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2011 - 2012 LEGISLATURE
October 12, 2011 - Introduced by Senators Erpenbach, Shilling, Vinehout, Miller,
C. Larson, King, Lassa, Hansen, Risser, S. Coggs
and Taylor, cosponsored by
Representatives Pasch, Richards, Milroy, Bernard Schaber, Zamarripa,
Roys, Pope-Roberts, Fields, Ringhand, Doyle, C. Taylor, Jorgensen, Sinicki,
Staskunas, Hebl, Berceau, Turner, Grigsby, Seidel
and Pocan. Referred to
Committee on Public Health, Human Services, and Revenue.
SB232,1,11 1An Act to repeal 49.45 (2m), 49.45 (3) (n), 49.45 (6m) (n), 49.46 (1) (n), 49.47 (5)
2(c) and 49.471 (13); and to amend 49.45 (8) (b), 49.45 (8) (c), 49.45 (8r), 49.45
3(8v), 49.45 (18) (ac), 49.45 (18) (ag) (intro.), 49.45 (18) (b) (intro.), 49.45 (18) (d),
449.45 (23) (a), 49.45 (23) (b), 49.45 (24g) (c), 49.45 (24s) (a), 49.45 (25g) (c), 49.45
5(27), 49.45 (39) (b) 1., 49.46 (2) (a) (intro.), 49.46 (2) (b) (intro.), 49.465 (2)
6(intro.), 49.47 (4) (a) (intro.), 49.47 (6) (a) (intro.), 49.472 (3) (intro.), 49.472 (4)
7(b) (intro.), 49.473 (2) (intro.) and 49.473 (5) of the statutes; relating to:
8eliminating the ability for the Department of Health Services to alter Medical
9Assistance eligibility, provider payment methods, and other Medical
10Assistance program procedures by policy and eliminating the requirement to
11request a waiver regarding Medical Assistance program eligibility.
Analysis by the Legislative Reference Bureau
Currently, the Department of Health Services (DHS) administers the Medical
Assistance (MA) program, which is a joint federal and state program that provides
health services to individuals who have limited resources. Some services are
provided through programs that operated under a waiver of federal Medicaid laws

(MA waiver programs). Current law requires DHS to study potential changes to the
MA state plan and to waivers of federal Medicaid law for certain purposes, including
increasing the cost effectiveness and efficiency of care for the MA program and MA
waiver programs and improving the health status of individuals who receive benefits
under the MA program or an MA waiver program. If DHS determines that revision
of existing statutes or rules would be necessary to advance any of the purposes for
which the study was conducted, DHS may propose a policy to do any of the following:
require cost sharing from program benefit recipients up to the maximum allowed by
the federal government; authorize providers to deny care or services if a program
benefit recipient is unable to share costs; modify existing benefits or establish
various benefits packages and offer different packages to different groups of
recipients; revise provider reimbursement models for particular services; mandate
that program benefit recipients enroll in managed care; restrict or eliminate
presumptive eligibility; impose restrictions on providing benefits to individuals who
are not citizens of the United States; set standards for establishing and verifying
eligibility requirements; develop standards and methodologies to assure accurate
eligibility determinations and redetermine continuing eligibility; and reduce income
levels for purposes of determining eligibility. Before implementing a policy that
conflicts with a state statute, DHS must submit to the Joint Committee on Finance
under the committee's passive review process the proposed amendment to the state
MA plan or proposed waiver of federal Medicaid law and estimates of the projected
cost savings associated with the amendment or waiver request. If the proposed state
MA plan amendment or waiver request is not rejected by the committee, DHS must
submit to the federal government the amendment or waiver request, if necessary, to
the extent necessary to implement its policy. If the federal government does not allow
the amendment or does not grant the waiver, DHS may not implement the policy.
Current law also requires DHS to request a waiver from the federal government
to allow the department to implement eligibility standards, methodologies, and
procedures under the state MA plan or federal Medicaid law waivers that are more
restrictive than those in place on March 23, 2010. If the federal government does not
approve the waiver request before December 31, 2011, DHS must reduce, on July 1,
2012, following the procedures under federal law, income levels to 133 percent of the
federal poverty line for adults who are not pregnant or disabled for the purposes of
determining eligibility, to the extent permitted under federal law.
This bill eliminates the requirement for DHS to conduct the study. DHS is not
authorized, under the bill, to create a policy that would override elements of the MA
program or MA waiver programs. The bill also eliminates the requirement for DHS
to request a waiver to implement more restrictive eligibility standards,
methodologies, and procedures for the MA program or MA waiver programs than
those in place on March 23, 2010, and also removes the requirement that DHS reduce
income eligibility levels on July 1, 2012, if that waiver is not approved by the federal
government.

