2. Changes in the allowable costs of the residential care center for children and youth, group home, or child welfare agency based on current actual cost data or documented projections of costs.
3. Changes in program utilization that affect the per client rate or per client administrative rate.
4. Changes in the department's expectations relating to service delivery.
5. Changes in service delivery proposed by the residential care center for children and youth, group home, or child welfare agency and agreed to by the department.
6. The loss of any source of revenue that had been used to pay expenses, resulting in a lower per client rate or per client administrative rate for services.
7. Changes in any state or federal laws, rules, or regulations that result in any change in the cost of providing services, including any changes in the minimum wage, as defined in s. 49.141 (1) (g).
8. Competitive factors.
9. The availability of funding to pay for the services to be provided under the proposed rate.
10. Any other factor relevant to the setting of a rate that the department may determine by rule promulgated under sub. (4).
28,1284
Section
1284. 49.343 (2) (c) of the statutes is created to read:
49.343 (2) (c) If the department determines under par. (b) that a proposed rate submitted under par. (a) is appropriate, the department shall approve the proposed rate. If the department does not approve a proposed rate, the department shall negotiate with the residential care center for children and youth, group home, or child welfare agency to determine an agreed to rate. If after negotiations a rate is not agreed to, the department and residential care center for children and youth, group home, or child welfare agency shall engage in mediation under the rate resolution procedure promulgated by rule under sub. (4) to arrive at an agreed to rate. If after mediation a rate is not agreed to, the residential care center for children and youth, group home, or child welfare agency may not provide the service for which the rate was proposed.
28,1285
Section
1285. 49.343 (3) of the statutes is amended to read:
49.343 (3) Audit. The department may require an audit of any residential care center for children and youth or, group home, as described in sub. (1) or (1m), or child welfare agency for the purpose of collecting federal funds.
28,1286
Section
1286. 49.343 (4) of the statutes is created to read:
49.343 (4) Rules. The department shall promulgate rules to implement this section. Those rules shall include rules providing for all of the following:
(a) Standards for determining whether a proposed rate is appropriate to the level of services to be provided, the qualifications of a residential care center for children and youth, group home, or child welfare agency to provide those services, and the reasonable and necessary costs of providing those services.
(b) Factors for the department to consider in reviewing a proposed rate.
(c) Procedures for reviewing proposed rates, including rate resolution procedures for mediating an agreed to rate when negotiations fail to produce an agreed to rate.
28,1287
Section
1287. 49.345 (14) (a) of the statutes is amended to read:
49.345 (14) (a) Except as provided in pars. (b) and (c), liability of a person specified in sub. (2) or s. 49.32 (1) for care and maintenance of persons under 18 years of age in residential, nonmedical facilities such as group homes, foster homes, treatment foster homes, subsidized guardianship homes, and residential care centers for children and youth is determined in accordance with the cost-based fee established under s. 49.32 (1). The department shall bill the liable person up to any amount of liability not paid by an insurer under s. 632.89 (2) or (2m) or by other 3rd-party benefits, subject to rules that include formulas governing ability to pay established by the department under s. 49.32 (1). Any liability of the person not payable by any other person terminates when the person reaches age 18, unless the liable person has prevented payment by any act or omission.
28,1288
Section
1288. 49.345 (14) (b) of the statutes is amended to read:
49.345 (14) (b) Except as provided in par. (c), and subject to par. (cm), liability of a parent specified in sub. (2) or s. 49.32 (1) for the care and maintenance of the parent's minor child who has been placed by a court order under s. 48.355 or 48.357 in a residential, nonmedical facility such as a group home, foster home, treatment foster home, subsidized guardianship home, or residential care center for children and youth shall be determined by the court by using the percentage standard established by the department under s. 49.22 (9) and by applying the percentage standard in the manner established by the department under par. (g).
