OC7 SB1: Bill Text

SB1,709,15 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.

SB1, s. 1557 Section 1557. 49.45 (52) of the statutes is amended to read:

SB1,710,2 49.45 (52) Payment adjustments. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payment adjustments to county departments under s. 46.215, 46.22, 46.23, or 51.42, or 51.437 or to local health departments, as defined in s. 250.01 (4), as appropriate, for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16. Payment adjustments under this subsection shall include the state share of the payments. The total of any payment adjustments under this subsection and Medical Assistance payments made from appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w), and (xd) may not exceed applicable limitations on payments under 42 USC 1396a (a) (30) (A).

SB1, s. 1558 Section 1558. 49.45 (53) of the statutes is amended to read:

SB1,710,7 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).

SB1, s. 1559e Section 1559e. 49.45 (55) of the statutes is created to read:

SB1,710,18 49.45 (55) Health Opportunity Accounts Demonstration Program. The department shall request from the federal Centers for Medicare and Medicaid Services approval to participate in a demonstration program under 42 USC 1396u-8, under which Badger Care recipients may voluntarily enroll to contribute to health opportunity accounts and receive certain alternative benefits under medical assistance. If the Centers for Medicare and Medicaid Services approve the department's request, the department shall submit a proposed plan for implementation of the demonstration program to the joint committee on finance. The department may not implement the plan until it is approved by the committee, as submitted or as modified.

SB1, s. 1559g Section 1559g. 49.45 (56) of the statutes is created to read:

SB1,711,2 49.45 (56) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57), the department shall develop and implement, for Medical Assistance recipients, disease management programs that are similar to that developed and followed by the Marshfield Clinic in this state under the Physician Group Practice Demonstration Program authorized under 42 USC 1315 (e) and (f). These programs shall have at least the following characteristics:

SB1,711,5 (a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.

SB1,711,7 (b) Educating health care providers on health care process improvement by developing best practice models.

SB1,711,10 (c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.

SB1,711,12 (d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.

SB1,711,14 (e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.

SB1, s. 1559h Section 1559h. 49.45 (57) of the statutes is created to read:

SB1,711,20 49.45 (57) Physical health risk assessment. The department shall encourage each individual who is determined on or after the effective date of this subsection .... [revisor inserts date], to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.

SB1, s. 1559n Section 1559n. 49.45 (58) of the statutes is created to read:

SB1,712,11 49.45 (58) Health maintenance organization payments to hospitals. (a) The department shall establish a schedule of amounts that each health maintenance organization that contracts with the department to provide medical assistance services or services under s. 49.665 for a capitated payment rate shall pay monthly to each hospital that serves recipients of medical assistance services or recipients of services under s. 49.665. The amounts shall be based on any increase in the capitated rate that the department pays a health maintenance organization, which increase is intended to cover inpatient and outpatient hospital services and which is associated with the assessment imposed on hospitals under s. 50.375. The department shall use the information that it uses to calculate the capitated rates that the department pays health maintenance organizations and encounter data that is provided by the health maintenance organizations to calculate the amounts in the schedule. The department shall disclose publicly the methodology it uses to calculate the amounts in the schedule. The department shall recalculate the amounts in the schedule at least once every 12 months.

SB1,712,15 (b) The department shall require, as a term of contracts with health maintenance organizations to provide medical assistance services or services under s. 49.665 for a capitated payment rate, that the health maintenance organization do all of the following:

SB1,712,16 1. Monthly pay hospitals the applicable amounts in the schedule under par. (a).

SB1,712,24 2. Every 6 months, and for each hospital to which the health maintenance organization made payments under par. (a), reconcile the amount that the health maintenance organization paid the hospital under par. (a) for the previous 6 months with the amount that the hospital charged the health maintenance organization for providing inpatient and outpatient services during the same 6 months to recipients of medical assistance or recipients of services under s. 49.665, and, if the amount of the charges exceeds the amount of the payments, pay the hospital the difference within 90 days.

SB1,713,7 (bm) If the total payments that a health maintenance organization makes to a hospital under par. (a), for a 6-month period that is subject to a reconciliation under par. (b), exceed the amount that the hospital charges the health maintenance organization for providing inpatient and outpatient services to recipients of medical assistance or recipients of services under s. 49.665 for that 6-month period, the hospital shall pay the health maintenance organization the difference within 90 days after the end of the 6-month period.

SB1,713,15 (c) If the department determines that a health maintenance organization has not complied with a condition under par. (b), the department shall require the health maintenance organization to comply with the condition within 15 days after the department's determination. The department may terminate a contract with a health maintenance organization to provide medical assistance services or services under s. 49.665 for a capitated payment rate for failure to comply with a condition under par. (b). The department may audit health maintenance organizations to determine whether they have complied with the conditions under par. (b).

