SECTION 9321. Initial applicability; Health and Family Services.
(1) APPROVAL OF FINANCIAL ASSISTANCE. The treatment of sections 146.75 (3) (d), 146.76, 231.03 (intro.), and 231.035 of the statutes first applies to applications for financial assistance made by a health facility or participating health institution under section 231.03 of the statutes, as affected by this act, on the effective date of this subsection.
(End)
LRB-0905LRB-0905/4
PJK:jld:rs
2007 - 2008 LEGISLATURE
DOA:......Pink, BB0185 - BadgerCare Plus
For 2007-09 Budget -- Not Ready For Introduction
2007 BILL
AN ACT ...; relating to: the budget.
Analysis by the Legislative Reference Bureau
HEALTH AND HUMAN SERVICES
Medical Assistance
Under current law, DHFS administers the Medical Assistance (MA) program and the Badger Care health care program (BadgerCare), both of which provide health care benefits for eligible individuals. Individuals who may be eligible for MA, generally, are pregnant women, certain children, and elderly or disabled individuals, all of whom must meet specific low-income requirements. Families, children who do not reside with their parents, and unborn children whose mothers are not eligible for MA or BadgerCare may be eligible for BadgerCare if their incomes do not exceed 185 percent of the federal poverty line and they meet certain nonfinancial criteria, such as not having access to employer-subsidized health care coverage.
Waiver to implement BadgerCare Plus
Under this bill, DHFS must request a waiver from, and submit amendments to the state MA plan to, the secretary of the federal department of health and human services to allow DHFS to implement an MA health care program called BadgerCare Plus (BC+). BC+ would be financed as are other MA programs, partly with federal funds and partly with state funds. BC+ would replace all of BadgerCare and part of MA. Thus, individuals who satisfy eligibility criteria under both BC+ and BadgerCare would receive benefits under BC+. Individuals who satisfy eligibility criteria under both BC+ and MA would receive benefits under either BC+ or MA, depending on the basis for their eligibility for MA. For example, an individual who is eligible for MA because he or she receives supplemental security income would continue to receive benefits as usual under MA rather than under BC+.
Benefits and general eligibility
BC+ would provide health care benefits to recipients under two different plans, depending on the basis for the recipient's eligibility. The first plan provides the same benefits that are provided under regular MA. Individuals eligible for BC+ benefits under that plan (regular MA plan) include: a pregnant woman whose family income does not exceed 200 percent of the poverty level (poverty); a child under one year of age whose mother, on the day on which the child was born, was eligible for and receiving benefits under MA or BC+ under the regular MA plan; any child whose family income does not exceed 200 percent of poverty; an individual whose family income does not exceed 200 percent of poverty and who is the parent or caretaker relative of a child who is, generally, living in the home of the parent or caretaker relative; certain migrant workers and their dependents; and an individual between 19 and 21 years of age who was in foster care on his or her 18th birthday.
The second plan, called the Benchmark Plan, provides specified benefits, including, but not limited to, coverage for prescription drugs; physicians' services; inpatient and outpatient hospital services; home health services; physical, occupational, and speech therapy; treatment for nervous and mental disorders and alcoholism and other drug abuse problems; durable medical equipment; and transportation to obtain emergency medical care. Individuals eligible for BC+ benefits under the Benchmark Plan include: a pregnant woman whose family income exceeds 200 percent, but does not exceed 300 percent, of poverty; a child under one year of age whose mother, on the day on which the child was born, was eligible for and receiving BC+ benefits under the Benchmark Plan; any child whose family income exceeds 200 percent, but does not exceed 300 percent, of poverty; and an individual whose family income exceeds 200 percent, but does not exceed 300 percent, of poverty and who is the parent or caretaker relative of a child who is, generally, living in the home of the parent or caretaker relative. In addition, any child whose family income exceeds 300 percent of poverty may purchase coverage under the Benchmark Plan at the full per member per month cost of the coverage.