28,1289
Section
1289. 49.45 (3) (e) 7. of the statutes is amended to read:
49.45
(3) (e) 7. The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home,
treatment foster home or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period
where when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under
42 USC 1320c to
1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
28,1289m
Section 1289m. 49.45 (3) (e) 10r. of the statutes is created to read:
49.45 (3) (e) 10r. All facilities listed in a certificate of approval issued to a free-standing pediatric teaching hospital under s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician clinic reimbursement rates to reimburse the facilities under this section for types of services for which, before July 1, 2009, the department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.
28,1290
Section
1290. 49.45 (6b) of the statutes is amended to read:
49.45 (6b) Centers for the developmentally disabled. From the appropriation under s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Reimbursement to the centers for the developmentally disabled shall be reduced following each placement made under s. 46.275 that involves a relocation from a center for the developmentally disabled, by $225 per day, beginning in fiscal year 2002-03, and by $325 per day, beginning in fiscal year 2004 Beginning in fiscal year 2009-10, following each placement made under s. 46.275 that involves a relocation from a center for the developmentally disabled, the department shall reduce the reimbursement to the center by an amount, as determined by the department for each placement, that is equal to the nonfederal share of the costs for the placement under s. 46.275.
28,1291
Section
1291. 49.45 (6m) (br) 1. of the statutes is amended to read:
49.45 (6m) (br) 1. Notwithstanding s. 20.410 (3) (cd), 20.435 (4) (bt) or (7) (b) or 20.437 (2) (dz), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.435 (4) (bt) or (7) (b), or the department shall direct the department of children and families to reduce allocations of funds to counties or Wisconsin Works agencies in the amount of the disallowance from the appropriation account under s. 20.437 (2) (dz) or direct the department of corrections to reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.410 (3) (cd), in accordance with s. 16.544 to the extent applicable.
28,1292
Section
1292. 49.45 (6m) (e) of the statutes is repealed.
28,1292n
Section 1292n. 49.45 (6u) (am) (intro.) of the statutes is amended to read:
49.45 (6u) (am) (intro.) Notwithstanding sub. (6m), from the appropriations under s. 20.435 (4) (o), and (w), for reduction of operating deficits, as defined under the methodology used by the department in December 2000, incurred by a facility that is established under s. 49.70 (1) or that is owned and operated by a city, village, or town, and as payment to care management organizations, the department
may not shall distribute to these facilities and to care management organizations more than $37,100,000 a total of $39,100,000 in each fiscal year
, as determined by the department . The total amount that a county certifies under this subsection may not exceed 100% of otherwise-unreimbursed care. In distributing funds under this subsection, the department shall perform all of the following:
28,1293
Section
1293. 49.45 (6u) (b) of the statutes is amended to read:
49.45 (6u) (b) Notwithstanding the limitation on the amount of disbursements under par. (am) (intro.), from the appropriation under s. 20.435 (4) (wm), the department shall, using the criteria specified in par. (am) 1. to 7., disburse any federal medical assistance funds that are received by the state as matching funds to federal financial participation for operating deficits incurred by a facility that is operated by a county, city, village, or town and that are in excess of the amount of match federal financial participation anticipated and budgeted as revenue in the biennial budget act for the fiscal year in which the funds are received.
28,1294m
Section 1294m. 49.45 (6y) (b) of the statutes is amended to read:
49.45 (6y) (b) The department need not promulgate as rules under ch. 227 the procedures, methods of distribution, and criteria required for distribution under pars. (a) and (am) par. (a).
28,1296
Section
1296. 49.45 (8r) of the statutes is amended to read:
49.45 (8r) Payment for certain obstetric and gynecological care. The rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in s. 560.183 36.60 (1) (cm), or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125% of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.
28,1297
Section
1297. 49.45 (18) (am) of the statutes is renumbered 49.45 (18) (am) 1. and amended to read:
49.45 (18) (am) 1. No Except as provided in subd. 2., no person is liable under this subsection for services provided through prepayment contracts. This paragraph does not apply to a person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.
28,1298
Section
1298. 49.45 (18) (am) 2. of the statutes is created to read:
49.45 (18) (am) 2. A person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 is liable under this subsection for services provided through a prepayment contract in the amounts and according to the procedures specified by the department.