SB1,713,24 (d) If a health maintenance organization and hospital cannot resolve the amount that a health maintenance organization owes a hospital under par. (b) 2. or that a hospital owes a health maintenance organization under par. (bm), and either the health maintenance organization or the hospital, within 6 months after the end of the time period to which the disputed amount relates, requests that the department determine the amount owed, the department shall determine the amount within 90 days after the request is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under ch. 227 on the department's determination.

SB1,713,25 (e) Paragraphs (a), (b), (bm), and (c) do not apply after December 31, 2010.

SB1, s. 1560 Section 1560. 49.453 (1) (a) of the statutes is amended to read:

SB1,714,2 49.453 (1) (a) "Assets" has the meaning given in 42 USC 1396p (e) (h) (1).

SB1, s. 1561 Section 1561. 49.453 (1) (ar) of the statutes is created to read:

SB1,714,5 49.453 (1) (ar) "Community spouse" means the spouse of either the institutionalized person or the noninstitutionalized person.

SB1, s. 1562 Section 1562. 49.453 (1) (d) of the statutes is amended to read:

SB1,714,7 49.453 (1) (d) "Income" has the meaning given in 42 USC 1396p (e) (h) (2).

SB1, s. 1563 Section 1563. 49.453 (1) (e) of the statutes is amended to read:

SB1,714,10 49.453 (1) (e) "Institutionalized individual" has the meaning given in 42 USC 1396p (e) (h) (3).

SB1, s. 1564 Section 1564. 49.453 (1) (f) (intro.) of the statutes is amended to read:

SB1,714,13 49.453 (1) (f) (intro.) "Look-back date" means for a covered individual, either of the following:

SB1,714,17 1m. For transfers made before February 8, 2006, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under s. 49.454 (2) (c) or (3) (b) the date that is 60 months before:

SB1, s. 1565 Section 1565. 49.453 (1) (f) 1. of the statutes is renumbered 49.453 (1) (f) 1m. a.

SB1, s. 1566 Section 1566. 49.453 (1) (f) 2. of the statutes is renumbered 49.453 (1) (f) 1m. b.

SB1, s. 1567 Section 1567. 49.453 (1) (f) 2m. of the statutes is created to read:

SB1,714,24 49.453 (1) (f) 2m. For all transfers made on or after February 8, 2006, the date that is 60 months before the dates specified in subd. 1m. a. and b.

SB1, s. 1568 Section 1568. 49.453 (1) (fm) of the statutes is amended to read:

SB1,715,2 49.453 (1) (fm) "Noninstitutionalized individual" has the meaning given in 42 USC 1396p (e) (h) (4).

SB1, s. 1569 Section 1569. 49.453 (1) (i) of the statutes is amended to read:

SB1,715,4 49.453 (1) (i) "Resources" has the meaning given in 42 USC 1396p (e) (h) (5).

SB1, s. 1570 Section 1570. 49.453 (3) (a) of the statutes is renumbered 49.453 (3) (a) (intro.) and amended to read:

SB1,715,8 49.453 (3) (a) (intro.) The period of ineligibility under this subsection begins on either of the following:

SB1,715,12 1. In the case of a transfer of assets made before February 8, 2006, the first day of the first month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value and that does not occur in any other periods of ineligibility under this subsection.

SB1, s. 1571 Section 1571. 49.453 (3) (a) 2. of the statutes is created to read:

SB1,715,21 49.453 (3) (a) 2. In the case of a transfer of assets made on or after February 8, 2006, the first day of a month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance and would otherwise be receiving institutional level care described in sub. (2) (a) 1. to 3. based on an approved application for the care but for the application of the penalty period, whichever is later, and that does not occur during any other period of ineligibility under this subsection.

SB1, s. 1572 Section 1572. 49.453 (3) (b) (intro.) of the statutes is amended to read:

SB1,715,24 49.453 (3) (b) (intro.) The Subject to par. (bc), the department shall determine the number of months of ineligibility as follows:

SB1, s. 1573 Section 1573. 49.453 (3) (bc) of the statutes is created to read:

SB1,716,4 49.453 (3) (bc) In determining the number of months of ineligibility under par. (b), with respect to asset transfers that occur after February 8, 2006, the department may not round down the quotient, or otherwise disregard any fraction of a month, obtained in the division under par. (b) 3.

SB1, s. 1574 Section 1574. 49.453 (4) (a) of the statutes is renumbered 49.453 (4) (ag).

