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LRB-0246LRB-0246/2
DAK:jld:jf
2007 - 2008 LEGISLATURE
DOA:......Rhodes, BB0006 - Birth to 3 Program carry-over
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
Mental illness, alcoholism, and developmental disabilities
Currently, the general purpose revenues (GPR) appropriation account from which DHFS provides moneys for early intervention services for infants and toddlers with disabilities (commonly known as the "Birth to Three Program") is an annual appropriation but permits transfer of funds between fiscal years. Funds distributed by DHFS to counties but not encumbered by December 31 of each year must lapse to the general fund on the next January 1 unless carried forward to the next calendar year by JCF.
This bill deletes from the DHFS appropriation account for the Birth to Three Program the requirement that funds distributed but not encumbered by December 31 of each year lapse to the general fund on the next January 1; deletes the fiscal year transfer authorization; and makes the appropriation account continuing.
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 (7) (bt) of the statutes is amended to read:
20.435 (7) (bt) Early intervention services for infants and toddlers with disabilities. The As a continuing appropriation, the amounts in the schedule for the early intervention services under s. 51.44. Notwithstanding ss. 20.001 (3) (a) and 20.002 (1), the department may transfer funds between fiscal years under this paragraph. All funds distributed by the department under s. 51.44 but not encumbered by December 31 of each year shall lapse to the general fund on the next January 1 unless carried forward to the next calendar year by the joint committee on finance.
****NOTE: This SECTION involves a change in an appropriation that must be reflected in the revised schedule in s. 20.005, stats.
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LRB-0247LRB-0247/1
DAK:kjf:rs
2007 - 2008 LEGISLATURE
DOA:......Rhodes, BB0007 - Group home revolving loan fund repeal
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
Mental illness, alcoholism, and developmental disabilities
Currently, DHFS administers a fund, known as the "group home revolving loan fund," to make limited two-year loans to applying nonprofit organizations to establish housing programs for individuals who are recovering from alcohol or other drug abuse. This bill eliminates the group home revolving loan fund.
For further information see the state 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 (6) (gd) of the statutes is repealed.
****NOTE: This SECTION involves a change in an appropriation that must be reflected in the revised schedule in s. 20.005, stats.
SECTION 2. 46.976 of the statutes is repealed.
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LRB-0248LRB-0248/3
DAK&PJK:jld:pg
2007 - 2008 LEGISLATURE
DOA:......Pink, BB0012 - Third-party liability; sharing health data
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
Public assistance
Under current law, DHFS provides financial assistance for the cost of medical care to persons with chronic kidney disease, cystic fibrosis, and hemophilia; this assistance is collectively referred to as the Chronic Disease Program. DHFS also provides payments to pharmacies and pharmacists for providing prescriptions to elderly persons at reduced rates; this program is referred to as Senior Care.
This bill requires health insurers, self-insured plans, service benefits plans, and pharmacy benefits managers (third parties) to provide to DHFS information from their records to enable DHFS to identify persons receiving benefits under the Chronic Disease Program and Senior Care who are eligible, or would be eligible as dependents, for health care coverage from a third party. These third parties may receive compensation for providing the information, must provide the information within certain deadlines, and may be subject to enforcement proceedings for noncompliance. The third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under the Chronic Disease Program or Senior Care has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Medical Assistance
Currently, DHFS may obtain from insurers information DHFS needs to identify a recipient of Medical Assistance (MA) who is eligible for benefits under a disability insurance policy or, if enrolled as the dependent of a beneficiary, would be eligible for benefits; claims submittal information; and types of benefits provided under the policy. DHFS must enter into an agreement with the insurer that identifies the information to be disclosed, safeguards confidentiality, and specifies how the insurer's reasonable costs will be determined and paid from state general purpose revenues and federal moneys. Insurers must provide the information within specified deadlines, and the commissioner of insurance may initiate enforcement proceedings for noncompliance.
This bill expands the sources from which DHFS may receive health care services coverage information about MA recipients to include entities that are responsible for payment of a claim for a health care item or service and makes available compensation for providing the information. The sources, termed "third parties," include, in addition to insurers, self-insured plans, service benefits plans, and pharmacy benefits managers. The bill authorizes DHFS to notify the attorney general of third parties, other than insurers, that fail to provide information requested.
Under the bill, third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under MA, or under a program administered under MA under a federal waiver, has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Lastly, the bill applies the information recovery, acceptance of assignment, recovery of third-party payment, and compensation provisions of current law and as affected by this bill so as to enable DHFS also to identify Badger Care health care program recipients who are eligible, or who would be eligible as dependents, for health care coverage from a third party.
Health
Currently, DHFS administers the Well-Woman Program, under which certain medical services related to breast cancer, cervical cancer, and multiple sclerosis and certain general medical services are provided to underinsured and uninsured women of low income.
This bill requires health insurers, self-insured plans, service benefits plans, and pharmacy benefits managers (third parties) to provide to DHFS information from their records to enable DHFS to identify persons receiving benefits under the Well-Woman Program who are eligible, or would be eligible as dependents, for health care coverage from a third party. These third parties may receive compensation for providing the information, must provide the information within certain deadlines, and may be subject to enforcement proceedings for noncompliance. The third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under the Well-Woman Program has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Other health and family services
Currently, DHFS administers Family Care, a program that provides a flexible benefit of long-term care and services to certain persons who are at least 18 years of age, meet functional and financial eligibility requirements, and have a physical or developmental disability or degenerative brain disorder.
This bill requires health insurers, self-insured plans, service benefits plans, and pharmacy benefits managers (third parties) to provide to DHFS information from their records to enable DHFS to identify persons receiving benefits under Family Care who are eligible, or would be eligible as dependents, for health care coverage from a third party. These third parties may receive compensation for providing the information, must provide the information within certain deadlines, and may be subject to enforcement proceedings for noncompliance. The third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under Family Care has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Under current law, DHFS may request from health insurers information to enable DHFS to identify Medical Assistance recipients who are eligible, or who would be eligible as dependents, for health insurance coverage. An insurer that receives a request must provide the information within a certain period of time. Under the bill, DHFS must provide any information that it receives from a health insurer, self-insured plan, service benefit plan, and pharmacy benefits manager to DWD for purposes of DWD's program related to child and spousal support, paternity establishment, and medical support liability. DWD may allow county and tribal child support agencies access to the information, subject to use and disclosure restrictions under current law, and must consult with DHFS regarding procedures to safeguard the confidentiality of the information.
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) (pa) of the statutes is amended to read:
20.435 (4) (pa) Federal aid; Medical Assistance and food stamp contracts administration. All federal moneys received for the federal share of the cost of contracting for payment and services administration and reporting, other than moneys received under par. (nn), to reimburse insurers 3rd parties for their costs under s. 49.475, for administrative contract costs for the food stamp program under s. 49.79, and for services of resource centers under s. 46.283.
SECTION 2. 46.286 (3m) of the statutes is repealed and recreated to read:
46.286 (3m) INFORMATION ABOUT ENROLLEES. The department shall obtain and share information about family care enrollees as provided in s. 49.475.
SECTION 3. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).
SECTION 4. 49.475 (1) (ag) of the statutes is created to read:
49.475 (1) (ag) "Covered entity" means any of the following that is not an insurer:
1. A nonprofit hospital, as defined in s. 46.21 (2) (m).
2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons organized in this state if the employer, labor union, or other group provides prescription drug coverage to covered individuals who reside or are employed in this state.
3. A comprehensive or limited health care benefits program administered by the state that provides prescription drug coverage.
SECTION 5. 49.475 (1) (am) of the statutes is created to read:
49.475 (1) (am) "Covered individual" means an individual who is a member, participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary of a covered entity, or a dependent of the individual, and who receives prescription drug coverage from or through the covered entity.
SECTION 6. 49.475 (1) (c) of the statutes is created to read:
49.475 (1) (c) "Pharmacy benefits management" means the procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals; or any of the following services provided in the administration of pharmacy benefits:
1. Dispensation of prescription drugs by mail.
2. Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals.
3. Clinical formulary development and management services.
4. Rebate contracting and administration.
5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.
SECTION 7. 49.475 (1) (d) of the statutes is created to read:
49.475 (1) (d) "Pharmacy benefits manager" means a person that performs pharmacy benefits management functions.
SECTION 8. 49.475 (1) (e) of the statutes is created to read:
49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:
1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.
2. An enrollee of family care.
3. A recipient of the Badger Care health care program.
4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.
5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.
6. A woman who receives services that are reimbursed under s. 255.06.
SECTION 9. 49.475 (1) (f) of the statutes is created to read:
49.475 (1) (f) "Third party" means an entity that by statute, rule, or contract is responsible for payment of a claim for a health care item or service. "Third party" includes all of the following:
1. An insurer.
2. An employee benefit plan described in 29 USC 1003 (a) that is not exempt under 29 USC 1003 (b) and is not a multiple employer welfare arrangement.
3. A service benefit plan, as specified in 42 USC 1396a (25) (I).
4. A pharmacy benefits manager.