28,1299
Section
1299. 49.45 (18) (b) 2. of the statutes is amended to read:
49.45 (18) (b) 2. Any service provided to a person who is less than 18 years old. This subdivision does not apply if the person's family income exceeds 100 percent of the poverty line and he or she is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.
28,1301
Section
1301. 49.45 (23) (b) of the statutes is amended to read:
49.45 (23) (b) If the waiver is granted and in effect, the department may promulgate rules defining the health care benefit plan, including more specific eligibility requirements and cost-sharing requirements. Cost sharing may include an annual enrollment fee, which may not exceed $75 per year. Notwithstanding s. 227.24 (3), the plan details under this subsection may be promulgated as an emergency rule under s. 227.24 without a finding of emergency. If the waiver is granted and in effect, the demonstration project under this subsection shall begin on January 1, 2009, or on the effective date of the waiver, whichever is later.
28,1301c
Section 1301c. 49.45 (24d) of the statutes is created to read:
49.45 (24d) Primary care provider; managed care organizations. (a) In this subsection, "managed care organization" includes a health maintenance organization, a limited service health organization, and a preferred provider plan.
(b) In a contract with a managed care organization to provide medical assistance, the department shall require the managed care organization to assign to each enrollee who receives medical assistance a primary care provider.
(c) The managed care organization under contract under par. (b) shall pay to the primary care provider a monthly fee per each patient who is a recipient of medical assistance for care coordination.
28,1301e
Section 1301e. 49.45 (24g) of the statutes is created to read:
49.45 (24g) Physician practice payment pilot. (a) The department shall develop a proposal to increase medical assistance reimbursement to providers to which at least one of the following applies:
1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
2. The secretary determines that the provider performs well with respect to all of the following aspects of care:
a. Adoption of written standards for patient access and patient communication.
b. Use of data to show that standards for patient access and patient communication are satisfied.
c. Use of paper or electronic charting tools to organize clinical information.
d. Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
e. Adoption and implementation of guidelines that are based on evidence for treatment and management of at least 3 chronic conditions.
f. Active support of patient self-management.
g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.
h. Systematic tracking of referrals using a paper or electronic system.
i. Measuring the quality of the performance of the physician practice and of individual physicians within the practice, including with respect to provision of clinical services, patient outcomes, and patient safety.
j. Reporting to members of the physician practice and to other persons on the quality of the performance of the physician practice and of individual physicians.
(c) The department's proposal under par. (a) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or 2., and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than July 1, 2011.
(d)
By the date that is 60 days after the effective date of this paragraph .... [LRB inserts date], the department shall submit the proposal under par. (a) to the joint committee on finance. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department's submittal that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under
42 USC 1396a, implement the proposal beginning January 1, 2010. If, within 14 working days after the date of the department's submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department may implement the proposal only upon approval of the committee. If the committee reviews the proposal and approves it, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under
42 USC 1396a, implement the proposal beginning January 1, 2010.
(e) By the first day of the 39th month beginning after the effective date of this paragraph .... [LRB inserts date], the department shall, if it was required under par. (d) to increase reimbursement to providers that satisfy a condition under par. (a) 1. or 2., submit a report to the joint committee on finance on whether the increased reimbursement results in net cost reductions for the Medical Assistance program under this subchapter and a recommendation as to whether to continue the increased reimbursement. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department's submittal that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may implement its recommendation. If, within 14 working days after the date of the department's submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may discontinue the increased reimbursement only upon the approval of the committee.
28,1302
Section
1302. 49.45 (24r) of the statutes is renumbered 49.45 (24r) (a) and amended to read:
49.45 (24r) (a) The department shall request a implement any waiver from granted by the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide family planning, as defined in s. 253.07 (1) (a), under medical assistance to any woman between the ages of 15 and 44 whose family income does not exceed 200% of the poverty line for a family the size of the woman's family. The department shall implement any waiver granted.
