49.45 (3) (b) 2. The contractor, if any, insuring benefits under s. 49.46, 49.465, 49.468 or, 49.47, or 49.471 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.
SECTION 33. 49.45 (3) (dm) of the statutes is amended to read:
49.45 (3) (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, or 49.471 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under 42 USC 1395.
SECTION 34. 49.45 (3) (f) 2. of the statutes is amended to read:
49.45 (3) (f) 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) or 49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
SECTION 35. 49.45 (3) (L) 2. of the statutes is amended to read:
49.45 (3) (L) 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, or 49.471, 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.
SECTION 36. 49.45 (3) (m) of the statutes is amended to read:
49.45 (3) (m) To be certified under sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in s. 340.01 (23g), that satisfies the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under s. 49.46 (2) (b) 3. or 49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.
SECTION 37. 49.45 (6c) (d) 1. of the statutes is amended to read:
49.45 (6c) (d) 1. No payment may be made under sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46 or, 49.47, or 49.471, who has developmental disability or mental illness and for whom under par. (b) or (c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.
SECTION 38. 49.45 (6c) (d) 2. of the statutes is amended to read:
49.45 (6c) (d) 2. Payment may be made under sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46 or, 49.47, or 49.471 and who has developmental disability or mental illness and is determined under par. (b) or (c) to need facility care, regardless of whether it is determined under par. (b) or (c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.
SECTION 39. 49.45 (8) (a) 4. of the statutes is amended to read:
49.45 (8) (a) 4. "Patient care visit" means a personal contact with a patient in a patient's home that is made by a registered nurse, licensed practical nurse, home health aide, physical therapist, occupational therapist, or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under s. 49.46 or, 49.47, or 49.471. "Patient care visit" does not include time spent by a nurse, therapist, or home health aide on case management, care coordination, travel, record keeping, or supervision that is related to the patient care visit.
SECTION 40. 49.45 (9) of the statutes is amended to read:
49.45 (9) FREE CHOICE. Any person eligible for medical assistance under ss. s. 49.46, 49.468 and, 49.47, or 49.471 may use the physician, chiropractor, dentist, pharmacist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist or dentist may be required to practice exclusively in the medical assistance program.
SECTION 41. 49.45 (18) (ac) of the statutes is amended to read:
49.45 (18) (ac) Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.
SECTION 42. 49.45 (18) (am) of the statutes is amended to read:
49.45 (18) (am) No person is liable under this subsection for services provided through prepayment contracts. This paragraph does not apply to a person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.
SECTION 43. 49.45 (18m) (a) 1. of the statutes, as created by 2007 Wisconsin Act .... (this act), is amended to read:
49.45 (18m) (a) 1. Medical assistance services under s. 49.46, 49.47, 49.471, or 49.472.
****NOTE: This is reconciled s. 49.45 (18m) (a) 1. This SECTION has been affected by drafts with the following LRB numbers: -0268 and -0905.
SECTION 44. 49.45 (24g) of the statutes is repealed.
SECTION 45. 49.45 (29) of the statutes is amended to read:
49.45 (29) HOSPICE REIMBURSEMENT. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46 and, 49.47, and 49.471.
SECTION 46. 49.45 (35) of the statutes is repealed.
SECTION 47. 49.45 (42m) (a) of the statutes is amended to read:
49.45 (42m) (a) If, in authorizing the provision of physical or occupational therapy services under s. 49.46 (2) (b) 6. b. or 49.471 (11) (i), the department authorizes a reduced duration of services from the duration that the provider specifies in the authorization request, the department shall substantiate the reduction that the department made in the duration of the services if the provider of the services requests any additional authorizations for the provision of physical or occupational therapy services to the same individual.
SECTION 48. 49.45 (48) of the statutes is amended to read:
49.45 (48) PAYMENT OF MEDICARE PART B OUTPATIENT HOSPITAL SERVICES COINSURANCES. The department shall include in the state plan for medical assistance a methodology for payment of the medicare part B outpatient hospital services coinsurance amounts that are authorized under ss. 49.46 (2) (c) 2., 4., and 5m., 49.468 (1) (b), and 49.47 (6) (a) 6. b., d., and f., and 49.471 (6) (j) 1.
SECTION 49. 49.45 (49m) (c) 1. of the statutes is amended to read:
49.45 (49m) (c) 1. A list of the prescription drugs that are included as a benefit under s. ss. 49.46 (2) (b) 6. h. and 49.471 (11) (a) that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.
SECTION 50. 49.45 (53) of the statutes is amended to read:
49.45 (53) PAYMENTS FOR CERTAIN SERVICES. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under s. ss. 49.46 (2) (a) 4. d. and (b) 6. j. and m. and 49.471 (11) (f).