For coverage under both the regular MA plan and the Benchmark Plan, a child is defined to include an unborn child whose mother is not eligible for MA or BC+ but satisfies all other eligibility criteria except that she is not a U.S. citizen or qualifying alien or is an inmate of a public institution. If the mother's family income does not exceed 200 percent of poverty, the unborn child is eligible for BC+ benefits, limited to prenatal care, under the regular MA plan; if the mother's family income exceeds 200 percent, but does not exceed 300 percent, of poverty, the unborn child is eligible for BC+ benefits, limited to prenatal care, under the Benchmark Plan.
Various other eligibility provisions apply under BC+. For example, regardless of any increase in income, a pregnant woman who is eligible for regular MA benefits remains eligible for those benefits until the last day of the month in which the 60th day after the last day of the pregnancy falls. A child who is receiving inpatient services under the regular MA plan on the day before his or her 19th birthday remains eligible for those services until the end of the stay for which the services are being provided. A pregnant woman, a child, or a parent or caretaker relative whose family income is less than 150 percent of poverty is eligible for benefits for any of the three months before he or she applied for coverage if he or she was otherwise eligible and his or her family income was less than 150 percent of poverty.
Health insurance-related provisions
Various health insurance qualifications and limitations apply under BC+. As a condition of eligibility for BC+, an individual who is eligible for enrollment in a group health plan must apply for enrollment in that plan if DHFS determines that it is cost-effective. With exceptions for pregnant women, individuals in foster care on their 18th birthday, and certain children, no individual whose family income exceeds 150 percent of poverty is eligible for BC+ if the individual has health care coverage under the state employee health plan or coverage that is provided by an employer and for which the employer pays at least 80 percent of the premium. Regardless of family income, however, an unborn child is not eligible for BC+ if the unborn child or its mother has any type of health insurance coverage. Unless there is a good cause reason for not enrolling in the coverage, if an individual whose family income exceeds 150 percent of poverty or an unborn child or its mother had access in the 12 months before applying for BC+ to health care coverage under the state employee health plan or coverage that is provided by an employer and for which the employer pays at least 80 percent of the premium, the individual or unborn child is not eligible for BC+. A pregnant woman whose family income exceeds 200 percent of poverty and who has health insurance coverage must maintain that coverage as a condition of eligibility for BC+. If an individual whose family income exceeds 150 percent of poverty had coverage under the state employee health plan or employer-provided coverage but no longer has the coverage, if an unborn child or its mother had health insurance coverage but no longer has the coverage, or if a pregnant woman whose family income exceeds 200 percent of poverty did not maintain coverage that she had, the individual, unborn child, or pregnant woman is not eligible for BC+ for three calendar months following the month in which the coverage ended, unless there was a good cause reason for the termination of the coverage.
Under the bill, with certain exceptions, for an individual whose family income exceeds 150 percent of poverty, DHFS must verify directly with the employer, if any, whether the individual has or had insurance coverage or access. An employer that receives a request from DHFS for that information must supply the information within a certain time or pay a penalty equal to the full per member per month cost of coverage under BC+ for each month the individual is covered under BC+ until the employer provides the information. Penalties are limited to no more than $1,000 in any six-month period for an employer with fewer than 250 employees, and to no more than $15,000 in any six-month period for other employers.
Cost sharing
Generally, the same copayment requirements that apply under MA apply to BC+ recipients with benefits under the regular MA plan. BC+ recipients with benefits under the Benchmark Plan are subject to the copayment and coinsurance requirements specified in the bill for that plan. A BC+ recipient who is an adult and who is not a pregnant woman must pay a premium for BC+ coverage if the recipient's family income is at least 150 percent of poverty. The premium may not exceed 5 percent of the recipient's family income. A BC+ recipient who is a child must pay a premium for BC+ coverage if the recipient's family income is at least 200 percent of poverty. The premium may not exceed the full per member per month cost of coverage for a child with a family income equal to 300 percent of poverty. A BC+ recipient who is an unborn child or a pregnant woman must pay a premium if the recipient's family income exceeds 200 percent of poverty. The premium may not exceed the full per member per month cost of coverage for an adult with a family income equal to 300 percent of poverty. If a recipient who is required to pay a premium does not pay it when it is due, the recipient's coverage terminates and the recipient may not be eligible for BC+ again for six months.
For further information see the state and local fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
SECTION 1. 20.435 (4) (b) of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:
20.435 (4) (b) Medical Assistance program benefits. Biennially, the amounts in the schedule to provide a portion of the state share of Medical Assistance program benefits administered under s. 49.45 subch. IV of ch. 49, for a portion of the Badger Care health care program under s. 49.665, to provide a portion of the Medical Assistance program benefits administered under s. 49.45 subch. IV of ch. 49 that are not also provided under par. (o), to fund the pilot project under s. 46.27 (9) and (10), to provide a portion of the facility payments under 1999 Wisconsin Act 9, section 9123 (9m), to fund services provided by resource centers under s. 46.283, for services under the family care benefit under s. 46.284 (5), for assisting victims of diseases, as provided in ss. 49.68, 49.683, and 49.685, and for reduction of any operating deficits as specified in 2005 Wisconsin Act 15, section 3. Notwithstanding s. 20.002 (1), the department may transfer from this appropriation account to the appropriation account under sub. (7) (kb) funds in the amount of and for the purposes specified in s. 46.485. Notwithstanding ss. 20.001 (3) (b) and 20.002 (1), the department may credit or deposit into this appropriation account and may transfer between fiscal years funds that it transfers from the appropriation account under sub. (7) (kb) for the purposes specified in s. 46.485 (3r). Notwithstanding s. 20.002 (1), the department may transfer from this appropriation account to the appropriation account under sub. (7) (bd) funds in the amount and for the purposes specified in s. 49.45 (6v).
****NOTE: This is reconciled s. 20.435 (4) (b). This SECTION has been affected by drafts with the following LRB numbers: LRB-0892, LRB-0905, and LRB-1521.
SECTION 2. 20.435 (4) (bm) of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:
20.435 (4) (bm) Medical Assistance, food stamps, and Badger Care administration; contract costs, reports, and resource centers. Biennially, the amounts in the schedule to provide a portion of the state share of administrative contract costs for the Medical Assistance program under s. 49.45 subch. IV of ch. 49 and the Badger Care health care program under s. 49.665 and to provide the state share of administrative costs for the food stamp program under s. 49.79, other than payments to counties and tribal governing bodies under s. 49.78 (8), to develop and implement a registry of recipient immunizations, to reimburse 3rd parties for their costs under s. 49.475, for costs associated with outreach activities, and for services of resource centers under s. 46.283. No state positions may be funded in the department of health and family services from this appropriation, except positions for the performance of duties under a contract in effect before January 1, 1987, related to the administration of the Medical Assistance program between the subunit of the department primarily responsible for administering the Medical Assistance program and another subunit of the department. Total administrative funding authorized for the program under s. 49.665 may not exceed 10% of the amounts budgeted under pars. (bc), (p), and (x).
****NOTE: This is reconciled s. 20.435 (4) (bm). This SECTION has been affected by drafts with the following LRB numbers: LRB-0905, LRB-0248, and LRB-0892.
SECTION 3. 20.435 (4) (bn) of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:
20.435 (4) (bn) Income maintenance. Biennially, the amounts in the schedule for funeral expenses under s. 49.785, for administration of the food stamp employment and training program under s. 49.79 (9), and for payments under s. 49.78 (8) relating to the administration of the Medical Assistance program under subch. IV of ch. 49, the Badger Care health care program under s. 49.665, the food stamp program, and the cemetery, funeral, and burial expenses program under s. 49.785.
****NOTE: This is reconciled s. 20.435 (4) (bn). This SECTION has been affected by drafts with the following LRB numbers: LRB-0905 and LRB-1313.
SECTION 4. 20.435 (4) (jw) of the statutes is created to read:
20.435 (4) (jw) BadgerCare Plus administrative costs. Biennially, the amounts in the schedule to provide a portion of the state share of administrative costs for the BadgerCare Plus Medical Assistance program under s. 49.471. Ten percent of all moneys received from penalty assessments under s. 49.471 (9) (c) shall be credited to this appropriation account.
****NOTE: This SECTION involves a change in an appropriation that must be reflected in the revised schedule in s. 20.005, stats.