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:
SB232, s. 1 1Section 1. 49.45 (2m) of the statutes, as affected by 2011 Wisconsin Act 10 and
22011 Wisconsin Act 32, section 1423k, is repealed.
SB232, s. 2 3Section 2. 49.45 (3) (n) of the statutes, as affected by 2011 Wisconsin Act 10
4and 2011 Wisconsin Act 32, section 1424p, is repealed.
SB232, s. 3 5Section 3. 49.45 (6m) (n) of the statutes, as affected by 2011 Wisconsin Act 10
6and 2011 Wisconsin Act 32, section 1430d, is repealed.
SB232, s. 4 7Section 4. 49.45 (8) (b) of the statutes, as affected by 2011 Wisconsin Act 32,
8section 1435y, is amended to read:
SB232,3,149 49.45 (8) (b) Unless otherwise provided by the department by a policy created
10under sub. (2m) (c), reimbursement
Reimbursement under s. 20.435 (4) (b), (gm), (o),
11and (w) for home health services provided by a certified home health agency or
12independent nurse shall be made at the home health agency's or nurse's usual and
13customary fee per patient care visit, subject to a maximum allowable fee per patient
14care visit that is established under par. (c).
SB232, s. 5 15Section 5. 49.45 (8) (c) of the statutes, as affected by 2011 Wisconsin Act 10
16and 2011 Wisconsin Act 32, section 1436h, is amended to read:
SB232,4,217 49.45 (8) (c) The department shall establish a maximum statewide allowable
18fee per patient care visit, for each type of visit with respect to provider, that may be
19no greater than the cost per patient care visit, as determined by the department from
20cost reports of home health agencies, adjusted for costs related to case management,

1care coordination, travel, record keeping and supervision, unless otherwise provided
2by the department by a policy created under sub. (2m) (c)
.
SB232, s. 6 3Section 6. 49.45 (8r) of the statutes, as affected by 2011 Wisconsin Act 10 and
42011 Wisconsin Act 32, section 1436y, is amended to read:
SB232,4,125 49.45 (8r) Payment for certain obstetric and gynecological care. Unless
6otherwise provided by the department by a policy created under sub. (2m) (c), the
The
7rate of payment for obstetric and gynecological care provided in primary care
8shortage areas, as defined in s. 36.60 (1) (cm), or provided to recipients of medical
9assistance who reside in primary care shortage areas, that is equal to 125% of the
10rates paid under this section to primary care physicians in primary care shortage
11areas, shall be paid to all certified primary care providers who provide obstetric or
12gynecological care to those recipients.
SB232, s. 7 13Section 7. 49.45 (8v) of the statutes, as affected by 2011 Wisconsin Act 10 and
142011 Wisconsin Act 32, section 1437e, is amended to read:
SB232,4,2515 49.45 (8v) Incentive-based pharmacy payment system. The department shall
16establish a system of payment to pharmacies for legend and over-the-counter drugs
17provided to recipients of medical assistance that has financial incentives for
18pharmacists who perform services that result in savings to the medical assistance
19program. Under this system, the department shall establish a schedule of fees that
20is designed to ensure that any incentive payments made are equal to or less than the
21documented savings unless otherwise provided by the department by a policy
22created under sub. (2m) (c)
. The department may discontinue the system established
23under this subsection if the department determines, after performance of a study,
24that payments to pharmacists under the system exceed the documented savings
25under the system.
SB232, s. 8
1Section 8. 49.45 (18) (ac) of the statutes, as affected by 2011 Wisconsin Act 10
2and 2011 Wisconsin Act 32, section 1437j, is amended to read:
SB232,5,153 49.45 (18) (ac) Except as provided in pars. (am) to (d), and subject to par. (ag),
4any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the
5benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum
6amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided
7under s. 49.46 (2). The service provider shall collect the specified or allowable
8copayment, coinsurance, or deductible, unless the service provider determines that
9the cost of collecting the copayment, coinsurance, or deductible exceeds the amount
10to be collected. The department shall reduce payments to each provider by the
11amount of the specified or allowable copayment, coinsurance, or deductible. Unless
12otherwise provided by the department by a policy created under sub. (2m) (c), no
No
13provider may deny care or services because the recipient is unable to share costs, but
14an inability to share costs specified in this subsection does not relieve the recipient
15of liability for these costs.
SB232, s. 9 16Section 9. 49.45 (18) (ag) (intro.) of the statutes, as affected by 2011 Wisconsin
17Act 10
and 2011 Wisconsin Act 32, section 1437n, is amended to read:
SB232,5,2018 49.45 (18) (ag) (intro.) Except as provided in pars. (am), (b), and (c), and subject
19to par. (d), a recipient specified in par. (ac) shall pay all of the following, unless
20otherwise provided by the department by a policy created under sub. (2m) (c)
:
SB232, s. 10 21Section 10. 49.45 (18) (b) (intro.) of the statutes, as affected by 2011 Wisconsin
22Act 10
and 2011 Wisconsin Act 32, section 1437q, is amended to read:
SB232,5,2523 49.45 (18) (b) (intro.) Unless otherwise provided by the department by a policy
24created under sub. (2m) (c), the
The following services are not subject to recipient cost
25sharing under this subsection:
SB232, s. 11
1Section 11. 49.45 (18) (d) of the statutes, as affected by 2011 Wisconsin Act 10
2and 2011 Wisconsin Act 32, section 1437t, is amended to read:
SB232,6,73 49.45 (18) (d) No person who designates a pharmacy or pharmacist as his or
4her sole provider of prescription drugs and who so uses that pharmacy or pharmacist
5is liable under this subsection for more than $12 per month for prescription drugs
6received, unless otherwise provided by the department by a policy created under sub.
7(2m) (c)
.
SB232, s. 12 8Section 12. 49.45 (23) (a) of the statutes, as affected by 2011 Wisconsin Act 10
9and 2011 Wisconsin Act 32, section 1438d, is amended to read:
SB232,6,1810 49.45 (23) (a) The department shall request a waiver from the secretary of the
11federal department of health and human services to permit the department to
12conduct a demonstration project to provide health care coverage for basic primary
13and preventive care to adults who are under the age of 65, who have family incomes
14not to exceed 200 percent of the poverty line, and who are not otherwise eligible for
15medical assistance under this subchapter, the Badger Care health care program
16under s. 49.665, or Medicare under 42 USC 1395 et seq. If the department creates
17a policy under sub. (2m) (c) 10., this paragraph does not apply to the extent that it
18conflicts with the policy.
SB232, s. 13 19Section 13. 49.45 (23) (b) of the statutes, as affected by 2011 Wisconsin Act 10
20and 2011 Wisconsin Act 32, section 1438h, is amended to read:
SB232,7,521 49.45 (23) (b) If the waiver is granted and in effect, the department may
22promulgate rules defining the health care benefit plan, including more specific
23eligibility requirements and cost-sharing requirements. Unless otherwise provided
24by the department by a policy created under sub. (2m) (c), cost
Cost sharing may
25include an annual enrollment fee, which may not exceed $75 per year.

1Notwithstanding s. 227.24 (3), the plan details under this subsection may be
2promulgated as an emergency rule under s. 227.24 without a finding of emergency.
3If the waiver is granted and in effect, the demonstration project under this subsection
4shall begin on January 1, 2009, or on the effective date of the waiver, whichever is
5later.
SB232, s. 14 6Section 14. 49.45 (24g) (c) of the statutes, as affected by 2011 Wisconsin Act
710
and 2011 Wisconsin Act 32, section 1438L, is amended to read:
SB232,7,178 49.45 (24g) (c) The department's proposal under par. (a) shall specify increases
9in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or
102., and shall provide for payment of a monthly per-patient care coordination fee to
11those providers. The department shall set the increases in reimbursement rates and
12the monthly per-patient care coordination fee so that together they provide
13sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The
14proposal shall specify effective dates for the increases in reimbursement rates and
15the monthly per-patient care coordination fee that are no sooner than July 1, 2011.
16If the department creates a policy under sub. (2m) (c) 4., this paragraph does not
17apply to the extent that it conflicts with the policy.
SB232, s. 15 18Section 15. 49.45 (24s) (a) of the statutes, as created by 2011 Wisconsin Act
1932
, section 1441b, is amended to read:
SB232,7,2420 49.45 (24s) (a) The department shall request a waiver from the secretary of the
21federal department of health and human services to permit the department to
22provide optional services for family planning, as defined in s. 253.07 (1) (a), under
23medical assistance, unless otherwise provided by the department by a policy created
24under sub. (2m) (c) 10
. The department shall implement any waiver granted.
SB232, s. 16
1Section 16. 49.45 (25g) (c) of the statutes, as affected by 2011 Wisconsin Act
210
and 2011 Wisconsin Act 32, section 1441c, is amended to read:
SB232,8,143 49.45 (25g) (c) The department's proposal under par. (b) shall specify increases
4in reimbursement rates for providers that satisfy the conditions under par. (b), and
5shall provide for payment of a monthly per-patient care coordination fee to those
6providers. The department shall set the increases in reimbursement rates and the
7monthly per-patient care coordination fee so that together they provide sufficient
8incentive for providers to satisfy a condition under par. (b) 1. or 2. The proposal shall
9specify effective dates for the increases in reimbursement rates and the monthly
10per-patient care coordination fee that are no sooner than January 1, 2011. The
11increases in reimbursement rates and monthly per-patient care coordination fees
12that are not provided by the federal government shall be paid from the appropriation
13under. s. 20.435 (1) (am). If the department creates a policy under sub. (2m) (c) 4.,
14this paragraph does not apply to the extent it conflicts with the policy.
SB232, s. 17 15Section 17. 49.45 (27) of the statutes, as affected by 2011 Wisconsin Act 10 and
162011 Wisconsin Act 32, section 1441f, is amended to read:
SB232,8,2117 49.45 (27) Eligibility of aliens. A person who is not a U.S. citizen or an alien
18lawfully admitted for permanent residence or otherwise permanently residing in the
19United States under color of law may not receive medical assistance benefits except
20as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v), unless otherwise
21provided by the department by a policy created under sub. (2m) (c)
.
SB232, s. 18 22Section 18. 49.45 (39) (b) 1. of the statutes, as affected by 2011 Wisconsin Act
2310
and 2011 Wisconsin Act 32, section 1442g, is amended to read:
SB232,9,2524 49.45 (39) (b) 1. `Payment for school medical services.' If a school district or a
25cooperative educational service agency elects to provide school medical services and

1meets all requirements under par. (c), the department shall reimburse the school
2district or the cooperative educational service agency for 60% of the federal share of
3allowable charges for the school medical services that it provides , unless otherwise
4provided by the department by a policy created under sub. (2m) (c),
and, as specified
5in subd. 2., for allowable administrative costs. If the Wisconsin Center for the Blind
6and Visually Impaired or the Wisconsin Educational Services Program for the Deaf
7and Hard of Hearing elects to provide school medical services and meets all
8requirements under par. (c), the department shall reimburse the department of
9public instruction for 60% of the federal share of allowable charges for the school
10medical services that the Wisconsin Center for the Blind and Visually Impaired or
11the Wisconsin Educational Services Program for the Deaf and Hard of Hearing
12provides, unless otherwise provided by the department by a policy created under sub.
13(2m) (c),
and, as specified in subd. 2., for allowable administrative costs. A school
14district, cooperative educational service agency, the Wisconsin Center for the Blind
15and Visually Impaired or the Wisconsin Educational Services Program for the Deaf
16and Hard of Hearing may submit, and the department shall allow, claims for common
17carrier transportation costs as a school medical service unless the department
18receives notice from the federal health care financing administration that, under a
19change in federal policy, the claims are not allowed. If the department receives the
20notice, a school district, cooperative educational service agency, the Wisconsin
21Center for the Blind and Visually Impaired, or the Wisconsin Educational Services
22Program for the Deaf and Hard of Hearing may submit, and the department shall
23allow, unreimbursed claims for common carrier transportation costs incurred before
24the date of the change in federal policy. The department shall promulgate rules
25establishing a methodology for making reimbursements under this paragraph.

1Alleother expenses for the school medical services provided by a school district or a
2cooperative educational service agency shall be paid for by the school district or the
3cooperative educational service agency with funds received from state or local taxes.
4The school district, the Wisconsin Center for the Blind and Visually Impaired, the
5Wisconsin Educational Services Program for the Deaf and Hard of Hearing, or the
6cooperative educational service agency shall comply with all requirements of the
7federal department of health and human services for receiving federal financial
8participation.
SB232, s. 19 9Section 19. 49.46 (1) (n) of the statutes, as affected by 2011 Wisconsin Act 10
10and 2011 Wisconsin Act 32, section 1453e, is repealed.
SB232, s. 20 11Section 20. 49.46 (2) (a) (intro.) of the statutes, as affected by 2011 Wisconsin
12Act 10
and 2011 Wisconsin Act 32, section 1453h, is amended to read:
SB232,10,1613 49.46 (2) (a) (intro.) Except as provided in par. (be) and unless otherwise
14provided by the department by a policy created under s. 49.45 (2m) (c)
, the
15department shall audit and pay allowable charges to certified providers for medical
16assistance on behalf of recipients for the following federally mandated benefits:
SB232, s. 21 17Section 21. 49.46 (2) (b) (intro.) of the statutes, as affected by 2011 Wisconsin
18Act 10
and 2011 Wisconsin Act 32, section 1453k, is amended to read:
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