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.
SECTION 10. 49.475 (2) of the statutes is repealed and recreated to read:
49.475 (2) REQUIREMENTS OF 3RD PARTIES. As a condition of doing business in this state, a 3rd party shall do all of the following:
(a) Upon the department's request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:
1. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.
2. If subd. 1. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.
(b) Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department's right to recover any 3rd-party payment made for which assignment has not been accepted.
(c) Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.
(d) If all of the following apply, agree not to deny a claim submitted by the department under par. (b) solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:
1. The department submits the claim less than 36 months after the date on which the health care item or service was provided.
2. Action by the department to enforce the department's rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.
SECTION 11. 49.475 (3) (intro.) of the statutes is amended to read:
49.475 (3) WRITTEN AGREEMENT. (intro.) Upon requesting an insurer a 3rd party to provide the information under sub. (2) (a), the department and the 3rd party shall enter into a written agreement with the insurer that satisfies all of the following:
SECTION 12. 49.475 (3) (a) of the statutes is amended to read:
49.475 (3) (a) Identifies in detail the detailed format of the information to be disclosed provided to the department.
SECTION 13. 49.475 (3) (c) of the statutes is amended to read:
49.475 (3) (c) Specifies how the insurer's 3rd party's reimbursable costs under sub. (5) will be determined and specifies the manner of payment.
SECTION 14. 49.475 (4) (a) of the statutes is amended to read:
49.475 (4) (a) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer 3rd party to disclose information under this section.
SECTION 15. 49.475 (4) (b) of the statutes is amended to read:
49.475 (4) (b) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 30 days after receiving the department's request if the department has previously requested the insurer 3rd party to disclose information under this section.
SECTION 16. 49.475 (4) (d) of the statutes is created to read:
49.475 (4) (d) If a 3rd party other than an insurer fails to comply with par. (a) or (b), the department may so notify the attorney general.
SECTION 17. 49.475 (5) of the statutes is amended to read:
49.475 (5) From the appropriations under s. 20.435 (4) (bm) and (pa), the department shall reimburse an insurer A 3rd party that provides information under this section sub. (2) (a) for the insurer's 3rd party's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of the information under this section.
SECTION 18. 49.475 (6) of the statutes is created to read:
49.475 (6) SHARING INFORMATION. The department of health and family services shall provide to the department of workforce development, for purposes of the medical support liability program under s. 49.22, any information that the department of health and family services receives under this section. The department of workforce development may allow a county child support agency under s. 59.53 (5) or a tribal child support agency access to the information, subject to the use and disclosure restrictions under s. 49.83, and shall consult with the department of health and family services regarding procedures and methods to adequately safeguard the confidentiality of the information provided under this subsection.
SECTION 19. 49.665 (5m) of the statutes is repealed and recreated to read:
49.665 (5m) INFORMATION ABOUT BADGER CARE RECIPIENTS. The department shall obtain and share information about Badger Care health care program recipients as provided in s. 49.475.
SECTION 20. 49.687 (6) of the statutes is created to read:
49.687 (6) The department shall obtain and share information about individuals who receive benefits under s. 49.68, 49.683, or 49.685 as provided in s. 49.475.
SECTION 21. 49.688 (8m) of the statutes is repealed and recreated to read:
49.688 (8m) The department shall obtain and share information about participants in the program under this section as provided in s. 49.475.
SECTION 22. 255.06 (4) of the statutes is created to read:
255.06 (4) INFORMATION ABOUT WOMEN WHO RECEIVE SERVICES. The department shall obtain and share information about women who receive services that are reimbursed under this section as provided in s. 49.475.
(End)
LRB-0249LRB-0249/2
DAK:kjf:rs
2007 - 2008 LEGISLATURE
DOA:......Pink, BB0014 - Medical Assistance contractor collections
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
Currently, DHFS contracts with private entities to maximize collections and other recoveries of moneys owed to DHFS under the Medical Assistance (MA) Program from care or service providers and third parties, including insurers. Receipt of these moneys is credited to several MA appropriations as a reduction to expense.
This bill provides for receipt of moneys from collections and other recoveries from providers, drug manufacturers, and other third parties under MA performance-based contracts, as program revenue, and authorizes expenditure of the moneys for collection and other recovery costs and for various benefits and other payments under the MA Program.
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) (im) of the statutes is amended to read:
20.435 (4) (im) Medical assistance; recovery of correct payments correct payment recovery; collections; other recoveries. All moneys received from the recovery of correct medical assistance payments under ss. 49.496 and 867.035 and rules promulgated under s. 46.286 (7) and all moneys received as collections and other recoveries from providers, drug manufacturers, and other 3rd parties under medical assistance performance-based contracts, for payments to counties and tribal governing bodies under s. 49.496 (4), for payment of claims under s. 867.035 (3), for payments to the federal government for its share of medical assistance benefits recovered, for the state share of medical assistance benefits provided under subch. IV of ch. 49 as specified in ss. 49.496 (5) and 867.035 (4), and for the state share of medical assistance benefits provided under s. 46.284 (5), and for costs related to collections and other recoveries.
****NOTE: This SECTION involves a change in an appropriation that must be reflected in the revised schedule in s. 20.005, stats.
(End)
LRB-0250LRB-0250/2
DAK:jld:nwn
2007 - 2008 LEGISLATURE
DOA:......Pink, BB0014 - Medical Assistance retroactive eligibility repayments
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, which provides federal and state moneys to pay providers for health care provided to MA recipients. MA recipients are persons with very low income and resources who apply for MA benefits and meet certain eligibility requirements. One category of MA recipients is termed "categorically needy"; these persons have incomes and resources at the eligible levels and can be determined to be retroactively eligible for MA for a certain period of months. Currently, if an MA applicant is found to be retroactively eligible as a "categorically needy" recipient and a provider has billed the recipient directly for services provided during the retroactive period, the provider, upon notice that the applicant is retroactively eligible, must submit claims for MA payment to DHFS. When paid by DHFS, the provider must reimburse the MA recipient for payment the MA recipient or another person made to the provider for services provided to the recipient during the retroactively eligible period. Regardless of the amount the provider has charged the MA recipient, no provider may be required to reimburse the recipient more than the amount that the provider is paid for the services by MA.
This bill eliminates the provision that prohibits requiring a health care provider to reimburse for services paid for by an MA "categorically needy" recipient in an amount that is greater than the provider is paid for the services under the MA program. Instead, the bill requires that the health care provider reimburse the MA recipient or another person in the amount that the recipient or other person has paid the provider for the recipient's care. The bill also extends this repayment requirement to persons who are determined to be retroactively eligible for MA as "medically needy" recipients (persons with higher incomes than are usually allowed who incur medical expenses that, if paid, bring their incomes within applicable limits).
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. 49.49 (3m) (a) 2. of the statutes is amended to read:
49.49 (3m) (a) 2. If an applicant is determined to be eligible retroactively under s. 49.46 (1) (b) or 49.47 (4) (d) and a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider shall, upon notification of the applicant's retroactive eligibility, submit claims for reimbursement payment under s. 49.45 for covered services or benefits rendered to the recipient during the retroactive period. Upon receipt of payment under s. 49.45, the provider shall reimburse the applicant recipient or other person who has made prior payment to the provider. No provider may be required to reimburse the applicant or other person in excess of the amount reimbursed under s. 49.45 for services provided to the recipient during the retroactive eligibility period, by the amount of the prior payment made.
(End)
LRB-0258LRB-0258/1
GMM:kjf:pg
2007 - 2008 LEGISLATURE
DOA:......Rhodes, BB0001 - Community aids funding
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