SB1, s. 1575 Section 1575. 49.453 (4) (ac) of the statutes is created to read:

SB1,716,9 49.453 (4) (ac) In this subsection, "transaction" means any action taken by an individual that changes the course of payments to be made under an annuity or the treatment of the income or principal of an annuity, including all of the following:

SB1,716,10 1. An addition of principal.

SB1,716,11 2. An elective withdrawal.

SB1,716,12 3. A request to change the distribution of the annuity.

SB1,716,13 4. An election to annuitize the contract.

SB1,716,14 5. A change in ownership.

SB1, s. 1576 Section 1576. 49.453 (4) (am) of the statutes is amended to read:

SB1,716,18 49.453 (4) (am) Paragraph (a) (ag) 1. does not apply to a variable annuity that is tied to a mutual fund that is registered with the federal securities and exchange commission.

SB1, s. 1577 Section 1577. 49.453 (4) (b) of the statutes is amended to read:

SB1,716,22 49.453 (4) (b) The amount of assets that is transferred for less than fair market value under par. (a) (ag) is the amount by which the transferred amount exceeds the expected value of the benefit.

SB1, s. 1578 Section 1578. 49.453 (4) (c) of the statutes is amended to read:

SB1,717,8 49.453 (4) (c) The department shall promulgate rules specifying the method to be used in calculating the expected value of the benefit, based on 26 CFR 1.72-1 to 1.72-18, and specifying the criteria for adjusting the expected value of the benefit based on a medical condition diagnosed by a physician before the assets were transferred to the annuity, or transferred by promissory note or similar instrument. In calculating the amount of the divestment when a transfer to an annuity, or a transfer by promissory note or similar instrument, is made, payments made to the transferor in any year subsequent to the year in which the transfer was made shall be discounted to the year in which the transfer was made by the applicable federal rate specified under par. (a) (ag) on the date of the transfer.

SB1, s. 1579 Section 1579. 49.453 (4) (cm) of the statutes is created to read:

SB1,717,11 49.453 (4) (cm) Paragraphs (ag) to (c) apply to annuities purchased before February 8, 2006, for which no transaction has occurred on or after February 8, 2006.

SB1, s. 1580 Section 1580. 49.453 (4) (d) of the statutes is created to read:

SB1,717,16 49.453 (4) (d) For purposes of sub. (2), the purchase of an annuity by an institutionalized individual or his or her community spouse, or anyone acting on their behalf, shall be treated as a transfer of assets for less than fair market value unless any of the following applies:

SB1,717,19 1. The state is designated as the remainder beneficiary in the first position for at least the total amount of medical assistance paid on behalf of the institutionalized individual.

SB1,717,23 2. The state is named as a beneficiary in the 2nd position after the community spouse or a minor or disabled child and is named in the first position if the community spouse or a representative of the minor or disabled child disposes of any remainder for less than fair market value.

SB1,717,24 3. The annuity satisfies the requirements under par. (e) 1. or 2.

SB1, s. 1581 Section 1581. 49.453 (4) (e) of the statutes is created to read:

SB1,718,4 49.453 (4) (e) For purposes of sub. (2), the purchase of an annuity by or on behalf of an annuitant who has applied for medical assistance for nursing facility services or other long-term care services described in sub. (2) is a transfer of assets for less than fair market value unless either of the following applies:

SB1,718,6 1. The annuity is either an annuity described in section 408 (b) or (q) of the Internal Revenue Code of 1986 or purchased with proceeds from any of the following:

SB1,718,8 a. An account or trust described in section 408 (a), (c), or (p) of the Internal Revenue Code of 1986.

SB1,718,10 b. A simplified employee pension, within the meaning of section 408 (k) of the Internal Revenue Code of 1986.

SB1,718,11 c. A Roth IRA described in section 408A of the Internal Revenue Code of 1986.

SB1,718,12 2. All of the following apply with respect to the annuity:

SB1,718,13 a. The annuity is irrevocable and nonassignable.

SB1,718,15 b. The annuity is actuarily sound, as determined in accordance with actuarial publications of the office of the chief actuary of the social security administration.

SB1,718,17 c. The annuity provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments made.

SB1, s. 1582 Section 1582. 49.453 (4) (em) of the statutes is created to read:

SB1,718,19 49.453 (4) (em) Paragraphs (d) and (e) apply to all of the following:

SB1,718,20 1. Annuities purchased on or after February 8, 2006.

SB1,718,22 2. Annuities purchased before February 8, 2006, for which a transaction has occurred on or after February 8, 2006.

SB1, s. 1583 Section 1583. 49.453 (4c) of the statutes is created to read: