SB40-CSA1, s. 1612 18Section 1612. 49.475 (1) (am) of the statutes is created to read:
SB40-CSA1,764,2219 49.475 (1) (am) "Covered individual" means an individual who is a member,
20participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary
21of a covered entity, or a dependent of the individual, and who receives prescription
22drug coverage from or through the covered entity.
SB40-CSA1, s. 1613 23Section 1613. 49.475 (1) (c) of the statutes is created to read:
SB40-CSA1,765,324 49.475 (1) (c) "Pharmacy benefits management" means the procurement of
25prescription drugs at a negotiated rate for dispensation in this state to covered

1individuals; the administration or management of prescription drug benefits
2provided by a covered entity for the benefit of covered individuals; or any of the
3following services provided in the administration of pharmacy benefits:
SB40-CSA1,765,44 1. Dispensation of prescription drugs by mail.
SB40-CSA1,765,65 2. Claims processing, retail network management, and payment of claims to
6pharmacies for prescription drugs dispensed to covered individuals.
SB40-CSA1,765,77 3. Clinical formulary development and management services.
SB40-CSA1,765,88 4. Rebate contracting and administration.
SB40-CSA1,765,109 5. Conduct of patient compliance, therapeutic intervention, generic
10substitution, and disease management programs.
SB40-CSA1, s. 1614 11Section 1614. 49.475 (1) (d) of the statutes is created to read:
SB40-CSA1,765,1312 49.475 (1) (d) "Pharmacy benefits manager" means a person that performs
13pharmacy benefits management functions.
SB40-CSA1, s. 1615 14Section 1615. 49.475 (1) (e) of the statutes is created to read:
SB40-CSA1,765,1615 49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent
16who has been or is one of the following:
SB40-CSA1,765,1817 1. A recipient of medical assistance or of a program administered under medical
18assistance under a waiver of federal Medicaid laws.
SB40-CSA1,765,1919 2. An enrollee of family care.
SB40-CSA1,765,2020 3. A recipient of the Badger Care health care program.
SB40-CSA1,765,2121 4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.
SB40-CSA1,765,2322 5. A participant in the program of prescription drug assistance for elderly
23persons under s. 49.688.
SB40-CSA1,765,2424 6. A woman who receives services that are reimbursed under s. 255.06.
SB40-CSA1, s. 1616 25Section 1616. 49.475 (1) (f) of the statutes is created to read:
SB40-CSA1,766,3
149.475 (1) (f) "Third party" means an entity that by statute, rule, or contract
2is responsible for payment of a claim for a health care item or service. "Third party"
3includes all of the following:
SB40-CSA1,766,44 1. An insurer.
SB40-CSA1,766,652. An employee benefit plan described in 29 USC 1003 (a) that is not exempt
6under 29 USC 1003 (b) and is not a multiple employer welfare arrangement.
SB40-CSA1,766,773. A service benefit plan, as specified in 42 USC 1396a (25) (I).
SB40-CSA1,766,88 4. A pharmacy benefits manager.
SB40-CSA1, s. 1617 9Section 1617. 49.475 (2) of the statutes is repealed and recreated to read:
SB40-CSA1,766,1110 49.475 (2) Requirements of 3rd parties. As a condition of doing business in this
11state, a 3rd party shall do all of the following:
SB40-CSA1,766,1412 (a) Upon the department's request and in the manner prescribed by the
13department, provide information to the department necessary for the department to
14ascertain all of the following with respect to a recipient:
SB40-CSA1,766,1615 1. Whether the recipient is being or has been provided coverage or a benefit or
16service by a 3rd party.
SB40-CSA1,766,1917 2. If subd. 1. applies, the nature and period of time of any coverage, benefit, or
18service provided, including the name, address, and identifying number of any
19applicable coverage plan.
SB40-CSA1,766,2320 (b) Accept assignment to the department of a right of a recipient to receive
213rd-party payment for an item or service for which payment under medical
22assistance has been made and accept the department's right to recover any
233rd-party payment made for which assignment has not been accepted.
SB40-CSA1,767,3
1(c) Respond to an inquiry by the department concerning a claim for payment
2of a health care item or service if the department submits the inquiry less than 36
3months after the date on which the health care item or service was provided.
SB40-CSA1,767,74 (d) If all of the following apply, agree not to deny a claim submitted by the
5department under par. (b) solely because of the claim's submission date, the type or
6format of the claim form, or failure by a recipient to present proper documentation
7at the time of delivery of the service, benefit, or item that is the basis of the claim:
SB40-CSA1,767,98 1. The department submits the claim less than 36 months after the date on
9which the health care item or service was provided.
SB40-CSA1,767,1210 2. Action by the department to enforce the department's rights under this
11section with respect to the claim is commenced less than 72 months after the
12department submits the claim.
SB40-CSA1, s. 1618 13Section 1618. 49.475 (3) (intro.) of the statutes is amended to read:
SB40-CSA1,767,1614 49.475 (3) Written agreement. (intro.) Upon requesting an insurer a 3rd party
15to provide the information under sub. (2) (a), the department and the 3rd party shall
16enter into a written agreement with the insurer that satisfies all of the following:
SB40-CSA1, s. 1619 17Section 1619. 49.475 (3) (a) of the statutes is amended to read:
SB40-CSA1,767,1918 49.475 (3) (a) Identifies in detail the detailed format of the information to be
19disclosed provided to the department.
SB40-CSA1, s. 1620 20Section 1620. 49.475 (3) (c) of the statutes is amended to read:
SB40-CSA1,767,2221 49.475 (3) (c) Specifies how the insurer's 3rd party's reimbursable costs under
22sub. (5) will be determined and specifies the manner of payment.
SB40-CSA1, s. 1621 23Section 1621. 49.475 (4) (a) of the statutes is amended to read:
SB40-CSA1,768,224 49.475 (4) (a) An insurer A 3rd party shall provide the information requested
25under sub. (2) (a) within 180 days after receiving the department's request if it is the

1first time that the department has requested the insurer 3rd party to disclose
2information under this section.
SB40-CSA1, s. 1622 3Section 1622. 49.475 (4) (b) of the statutes is amended to read:
SB40-CSA1,768,74 49.475 (4) (b) An insurer A 3rd party shall provide the information requested
5under sub. (2) (a) within 30 days after receiving the department's request if the
6department has previously requested the insurer 3rd party to disclose information
7under this section.
SB40-CSA1, s. 1623 8Section 1623. 49.475 (4) (d) of the statutes is created to read:
SB40-CSA1,768,109 49.475 (4) (d) If a 3rd party other than an insurer fails to comply with par. (a)
10or (b), the department may so notify the attorney general.
SB40-CSA1, s. 1624 11Section 1624. 49.475 (5) of the statutes is amended to read:
SB40-CSA1,768,1712 49.475 (5) From the appropriations under s. 20.435 (4) (bm) and (pa), the
13department shall reimburse an insurer A 3rd party that provides information under
14this section sub. (2) (a) for the insurer's 3rd party's reasonable costs incurred in
15providing the requested information, including its reasonable costs, if any, to develop
16and operate automated systems specifically for the disclosure of the information
17under this section.
SB40-CSA1, s. 1625 18Section 1625. 49.475 (6) of the statutes is created to read:
SB40-CSA1,769,319 49.475 (6) Sharing information. The department of health and family services
20shall provide to the department of workforce development, for purposes of the
21medical support liability program under s. 49.22, any information that the
22department of health and family services receives under this section. The
23department of workforce development may allow a county child support agency
24under s. 59.53 (5) or a tribal child support agency access to the information, subject
25to the use and disclosure restrictions under s. 49.83, and shall consult with the

1department of health and family services regarding procedures and methods to
2adequately safeguard the confidentiality of the information provided under this
3subsection.
SB40-CSA1, s. 1626 4Section 1626. 49.475 (6) of the statutes, as created by 2007 Wisconsin Act ....
5(this act), is amended to read:
SB40-CSA1,769,156 49.475 (6) Sharing information. The department of health and family services
7shall provide to the department of workforce development children and families, for
8purposes of the medical support liability program under s. 49.22, any information
9that the department of health and family services receives under this section. The
10department of workforce development children and families may allow a county child
11support agency under s. 59.53 (5) or a tribal child support agency access to the
12information, subject to the use and disclosure restrictions under s. 49.83, and shall
13consult with the department of health and family services regarding procedures and
14methods to adequately safeguard the confidentiality of the information provided
15under this subsection.
SB40-CSA1, s. 1627 16Section 1627. 49.48 (1m) of the statutes is amended to read:
SB40-CSA1,769,2317 49.48 (1m) If an individual who applies for or to renew a certification under
18sub. (1) does not have a social security number, the individual, as a condition of
19obtaining the certification, shall submit a statement made or subscribed under oath
20or affirmation to the department that the applicant does not have a social security
21number. The form of the statement shall be prescribed by the department of
22workforce development children and families. A certification issued or renewed in
23reliance upon a false statement submitted under this subsection is invalid.
SB40-CSA1, s. 1628 24Section 1628. 49.48 (2) of the statutes is amended to read:
SB40-CSA1,770,4
149.48 (2) The department of health and family services may not disclose any
2information received under sub. (1) to any person except to the department of
3workforce development children and families for the purpose of making
4certifications required under s. 49.857.
SB40-CSA1, s. 1629 5Section 1629. 49.48 (3) of the statutes is amended to read:
SB40-CSA1,770,176 49.48 (3) The department of health and family services shall deny an
7application for the issuance or renewal of a certification specified in sub. (1), shall
8suspend a certification specified in sub. (1) or may, under a memorandum of
9understanding under s. 49.857 (2), restrict a certification specified in sub. (1) if the
10department of workforce development children and families certifies under s. 49.857
11that the applicant for or holder of the certificate is delinquent in the payment of
12court-ordered payments of child or family support, maintenance, birth expenses,
13medical expenses or other expenses related to the support of a child or former spouse
14or fails to comply, after appropriate notice, with a subpoena or warrant issued by the
15department of workforce development children and families or a county child
16support agency under s. 59.53 (5) and related to paternity or child support
17proceedings.
SB40-CSA1, s. 1629m 18Section 1629m. 49.485 of the statutes is created to read:
SB40-CSA1,770,25 1949.485 False claims. Whoever knowingly presents or causes to be presented
20to any officer, employee, or agent of this state a false claim for medical assistance
21shall forfeit not less than $5,000 nor more than $10,000, plus 3 times the amount of
22the damages that were sustained by the state or would have been sustained by the
23state, whichever is greater, as a result of the false claim. The attorney general may
24bring an action on behalf of the state to recover any forfeiture incurred under this
25section.
SB40-CSA1, s. 1630
1Section 1630. 49.49 (3m) (a) (intro.) of the statutes is amended to read:
SB40-CSA1,771,52 49.49 (3m) (a) (intro.) No provider may knowingly impose upon a recipient
3charges in addition to payments received for services under ss. 49.45 to 49.47 49.471
4or knowingly impose direct charges upon a recipient in lieu of obtaining payment
5under ss. 49.45 to 49.47 49.471 except under the following conditions:
SB40-CSA1, s. 1631 6Section 1631. 49.49 (3m) (a) 1. of the statutes is amended to read:
SB40-CSA1,771,87 49.49 (3m) (a) 1. Benefits or services are not provided under s. 49.46 (2) or
849.471 (11)
and the recipient is advised of this fact prior to receiving the service.
SB40-CSA1, s. 1632 9Section 1632. 49.49 (3m) (a) 2. of the statutes is amended to read:
SB40-CSA1,771,2010 49.49 (3m) (a) 2. If an applicant is determined to be eligible retroactively under
11s. 49.46 (1) (b) or 49.47 (4) (d) and a provider bills the applicant directly for services
12and benefits rendered during the retroactive period, the provider shall, upon
13notification of the applicant's retroactive eligibility, submit claims for
14reimbursement payment under s. 49.45 for covered services or benefits rendered to
15the recipient
during the retroactive period. Upon receipt of payment under s. 49.45,
16the provider shall reimburse the applicant recipient or other person who has made
17prior payment to the provider. No provider may be required to reimburse the
18applicant or other person in excess of the amount reimbursed under s. 49.45
for
19services provided to the recipient during the retroactive eligibility period, by the
20amount of the prior payment made
.
SB40-CSA1, s. 1633 21Section 1633 . 49.49 (3m) (a) 2. of the statutes, as affected by 2007 Wisconsin
22Act .... (this act), is amended to read:
SB40-CSA1,772,623 49.49 (3m) (a) 2. If an applicant is determined to be eligible retroactively under
24s. 49.46 (1) (b) or, 49.47 (4) (d), or 49.471 and a provider bills the applicant directly
25for services and benefits rendered during the retroactive period, the provider shall,

1upon notification of the applicant's retroactive eligibility, submit claims for payment
2under s. 49.45 for covered services or benefits rendered to the recipient during the
3retroactive period. Upon receipt of payment under s. 49.45, the provider shall
4reimburse the recipient or other person who has made prior payment to the provider
5for services provided to the recipient during the retroactive eligibility period, by the
6amount of the prior payment made.
SB40-CSA1, s. 1634 7Section 1634 . 49.49 (3m) (a) 3. of the statutes is amended to read:
SB40-CSA1,772,118 49.49 (3m) (a) 3. Benefits or services for which recipient copayment,
9coinsurance, or deductible is required under s. 49.45 (18), not to exceed maximum
10amounts allowable under 42 CFR 447.53 to 447.58, or for which recipient copayment
11or coinsurance is required under s. 49.471 (11)
.
SB40-CSA1, s. 1634r 12Section 1634r. 49.496 (3) (a) (intro.) of the statutes is amended to read:
SB40-CSA1,772,1613 49.496 (3) (a) (intro.) Except as provided in par. (b), the department shall file
14a claim against the estate of a recipient for all of the following , subject to the exclusion
15of any amounts under the Long-Term Care Partnership Program established under
16s. 49.45 (31),
unless already recovered by the department under this section:
SB40-CSA1, s. 1635 17Section 1635. 49.497 (title) of the statutes is amended to read:
SB40-CSA1,772,19 1849.497 (title) Recovery of incorrect Medical Assistance or Badger Care
19payments
and of unpaid employer penalties.
SB40-CSA1, s. 1636 20Section 1636. 49.497 (1r) of the statutes is created to read:
SB40-CSA1,773,621 49.497 (1r) (a) The department may recover any penalty assessment not paid
22under s. 49.471 (9) (c) from the employer against which the penalty was assessed.
23If, after notice that payment of a penalty is overdue, the employer who is liable fails
24to pay the penalty amount, or enter into or comply with an agreement for payment,
25the department may bring an action to enforce the liability or may issue an order to

1compel payment of the liability. Any person aggrieved by an order issued by the
2department under this paragraph may appeal the order as a contested case under
3ch. 227 by filing with the department a request for a hearing within 30 days after the
4date of the order. The only issue at the hearing shall be the determination by the
5department that the person has not paid the penalty or entered into, or complied
6with, an agreement for payment.
SB40-CSA1,773,167 (b) If any employer named in an order to compel payment issued under par. (a)
8fails to pay the department any amount due under the terms of the order and no
9contested case to review the order is pending and the time for filing for a contested
10case review has expired, the department may present a certified copy of the order to
11the circuit court for any county. The sworn statement of the secretary shall be
12evidence of the failure to pay the penalty. The circuit court shall, without notice,
13render judgment in accordance with the order. A judgment rendered under this
14paragraph shall have the same effect and shall be entered in the judgment and lien
15docket and may be enforced in the same manner as if the judgment had been
16rendered in an action tried and determined by the circuit court.
SB40-CSA1,773,1817 (c) The recovery procedure under this subsection is in addition to any other
18recovery procedure authorized by law.
SB40-CSA1, s. 1637 19Section 1637. 49.497 (4) of the statutes is amended to read:
SB40-CSA1,773,2420 49.497 (4) The department may appear for the state in any and all collection
21matters under this section, and may commence suit in the name of the department
22to recover an incorrect payment from the recipient to whom or on whose behalf it was
23made or to recover an unpaid penalty from the employer against which the penalty
24was assessed
.
SB40-CSA1, s. 1638 25Section 1638. 49.665 (4) (ap) 2. of the statutes is repealed.
SB40-CSA1, s. 1639
1Section 1639. 49.665 (4) (at) 1. a. of the statutes is amended to read:
SB40-CSA1,774,62 49.665 (4) (at) 1. a. Except as provided in subd. 1. b., the department shall
3establish a lower maximum income level for the initial eligibility determination if
4funding under s. 20.435 (4) (bc), (jz), (p), and (x) is insufficient to accommodate the
5projected enrollment levels for the health care program under this section. The
6adjustment may not be greater than necessary to ensure sufficient funding.
SB40-CSA1, s. 1640 7Section 1640. 49.665 (4) (at) 1. cm. of the statutes is amended to read:
SB40-CSA1,774,188 49.665 (4) (at) 1. cm. Notwithstanding s. 20.001 (3) (b), if, after reviewing the
9plan submitted under subd. 1. b., the joint committee on finance determines that the
10amounts appropriated under s. 20.435 (4) (bc), (jz), (p), and (x) are insufficient to
11accommodate the projected enrollment levels, the committee may transfer
12appropriated moneys from the general purpose revenue appropriation account of any
13state agency, as defined in s. 20.001 (1), other than a sum sufficient appropriation
14account, to the appropriation account under s. 20.435 (4) (bc) (b) to supplement the
15health care program under this section if the committee finds that the transfer will
16eliminate unnecessary duplication of functions, result in more efficient and effective
17methods for performing programs, or more effectively carry out legislative intent,
18and that legislative intent will not be changed by the transfer.
SB40-CSA1, s. 1641 19Section 1641. 49.665 (4) (at) 2. of the statutes is amended to read:
SB40-CSA1,774,2420 49.665 (4) (at) 2. If, after the department has established a lower maximum
21income level under subd. 1., projections indicate that funding under s. 20.435 (4) (bc),
22(jz), (p), and (x) is sufficient to raise the level, the department shall, by state plan
23amendment, raise the maximum income level for initial eligibility, but not to exceed
24185% of the poverty line.
SB40-CSA1, s. 1641d 25Section 1641d. 49.665 (4g) of the statutes is created to read:
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