SECTION 5. 20.435 (4) (jz) of the statutes is amended to read:
20.435 (4) (jz) Medical Assistance and Badger Care cost sharing and employer penalty assessments. All moneys received from in cost sharing from medical assistance recipients, including payments under s. 49.665 (5) and, all moneys received from penalty assessments under s. 49.665 (7) (b) 2., and 90 percent of all moneys received from penalty assessments under s. 49.471 (9) (c) to be used for the Badger Care health care program under s. 49.665 and for the Medical Assistance program under subch. IV of ch. 49.
****NOTE: This SECTION involves a change in an appropriation that must be reflected in the revised schedule in s. 20.005, stats.
SECTION 6. 20.435 (4) (o) of the statutes is amended to read:
20.435 (4) (o) Federal aid; medical assistance. All federal moneys received for meeting costs of medical assistance Medical Assistance administered under ss. 46.284 (5), 49.45 and 49.665 and subch. IV of ch. 49, to be used for those purposes and for transfer to the medical assistance Medical Assistance trust fund, for those purposes.
SECTION 7. 45.51 (13) (intro.) of the statutes is amended to read:
45.51 (13) ADDITIONAL ELIGIBILITY REQUIREMENTS FOR SKILLED NURSING FACILITIES. (intro.) Any person admitted to a skilled nursing facility at a veterans home shall meet the eligibility requirements under ss. 49.45 and 49.46, and, if applicable, s. 49.471 and rules promulgated under those sections during residence at the skilled nursing facility except if any of the following apply:
SECTION 8. 45.51 (13) (a) of the statutes is amended to read:
45.51 (13) (a) Persons with sufficient income and resources to meet the expenses of care for one or more months may be admitted to the skilled nursing facility but shall apply income and resources to costs to the extent required under ss. 49.45 and 49.46, and, if applicable, s. 49.471 and rules promulgated under those sections.
SECTION 9. 45.51 (13) (b) of the statutes is amended to read:
45.51 (13) (b) Persons who meet all the requirements of this section but whose degree of physical disability does not meet the minimum requirements under ss. 49.45 and 49.46 and rules promulgated under those sections may be admitted to the skilled nursing facility but shall apply income and resources to costs to the extent required by ss. 49.45 and 49.46, and, if applicable, s. 49.471 and rules promulgated under those sections.
SECTION 10. 46.206 (1) (bm) of the statutes is amended to read:
46.206 (1) (bm) All records of the department relating to aid provided under s. 49.46, 49.465, 49.468, 49.47, 49.471, or 49.77 are open to inspection at reasonable hours by members of the legislature who require the information contained in the records in pursuit of a specific state legislative purpose. All records of any county relating to aid provided under s. 49.46, 49.465, 49.468, 49.47, 49.471, or 49.77 are open to inspection at reasonable hours by members of the board of supervisors of the county or the governing body of a city, village or town located in the county who require the information contained in the records in pursuit of a specific county or municipal legislative purpose. The right to records access provided by this paragraph does not apply if access is prohibited by federal law or regulation or if this state is required to prohibit such access as a condition precedent to participation in a federal program in which this state participates.
SECTION 11. 46.22 (1) (b) 1. d. of the statutes is amended to read:
46.22 (1) (b) 1. d. To submit a final budget in accordance with s. 46.031 (1) for services authorized in this section, except for the administration of and cost of aid granted under ss. 49.02, 49.19 and 49.45 to 49.47 49.471.
SECTION 12. 46.27 (6u) (c) 1. a. of the statutes is amended to read:
46.27 (6u) (c) 1. a. Eligible for medical assistance under s. 49.46, 49.468 or, 49.47, or 49.471 (4) (a).
SECTION 13. 46.27 (6u) (d) (intro.) of the statutes is amended to read:
46.27 (6u) (d) (intro.) In determining financial eligibility under par. (c) 1. and in calculating the amount under par. (c) 2., the county department or aging unit shall include as the assets for any person, except those persons who are eligible for medical assistance under s. 49.46, 49.468 or, 49.47, or 49.471 (4) (a), any portion of assets that the person or the person's spouse has, after August 12, 1993, transferred to another as specified in par. (b), unless one of the following conditions applies:
SECTION 14. 46.27 (7) (am) of the statutes is amended to read:
46.27 (7) (am) From the appropriation under s. 20.435 (7) (bd), the department shall allocate funds to each county or private nonprofit agency with which the department contracts to pay assessment and case plan costs under sub. (6) not otherwise paid by fee or under s. 49.45 or 49.78 (2). The department shall reimburse counties for the cost of assessing persons eligible for medical assistance under s. 49.46, 49.468, or 49.47, or 49.471 (4) (a) as part of the administrative services of medical assistance, payable under s. 49.45 (3) (a). Counties may use unspent funds allocated under this paragraph to pay the cost of long-term community support services and for a risk reserve under par. (fr).
SECTION 15. 46.27 (7) (b) of the statutes is amended to read:
46.27 (7) (b) From the appropriations under s. 20.435 (7) (bd) and (im), the department shall allocate funds to each county to pay the cost of providing long-term community support services under sub. (5) (b) not otherwise paid under s. 49.45 to persons eligible for medical assistance under s. 49.46 or, 49.47, or 49.471 (4) (a) or to persons whom the county department or aging unit administering the program finds likely to become medically indigent within 6 months by spending excess income or assets for medical or remedial care. The average per person reimbursement under this paragraph may not exceed the state share of the average per person payment rate the department expects under s. 49.45 (6m). The county department or aging unit administering the program may spend funds received under this paragraph only in accordance with the case plan and service contract created for each person receiving long-term community support services. Counties may use unspent funds allocated under this paragraph from the appropriation under s. 20.435 (7) (bd) for a risk reserve under par. (fr).
SECTION 16. 46.275 (1m) (a) of the statutes is amended to read:
46.275 (1m) (a) "Medical assistance" means aid provided under subch. IV of ch. 49, except s. ss. 49.468 and 49.471.
SECTION 17. 46.277 (1m) (a) of the statutes is amended to read:
46.277 (1m) (a) "Medical assistance" means aid provided under subch. IV of ch. 49, except s. ss. 49.468 and 49.471.
SECTION 18. 46.278 (1m) (b) of the statutes is amended to read:
46.278 (1m) (b) "Medical assistance" means aid provided under subch. IV of ch. 49, except s. ss. 49.468 and 49.471.
SECTION 19. 46.283 (3) (k) of the statutes is amended to read:
46.283 (3) (k) A determination of eligibility for state supplemental payments under s. 49.77, medical assistance under s. 49.46, 49.468 or, 49.47, or 49.471, or the federal food stamp program under 7 USC 2011 to 2029.
SECTION 20. 46.485 (3g) of the statutes is amended to read:
46.485 (3g) The amount that the department may transfer under sub. (2g) for counties may not exceed the estimated state share of payments under s. 49.45, 49.46 or, 49.47, or 49.471 for mental health care and treatment that is provided in inpatient facilities for children with severe emotional disturbances.
SECTION 21. 48.57 (3m) (e) of the statutes is amended to read:
48.57 (3m) (e) The department shall determine whether the child is eligible for medical assistance under ss. 49.43 to 49.47 49.471.
SECTION 22. 48.57 (3n) (e) of the statutes is amended to read:
48.57 (3n) (e) The department shall determine whether the child is eligible for medical assistance under ss. 49.43 to 49.47 49.471.
SECTION 23. 49.22 (2m) (a) of the statutes is amended to read:
49.22 (2m) (a) The department may request from any person in this state information it determines appropriate and necessary for the administration of this section, ss. 49.141 to 49.161, 49.19, 49.46, 49.468 and, 49.47, and 49.471 and programs carrying out the purposes of 7 USC 2011 to 2029. Unless access to the information is prohibited or restricted by law, or unless the person has good cause, as determined by the department in accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort to provide this information within 7 days after receiving a request under this paragraph. Except as provided in subs. (2p) and (2r) and subject to sub. (12), the department or the county child support agency under s. 59.53 (5) may disclose information obtained under this paragraph only in the administration of this section, ss. 49.141 to 49.161, 49.19, 49.46 and, 49.47, and 49.471 and programs carrying out the purposes of 7 USC 2011 to 2029. Employees of the department or a county child support agency under s. 59.53 (5) are subject to s. 49.83.
SECTION 24. 49.22 (2m) (b) of the statutes is amended to read:
49.22 (2m) (b) The department or county child support agency under s. 59.53 (5) may issue a subpoena, in substantially the form authorized under s. 885.02, to compel the production of financial information and other documentary evidence in the administration of this section, ss. 49.145, 49.19, 49.46 and, 49.47, and 49.471 and programs carrying out the purposes of 7 USC 2011 to 2029.
SECTION 25. 49.22 (2m) (c) 3. of the statutes is amended to read:
49.22 (2m) (c) 3. Any other action taken in good faith to comply with this section or a subpoena described in par. (bc) or to comply with a request for information or access to records from the department or a county child support agency under s. 59.53 (5) in the administration of this section, ss. 49.145, 49.19, 49.46 and, 49.47, and 49.471 and programs carrying out the purposes of 7 USC 2011 to 2029.
SECTION 26. 49.22 (6) of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:
49.22 (6) The department shall establish, pursuant to federal and state laws, rules and regulations, a uniform system of fees for services provided under this section to individuals not receiving aid under s. 48.645, 49.19 or, 49.47, or 49.471; benefits under s. 49.148, 49.155, or 49.79; foster care maintenance payments under 42 USC 670 to 679a; or kinship care payments under s. 48.57 (3m) or long-term kinship care payments under s. 48.57 (3n). The system of fees may take into account an individual's ability to pay. Any fee paid and collected under this subsection may be retained by the county providing the service except for the fee specified in 42 USC 653 (e) (2) for federal parent locator services.
****NOTE: This is reconciled s. 49.22 (6). This SECTION has been affected by drafts with the following LRB numbers: LRB-0905 and LRB-1261.
SECTION 27. 49.45 (2) (a) 1. of the statutes is amended to read:
49.45 (2) (a) 1. Exercise responsibility relating to fiscal matters, the eligibility for benefits under standards set forth in ss. 49.46 to 49.47 49.471, and general supervision of the medical assistance program.
SECTION 28. 49.45 (2) (a) 3. of the statutes is amended to read:
49.45 (2) (a) 3. Determine the eligibility of persons for medical assistance, rehabilitative, and social services under ss. 49.46, 49.468, and 49.47, and 49.471 and rules and policies adopted by the department and may, under a contract under s. 49.78 (2), delegate all, or any portion, of this function to the county department under s. 46.215, 46.22, or 46.23 or a tribal governing body.
SECTION 29. 49.45 (2) (b) 3. of the statutes is amended to read:
49.45 (2) (b) 3. Audit all claims filed by any contractor making the payment of benefits paid under ss. 49.46 to 49.47 49.471 and make proper fiscal adjustments.
SECTION 30. 49.45 (2) (b) 7. (intro.) of the statutes is amended to read:
49.45 (2) (b) 7. (intro.) Require, as a condition of certification under par. (a) 11., all providers of a specific service that is among those enumerated under s. 49.46 (2) or, 49.47 (6) (a), or 49.471 (11), as specified in this subdivision, to file with the department a surety bond issued by a surety company licensed to do business in this state. Providers subject to this subdivision provide those services specified under s. 49.46 (2) or, 49.47 (6) (a), or 49.471 (11) for which providers have demonstrated significant potential to violate s. 49.49 (1) (a), (2) (a) or (b), (3), (3m) (a), (3p), (4) (a), or (4m) (a), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13. The surety bond shall be payable to the department in an amount that the department determines is reasonable in view of amounts of former recoveries against providers of the specific service and the department's costs to pursue those recoveries. The department shall promulgate rules to implement this subdivision that specify all of the following:
SECTION 31. 49.45 (3) (b) 1. of the statutes is amended to read:
49.45 (3) (b) 1. The contractor, if any, administering benefits or providing prepaid health care under s. 49.46, 49.465, 49.468 or, 49.47, or 49.471 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in sub. (2) (a) 4., but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
SECTION 32. 49.45 (3) (b) 2. of the statutes is amended to read:
