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SECTION 44. 49.45 (24g) of the statutes is repealed.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SECTION 46. 49.45 (35) of the statutes is repealed.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):
1. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
2. A child who is under one year of age, whose mother was, on the day the child was born, eligible for and receiving medical assistance under subd. 1. or 5. or s. 49.46 or 49.47, and who lives with his or her mother in this state.
3. A child whose family income does not exceed 200 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care.
3m. A child who obtains eligibility under sub. (7) (b) 2.
4. An individual who satisfies all of the following criteria:
a. The individual is a parent or caretaker relative of a child who is living in the home with the parent or caretaker relative or who is temporarily absent from the home for not more than 6 months or, if the child has been removed from the home for more than 6 months, the parent or caretaker relative is working toward unifying the family by complying with a permanency plan under s. 48.38.
b. Except as provided in subd. 4. c., the individual's family income does not exceed 200 percent of the poverty line and does not include self-employment income.
c. If the individual's family income includes self-employment income, the individual's family income does not exceed 200 percent of the poverty line as calculated under sub. (7) (a) 2.
5. An individual who, regardless of family income, was born on or after January 1, 1990, and who, on his or her 18th birthday, was in a foster care or treatment foster care placement under the responsibility of a state, as determined by the department. The coverage for an individual under this subdivision ends on the last day of the month in which the individual becomes 21 years of age, unless he or she otherwise loses eligibility sooner.
6. Migrant workers and their dependents who are determined eligible under sub. (6) (f).
(b) Except as otherwise provided in this section, all of the following individuals are eligible for the benefits described in sub. (11):
1. A pregnant woman whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line.
1m. A pregnant woman or unborn child who obtains eligibility under sub. (7) (b) 1.
2. A child who is under one year of age, whose mother was determined to be eligible under subd. 1., and who lives with his or her mother in this state.
3. A child whose family income exceeds 200 percent but does not exceed 300 percent of the poverty line. For a child under this subdivision who is an unborn child, benefits are limited to prenatal care.
4. An individual who satisfies all of the following criteria:
a. The individual is a parent or caretaker relative of a child who is living in the home with the parent or caretaker relative or who is temporarily absent from the home for not more than 6 months or, if the child has been removed from the home for more than 6 months, the parent or caretaker relative is working toward unifying the family by complying with a permanency plan under s. 48.38.