a
specified percentage of uranium or thorium), and special nuclear material (uranium
enriched in specified isotopes and plutonium). Rules that DHFS must promulgate
for by-product, source, and special nuclear material must be no less stringent than
federal requirements.
This bill modifies the definition of "source material" to be uranium, thorium, or
any combination of the two in any physical or chemical form, or ores that contain, by
weight, 0.05% of uranium, thorium, or a combination of the two. The bill requires
that DHFS's rules be compatible with federal requirements; however, the rules must
also be in accordance with specific federal requirements relating to by-product
material. The bill also authorizes DHFS to develop qualification, certification,
training, and experience requirements and to recognize certification by another
state or a nationally recognized organization that is substantially equivalent to the
DHFS certification, for persons who operate radiation generating equipment; who
utilize, store, transfer, transport, or possess radioactive materials; or who act as
radiation safety consultants.
Currently, DHFS administers a breast cancer screening program that awards
grants to hospitals and other organizations to provide breast cancer screening
services to women who are 40 years of age or older. As part of this program, DHFS
must expend $20,000 annually to develop and provide media announcements and
educational materials concerning the need for and availability of breast cancer
screening services to women in areas served by the program.
DHFS also currently administers a low-income women health screening
program that awards grants to applicants to provide health care screening, referral,
follow-up, and patient education services to low-income, underinsured, and
uninsured women.
This bill eliminates the requirement that DHFS expend at least $20,000 in each
fiscal year for developing and providing media announcements and educational
materials under the breast cancer screening program. The bill requires DHFS to
allocate $20,000 for developing and providing media services and educational
materials to promote both health care services available under the Low-Income
Women Health Screening Program and to promote breast cancer screening services
available under the breast cancer screening program.
Current law requires DHFS to expend under the federal Preventive Health
Services Project Grant Program $25,000 in each fiscal year for a state medical
director for the state Emergency Medical Services (EMS) program. This bill
eliminates this requirement.
Wisconsin works
Under current law, DWD administers the Wisconsin Works (W-2) Child Care
Subsidy Program. Under this program, an individual who meets certain
nonfinancial and financial eligibility requirements and who is the parent, foster
parent, guardian, or kinship care relative of a child under the age of 13 or, if the child
is disabled, under the age of 19, may be eligible for a child care subsidy if the
individual needs child care to work or to pursue basic or technical college education.
A kinship care relative is an individual who receives monthly payments under the
Kinship Care Program. The Kinship Care Program provides monthly payments to
individuals who are relatives of children and who provide care and maintenance for
the children either temporarily (short-term kinship care relative) or on a more
permanent basis (long-term kinship care relative).
Under this bill, if DWD determines that moneys allocated for the Child Care
Subsidy Program are insufficient to provide the child care subsidy to all eligible
individuals, DWD may develop a plan to limit participation in the Child Care
Subsidy Program. If the secretary of administration approves the plan, DWD may
implement it.
Under current law, to be eligible for the child care subsidy, a long-term kinship
care relative must cooperate with child support enforcement efforts, provide DWD
with any information that DWD requires, and assign to DWD any right the
individual has to child or spousal support or maintenance. Short-term kinship care
relatives are not required to meet these requirements. Under current law, a
short-term kinship care relative is eligible for the child care subsidy if the child's
biological or adoptive family has income that is at or below 200% of the federal
poverty line while a long-term kinship care relative must have income that is at or
below 185% of the federal poverty line to be eligible for the child care subsidy. Under
this bill, the eligibility requirements for the child care subsidy that currently apply
to short-term kinship care relatives apply to long-term kinship care relatives.
Under current law, DWD distributes federal funds to child care providers and
counties for child care services that are provided to individuals who are eligible for
the W-2 child care subsidy and to private nonprofit agencies that provide child care
for children of migrant workers. Currently, the funds may not be used to cover the
costs of child care services that are provided to a child by a person who resides with
the child, unless a county determines that the child care is necessary because of a
special health condition of the child.
The bill permits DWD to reimburse a W-2 agency (an entity that administers
the W-2 program on behalf of DWD) for child care services that the W-2 agency
provides to W-2 participants and applicants and prohibits the use of the funds for
child care services that are provided for a child by the child's custodial parent,
guardian, foster parent, treatment foster parent, legal custodian, or person acting in
place of a parent, unless a county determines that the child care is necessary because
of a special health condition of the child.
Under current law, DWD contracts with W-2 agencies to administer the W-2
program. Current law requires that these two-year contracts require the W-2
agency to establish a community steering committee that consists of at least 12
members but not more than 15 members. A community steering committee is
responsible for advising W-2 agencies on employment and training activities,
creating and encouraging others to create subsidized jobs for W-2 participants,
identifying child care needs, improving child care access, and expanding the
availability of child care.
This bill eliminates the requirement that the community steering committee
consist of a specified number of members. The bill also requires that a W-2 contract
require the community steering committee to serve individuals who are receiving
services under the federal Temporary Assistance for Needy Families (TANF) block
grant program and to coordinate its services with a local workforce development
board.
Public assistance
Current law directs DWD to allocate specific amounts of moneys in each fiscal
year, including federal moneys received under the TANF block grant program, for
various public assistance programs. This bill eliminates the allocation for some of
the programs, including start-up funding for W-2 contracts, the Passports for Youth
Program, the Community Marriage Policy Project, and payments to the Wisconsin
Trust Account Foundation for the provision of legal services to certain low-income
individuals.
Under the bill, if the amounts of TANF moneys that are received from the
federal government are less than the amounts of TANF moneys appropriated to
DWD, DWD must submit a plan to the secretary of administration for reducing the
amounts allocated for the public assistance programs. If the secretary approves the
plan, DWD may reduce the amounts allocated.
Current law requires DWD to distribute a portion of the federal Child Care
Development Block Grant (CCDBG) funds to provide various child care services and
grant programs, including technical assistance to child care providers, grants for the
start-up and expansion of child day care services, and grants for improving the
quality of care standards. This bill requires DWD also to distribute CCDBG funds
as grants to local governments and tribal governing bodies for programs to improve
the quality of child care.
Under current law, DWD awards grants of up to $500 to eligible individuals for
the costs of tuition, books, transportation, or other direct costs of training or
education in a vocational or educational program. As a condition of eligibility for a
grant, an individual's income may not exceed 165% of the federal poverty line and
the individual must contribute matching funds equal to the amount of the grant. The
total amount of all grants awarded to an individual may not exceed $500. This bill
increases the maximum income level for eligibility for an employment skills
advancement grant to 185% of the federal poverty line, reduces the amount of
matching funds that an individual must contribute to 50% of the amount of the grant,
and increases the maximum amount of all grants that an individual may receive to
$1,000.
Under current law, DWD contracts with counties and W-2 agencies to
administer a work experience program for noncustodial parents, commonly referred
to as the Children First Program. Under the program, counties and W-2 agencies
provide work experience, job training, and job search assistance to noncustodial
parents (parents who do not live with their children for substantial periods) who are
required to participate in the program because they failed to pay court-ordered child
support or to meet their child's needs for support because of unemployment or
underemployment. Current law requires DWD to pay the county or W-2 agency
administering the program $400 for each noncustodial parent who participates in
the program.
This bill authorizes DWD to contract with elected tribal governing bodies of
federally recognized American Indian tribes or bands to administer the Children
First Program. The bill also changes the amount that DWD is required to pay to each
county, W-2 agency, or tribal governing body for each noncustodial parent who
participates in the program from $400 to an amount that is not more than $400.
