2017 Wisconsin Act 59

(b) The department shall request any waiver from and submit any amendments to the state Medical Assistance plan to the federal department of health and human services necessary for the Medical Assistance reimbursement rate increase under par. (a). If any necessary waiver request or state plan amendment request is approved, the department shall implement par. (a) beginning on the effective date of the waiver or plan amendment.

59,928g Section 928g. 49.45 (26g) of the statutes is created to read:

49.45 (26g) Intensive care coordination program. (a) Subject to par. (h), the department shall create and implement a program to reimburse hospitals and health care systems for intensive care coordination services provided to recipients of Medical Assistance under this subchapter who are not enrolled in coverage under Medicare, 42 USC 1395 et seq.

(b) The department shall select hospitals and health care systems to receive reimbursement under this subsection that submit to the department a description of their intensive care coordination program that includes all of the following:

1. A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.

2. The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.

3. A description of the hospital's or health care system's intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.

4. That the hospital or health care system provides to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care:

a. Discharge instructions and contacts for following up on care and treatment.

b. Referral information.

c. Appointment scheduling.

d. Medication instructions.

e. Intensive care coordination by a social worker, case manager, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization.

f. Information about other health and social resources, such as transportation and housing.

5. The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or the managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.

(c) The department shall do all of the following:

1. Respond to the hospital or health care system indicating if additional information is required to determine eligibility for the reimbursement program under this subsection.

2. If the hospital or health care system is eligible for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement.

(d) The department shall provide as reimbursement for intensive care coordination to eligible hospitals and health care systems participating in the program under this subsection $500 for each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the hospital or health care system enrolls in intensive care coordination. The initial enrollment for each recipient lasts for 6 months, and the health care provider may enroll the Medical Assistance recipient in one additional 6-month period for an additional $500 reimbursement payment. The department shall pay no more than $1,500,000 cumulatively in each fiscal year from all funding sources for reimbursements under this paragraph.

(e) Annually, each hospital and health care system that is eligible for the reimbursement program under this subsection shall submit a report to the department containing all of the following:

1. The number of Medical Assistance recipients served by intensive care coordination.

2. For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination.

3. Any demonstrated outcomes, such as those described in par. (b) 5., for Medical Assistance recipients.

(f) For each hospital or health care system eligible for the reimbursement program under this subsection, the department shall calculate the costs saved to the Medical Assistance program by avoiding emergency department visits by subtracting the sum of reimbursements made under par. (d) to the hospital or health care system from the sum of costs of visits to the emergency department as reported under par. (e) 2. that were expected to occur without intensive care coordination. If the result of the calculation is positive, the department shall distribute half of the amount saved to the hospital or health care system subject to par. (h).

(g) No later than 24 months after the date on which the first hospital or health care system is able to enroll individuals in the intensive care coordination program under this subsection, the department shall submit a report to the joint committee on finance summarizing the information reported under par. (e) including the costs saved by avoiding emergency department visits as calculated under par. (f).

(h) The department shall seek any necessary approval from the federal department of health and human services to implement the program under this subsection. If the federal department of health and human services disapproves the request for approval, the department may implement the reimbursement under par. (d), the savings distribution under par. (f), or both or any part of the program under this subsection.

59,928h Section 928h. 49.45 (29y) of the statutes is created to read:

49.45 (29y) Mental health consultation reimbursement. (a) In this subsection, “clinical consultation" means, for a student up to age 21, communication from a mental health professional or a qualified treatment trainee working under the supervision of a mental health professional to another individual who is working with the client to inform, inquire, and instruct regarding all of the following and to direct and coordinate clinical service components:

1. The client's symptoms.

2. Strategies for effective engagement, care, and intervention for the client.

3. Treatment expectations for the client across service settings.

(b) The department shall, subject to any approval necessary from the federal department of health and human services, reimburse clinical consultation from the Medical Assistance program under this subchapter.

(c) By March 31, 2019, the department shall submit a report to the joint committee on finance on the utilization of the clinical consultation services under this subsection.

(d) The department may not provide the reimbursement for clinical consultation that occurs after June 30, 2019.