28,1303
Section
1303. 49.45 (24r) (b) of the statutes is created to read:
49.45 (24r) (b) The department may request an amended waiver from the secretary to permit the department to conduct a demonstration project to provide family planning to any man between the ages of 15 and 44 whose family income does not exceed 200 percent of the poverty line for a family the size of the man's family. If the amended waiver is granted, the department may implement the waiver.
28,1304
Section
1304. 49.45 (25) (be) of the statutes is amended to read:
49.45 (25) (be) A private nonprofit agency that is a certified case management provider may elect to provide case management services to medical assistance beneficiaries who have HIV infection, as defined in s. 252.01 (2). The amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.435 (5) (1) (am).
28,1305
Section
1305. 49.45 (25) (bg) of the statutes is amended to read:
49.45 (25) (bg) An independent living center, as defined in s. 46.96 (1) (ah), that is a certified case management provider and satisfies the criteria in s. 46.96 (3m) (a) 1. to 3. and (am) may elect to provide case management services to one or more of the categories of medical assistance beneficiaries specified under par. (am). The amount of allowable charges for the services under the medical assistance program that is not provided by the federal government shall be paid from nonfederal, public funds received by the independent living center from a county, city, village or town or from funds distributed as a grant under s. 46.96.
28,1305r
Section 1305r. 49.45 (30f) of the statutes is created to read:
49.45 (30f) Psychotherapy and alcohol and other drug abuse services. The department shall include licensed mental health professionals, as defined in s. 632.89 (1) (dm), and licensed psychologists, as defined in s. 455.01 (4), as providers of psychotherapy and of alcohol and other drug abuse services. Except for services provided under sub. (30e), the department may not require that licensed mental health professionals or licensed psychologists be supervised; may not require that clinical psychotherapy or alcohol and other drug abuse services be provided under a certified program; and, notwithstanding subs. (9) and (9m), may not require that a physician or other health care provider first prescribe psychotherapy or alcohol and other drug abuse services to be provided by a licensed mental health professional or licensed psychologist before the professional or psychologist may provide the services to the recipient. This subsection does not affect the department's powers under ch. 50 or 51 to establish requirements for facilities that are licensed, certified, or operated by the department.
28,1306
Section
1306. 49.45 (30g) of the statutes is created to read:
49.45 (30g) Community recovery services. (a) When services are reimbursable. Community recovery services under s. 49.46 (2) (b) 6. Lo. provided to an individual are reimbursable under the Medical Assistance program only if all of the following conditions are met:
1. An approved amendment to the state medical assistance plan submitted under
42 USC 1396n (i) permits reimbursement for the services under s. 49.46 (2) (b) 6. Lo. in the manner provided under this subsection.
2. The county in which the individual resides elects to provide the community recovery services under s. 49.46 (2) (b) 6. Lo. through the Medical Assistance program.
3. The individual, the community recovery services, and the community recovery services provider meet any condition set forth in the approved amendment to the medical assistance plan submitted under
42 USC 1396n (i).
(b) Limit on the amount of reimbursement. If community recovery services are reimbursable under par. (a), the department shall reimburse each participating county for the portion of the federal share of allowable charges for the community recovery services provided by the county that exceeds that county's proportionate share of $600,000 in fiscal year 2010-2011 and for 95 percent of the federal share of allowable charges for the community recovery services provided by the county in each fiscal year thereafter. The portion of the federal share of allowable charges not reimbursed to counties shall be transferred to the appropriation account under s. 20.435 (5) (kx).
28,1307
Section
1307. 49.45 (30m) (am) of the statutes is renumbered 49.45 (30m) (am) 1.
28,1308
Section
1308. 49.45 (30m) (am) 2. of the statutes is created to read:
49.45 (30m) (am) 2. For individuals receiving the family care benefit under s. 46.286, the care management organization that manages the family care benefit for the recipient shall pay the portion of the payment that is not covered by the federal government for services that are described under par. (a) 1. and are covered services under the family care benefit; the department shall pay the remainder of the portion of the payment that is not covered by the federal government.
28,1309
Section
1309. 49.45 (30r) of the statutes is created to read:
