2007 - 2008 LEGISLATURE
May 31, 2007 - Introduced by Representatives Friske, Mursau, Townsend, Bies,
Gunderson, A. Ott
and Jeskewitz, cosponsored by Senator S. Fitzgerald.
Referred to Committee on Health and Healthcare Reform.
AB385,1,4 1An Act to amend 49.665 (3) and 49.688 (7) (a); and to create 49.45 (3) (cm) of
2the statutes; relating to: deadlines for payment of provider claims under the
3Medical Assistance and Badger Care programs and the prescription drug
4assistance program for elderly persons.
Analysis by the Legislative Reference Bureau
Under current administrative rules, the Department of Health and Family
Services (DHFS) must issue payment for at least 95 percent of provider claims under
the Medical Assistance (MA), Badger Care, and Senior Care programs within 30
days of receipt of the claims, issue payment for at least 99 percent of claims within
90 days of receipt, and issue payment for 100 percent of claims within 180 days of
receipt. The rules allow exceptions to these deadlines under the following
circumstances: for a claim that is paid in accordance with a court order, hearing
decision, or corrective action taken by DHFS; if a claim for payment is also made
under Medicare; or if the U.S. Department of Health and Human Services waives the
federal payment deadlines.
This bill codifies the requirement that DHFS issue payment for at least 95
percent of claims under MA, Badger Care, and Senior Care programs within 30 days
of receipt of the claims and requires that DHFS issue payment for 100 percent of such
claims within 45 days of receipt. The bill also codifies the exceptions to payment
deadlines for payments in accordance with court orders, hearing decisions, or
corrective actions, for claims for which a Medicare claim is submitted, and if the
federal government has granted a waiver of payment deadlines.

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:
AB385, s. 1 1Section 1. 49.45 (3) (cm) of the statutes is created to read:
AB385,2,52 49.45 (3) (cm) 1. Except as provided under subd. 2., the department shall issue
3payment for at least 95 percent of proper provider claims for reimbursement under
4the Medical Assistance program within 30 days of receipt of the claims and shall
5issue payment for 100 percent of such claims within 45 days of receipt of the claims.
AB385,2,76 2. The department may exceed the claims payment deadlines under subd.1.
7under any of the following circumstances:
AB385,2,118 a. If a claim is filed under Medicare, as defined in par. (L) 1. b., for payment for
9a service, the department has up to 6 months after the department or the provider
10receives notice of the disposition of the Medicare claim to issue payment for the
AB385,2,1412 b. The department may issue payments at any time in accordance with a court
13order or to comply with a hearing decision or a corrective action taken by the
AB385,2,1715c. If the department is granted a waiver under 42 CFR 447.45 (e) that exempts
16the department from federal deadlines for payment of claims, the department may
17exceed the deadlines under subd.1. to the extent permitted in the waiver.
AB385, s. 2 18Section 2. 49.665 (3) of the statutes is amended to read:
AB385,3,1019 49.665 (3) Administration. Subject to sub. (2) (a) 2., the department shall
20administer a program to provide the health services and benefits described in s. 49.46
21(2) to persons that meet the eligibility requirements specified in sub. (4) and issue

1payment for such services in accordance with s. 49.45 (3) (cm)
. The department shall
2promulgate rules setting forth the application procedures and appeal and grievance
3procedures. The department may promulgate rules limiting access to the program
4under this section to defined enrollment periods. The department may also
5promulgate rules establishing a method by which the department may purchase
6family coverage offered by the employer of a member of an eligible family or of a
7member of an eligible child's household, or family or individual coverage offered by
8the employer of an eligible unborn child's mother or her spouse, under circumstances
9in which the department determines that purchasing that coverage would not be
10more costly than providing the coverage under this section.
AB385, s. 3 11Section 3. 49.688 (7) (a) of the statutes is amended to read:
AB385,4,412 49.688 (7) (a) Except as provided in par. (b), from the appropriation accounts
13under s. 20.435 (4) (bv), (j), and (pg), beginning on September 1, 2002, the department
14shall, under a schedule that is identical to that used by the department for payment
15of pharmacy provider claims under medical assistance, including payment deadlines
16under s. 49.45 (3) cm),
provide to pharmacies and pharmacists payments for
17prescription drugs sold by the pharmacies or pharmacists to persons eligible under
18sub. (2) who have paid the deductible specified under sub. (3) (b) 1. or 2. or who, under
19sub. (3) (b) 1., are not required to pay a deductible. The payment for each prescription
20drug under this paragraph shall be at the program payment rate, minus any
21copayment paid by the person under sub. (5) (a) 2. or 4., and plus, if applicable,
22incentive payments that are similar to those provided under s. 49.45 (8v). The
23department shall devise and distribute a claim form for use by pharmacies and
24pharmacists under this paragraph and may limit payment under this paragraph to
25those prescription drugs for which payment claims are submitted by pharmacists or

1pharmacies directly to the department. The department may apply to the program
2under this section the same utilization and cost control procedures that apply under
3rules promulgated by the department to medical assistance under subch. IV of ch.
AB385,4,55 (End)