SECTION 51. 49.46 (1) (a) 5. of the statutes is amended to read:
49.46 (1) (a) 5. Any child in an adoption assistance, foster care, kinship care, long-term kinship care, treatment foster care, or subsidized guardianship placement under ch. 48 or 938, as determined by the department.
SECTION 52. 49.468 (1) (b) of the statutes is amended to read:
49.468 (1) (b) For an elderly or disabled individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare and who does not meet the eligibility criteria for medical assistance under s. 49.46 (1), 49.465 or, 49.47 (4), or 49.471 but meets the limitations on income and resources under par. (d), medical assistance shall pay the deductible and coinsurance portions of medicare services under 42 USC 1395 to 1395zz which are not paid under 42 USC 1395 to 1395zz, including those medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums payable under 42 USC 1395v; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare. Payment of coinsurance for a service under part B of medicare under 42 USC 1395j to 1395w, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
SECTION 53. 49.468 (1) (c) of the statutes is amended to read:
49.468 (1) (c) For an elderly or disabled individual who is only entitled to coverage under part A of medicare and who does not meet the eligibility criteria for medical assistance under s. 49.46 (1), 49.465 or, 49.47 (4), or 49.471 but meets the limitations on income and resources under par. (d), medical assistance shall pay the deductible and coinsurance portions of medicare services under 42 USC 1395 to 1395i which are not paid under 42 USC 1395 to 1395i, including those medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty for premiums under part A of medicare, if applicable.
SECTION 54. 49.468 (1m) (a) of the statutes is amended to read:
49.468 (1m) (a) Beginning on January 1, 1993, for an elderly or disabled individual who is entitled to coverage under part A of medicare and is entitled to coverage under part B of medicare, does not meet the eligibility criteria for medical assistance under s. 49.46 (1), 49.465 or, 49.47 (4), or 49.471 but meets the limitations on income and resources under par. (b), medical assistance shall pay the monthly premiums under 42 USC 1395r.
SECTION 55. 49.468 (2) (a) of the statutes is amended to read:
49.468 (2) (a) Beginning on January 1, 1991, for a disabled working individual who is entitled under P.L. 101-239, section 6012 (a), to coverage under part A of medicare and who does not meet the eligibility criteria for medical assistance under s. 49.46 (1), 49.465 or, 49.47 (4), or 49.471 but meets the limitations on income and resources under par. (b), medical assistance shall pay the monthly premiums for the coverage under part A of medicare, including late enrollment fees, if applicable.
SECTION 56. 49.471 of the statutes is created to read:
49.471 BadgerCare Plus. (1) DEFINITIONS. In this section, unless the context requires otherwise:
(a) "BadgerCare Plus" means the Medical Assistance program described in this section.
(b) "Caretaker relative" means an individual who is maintaining a residence as a child's home, who exercises primary responsibility for the child's care and control, including making plans for the child, and who is any of the following with respect to the child:
1. A blood relative, including those of half-blood, and including first cousins, nephews, nieces, and individuals of preceding generations as denoted by prefixes of grand, great, or great-great.
2. A stepfather, stepmother, stepbrother, or stepsister.
3. An individual who is the adoptive parent of the child's parent, a natural or legally adopted child of such individual, or a relative of an adoptive parent.
4. A spouse of any individual named in this paragraph even if the marriage is terminated by death or divorce.
(c) "Child" means an individual who is under the age of 19 years. "Child" includes an unborn child.
(d) "Essential person" means an individual who satisfies all of the following:
1. Is related to an individual receiving benefits under this section.
2. Is otherwise nonfinancially eligible, except that the individual need not have a minor child under his or her care.
3. Provides at least one of the following to an individual receiving benefits under this section:
a. Child care that enables a caretaker to work outside the home for at least 30 hours per week for pay, to receive training for at least 30 hours per week, or to attend, on a full-time basis as defined by the school, high school or a course of study meeting the standards established by the state superintendent of public instruction for the granting of a declaration of equivalency of high school graduation under s. 115.29 (4).
b. Care for anyone who is incapacitated.
(e) "Family" means all children for whom assistance is requested, their minor siblings, including half brothers, half sisters, stepbrothers, and stepsisters, and any parents of these minors and their spouses.
(f) "Family income" means the total gross earned and unearned income received by all members of a family.
(g) "Group health plan" has the meaning given in 42 USC 300gg-91 (a) (1).
(h) "Health insurance coverage" has the meaning given in 42 USC 300gg-91 (b) (1), and also includes any arrangement under which a 3rd party agrees to pay for the health care costs of the individual.
(i) "Parent" has the meaning given in s. 49.141 (1) (j).
(j) "Recipient" means an individual receiving benefits under this section.
(k) "Unborn child" means an individual from conception until he or she is born alive for whom all of the following requirements are met:
1. The unborn child's mother is not eligible for medical assistance under this subchapter, except that she may be eligible for benefits under s. 49.45 (27).
2. The income of the unborn child's mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 300 percent of the poverty line.
3. Each of the following applicable persons who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings:
a. The unborn child's mother.
b. The spouse of the unborn child's mother.
c. Members of the unborn child's mother's family.
4. The unborn child's mother provides medical verification of her pregnancy, in the manner specified by the department. An unborn child's eligibility for coverage under this section does not begin before the first day of the month in which the unborn child's mother provides the medical verification.
5. The unborn child and the mother of the unborn child meet all other applicable eligibility requirements under this chapter or established by the department by rule except for any of the following:
a. The mother is not a U.S. citizen or an alien qualifying for Medicaid under 8 USC 1612.
b. The mother is an inmate of a public institution.
c. The mother does not provide a social security number, but only if subd. 5. a. applies.
(2) WAIVER. The department shall request a waiver from, and submit amendments to the state Medical Assistance plan to, the secretary of the federal department of health and human services to implement BadgerCare Plus. If the state plan amendments are approved and a waiver that is consistent with all of the provisions of this section is granted and in effect, the department shall implement BadgerCare Plus beginning on January 1, 2008, the effective date of the state plan amendments, or the effective date of the waiver, whichever is latest. If the state plan amendments are not approved or if a waiver that is consistent with all of the provisions of this section is not granted, BadgerCare Plus may not be implemented. If the state plan amendments are approved but approval is not continued or if a waiver that is consistent with all of the provisions of this section is granted but not continued in effect, BadgerCare Plus shall be discontinued.
(3) INELIGIBILITY FOR OTHER MEDICAL ASSISTANCE BENEFITS. (a) 1. Notwithstanding ss. 49.46 (1), 49.465, 49.47 (4), and 49.665 (4), if the amendments to the state plan under sub. (2) are approved and a waiver under sub. (2) that is consistent with all of the provisions of this section is granted and in effect, an individual described in sub. (4) (a) or (b) or (5) is not eligible under s. 49.46, 49.465, 49.47, or 49.665 for Medical Assistance or BadgerCare health program benefits. The eligibility of an individual described in sub. (4) (a) or (b) or (5) for Medical Assistance benefits shall be determined under this section.
2. Notwithstanding subd. 1., an individual who is eligible for medical assistance under s. 49.46 (1) (a) 3. or 4. may not receive benefits under this section.
3. Notwithstanding subd. 1., an individual described in sub. (4) (a) or (b) or (5) who is eligible for medical assistance under s. 49.46 (1) (a) 5., 6m., 14., 14m., or 15. or (d) or 49.47 (4) (a) or (as) may receive medical assistance benefits under this section or under s. 49.46 or 49.47.
(b) 1. If an individual over 18 years of age who is eligible for and receiving Medical Assistance benefits under s. 49.46, 49.47, or 49.665 in the month before BadgerCare Plus is implemented loses that eligibility solely due to the implementation of BadgerCare Plus and, because of his or her income, is not eligible for BadgerCare Plus, the individual shall continue receiving for 18 consecutive months the medical assistance he or she was receiving before the implementation of BadgerCare Plus if all of the following are satisfied:
a. The individual's eligibility for the Medical Assistance benefits in the month before the implementation of BadgerCare Plus was based on an application filed before the implementation of BadgerCare Plus.
b. The individual continues to pay any premium that he or she was required to pay for the Medical Assistance coverage in the same amount as the amount that was due in the month before the implementation of BadgerCare Plus.
c. The individual continues to meet all nonfinancial eligibility requirements for the coverage that he or she had in the month before the implementation of BadgerCare Plus.
d. The individual continues to be ineligible for BadgerCare Plus because of his or her income.
2. Notwithstanding subd. 1., if at any time during an individual's 18-month eligibility extension under subd. 1. any criterion under subd. 1. a. to d. is not satisfied, the individual's eligibility for the extended coverage is terminated and any time remaining in the eligibility period is lost.
(4) GENERAL ELIGIBILITY CRITERIA; APPLICABLE BENEFITS. (a) Except as otherwise provided in this section, all of the following individuals are eligible for the benefits described in s. 49.46 (2) (a) and (b), subject to sub. (6) (k):