59,928n Section 928n. 49.45 (39) (bm) of the statutes is repealed.

59,928r Section 928r. 49.45 (47m) of the statutes is created to read:

49.45 (47m) Family Care funding. (a) In this subsection, “care management organization” means a care management organization under contract with the department of health services as described under s. 46.284.

(b) The department shall collaborate with care management organizations and the federal centers for Medicare and Medicaid services to develop an allowable payment mechanism to increase the direct care and services portion of the capitation rates to address the direct caregiver workforce challenges in the state.

(c) By December 31, 2017, the department shall seek any federal approval necessary from the federal centers for Medicare and Medicaid services to implement the payment mechanism developed under par. (b).

(d) The department may not implement the plan developed under this subsection unless the department receives federal approval under par. (c) . The department may submit one or more requests to the joint committee on finance under s. 13.10 to supplement the appropriation under s. 20.435 (4) (b) from the appropriation under s. 20.865 (4) (a) for implementation of the payment mechanism under par. (b). The department may only use moneys for the payment mechanism under par. (b) if the joint committee on finance approves the request under this paragraph . Notwithstanding s. 13.101, the joint committee on finance is not required to find that an emergency exists before making a supplementation under this paragraph.

59,928t Section 928t. 49.45 (53m) of the statutes is created to read:

49.45 (53m) Coverage program for institutions for mental disease. Subject to any necessary waiver approval of the federal department of health and human services, or as otherwise permitted under federal law, the department may, if federal funding participation is available, provide Medical Assistance coverage of services provided in an institution for mental disease to persons ages 21 to 64.

59,929 Section 929 . 49.45 (54) (b) of the statutes is repealed.

59,930 Section 930 . 49.45 (54) (c) of the statutes is created to read:

49.45 (54) (c) Special services. From the appropriations under s. 20.435 (4) (b) and (o) and (7) (bt), the department may pay the costs of services provided under the early intervention program under s. 51.44 that are included in program participant's individualized family service plan and that were not authorized for payment under the state Medicaid plan or a department policy before July 1, 2017, including any services under the early intervention program under s. 51.44 that are delivered by a type of provider that becomes certified to provide Medical Assistance service on July 1, 2017, or after.

59,931 Section 931 . 49.46 (1) (em) of the statutes is created to read:

49.46 (1) (em) To the extent approved by the federal government, for the purposes of determining financial eligibility and any cost-sharing requirements of an individual under par. (a) 6m., 14., or 14m., (d) 2., or (e), the department or its designee shall exclude any assets accumulated in a person's independence account, as defined in s. 49.472 (1) (c), and any income or assets from retirement benefits earned or accumulated from income or employer contributions while employed and receiving state-funded benefits under s. 46.27 or medical assistance under s. 49.472.

59,931n Section 931n. 49.46 (2) (b) 6. dm. of the statutes is created to read:

49.46 (2) (b) 6. dm. Subject to the requirements under s. 49.45 (9r), durable medical equipment that is considered complex rehabilitation technology, excluding speech generating devices.

59,931p Section 931p. 49.46 (2) (b) 6. e. of the statutes is amended to read:

49.46 (2) (b) 6. e. Subject to the limitation under s. 49.45 (30r), inpatient hospital, skilled nursing facility and intermediate care facility services for patients of any institution for mental diseases who are under 21 years of age, are under 22 years of age and who were receiving these services immediately prior to reaching age 21, or are 65 years of age or older, or are otherwise permitted under s. 49.45 (53m).

59,932 Section 932 . 49.46 (2) (b) 17. of the statutes is amended to read:

49.46 (2) (b) 17. Services under s. 49.45 (54) (b) (c) for children participating in the early intervention program under s. 51.44, that are provided by a special educator.

59,932n Section 932n. 49.46 (2) (dm) of the statutes is amended to read:

49.46 (2) (dm) Benefits Except as provided under s. 49.45 (53m), benefits under this section may not include payment for services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this paragraph, the department shall define “convalescent leave" and “conditional release" by rule.

59,933 Section 933 . 49.47 (4) (c) 1. of the statutes is amended to read:

49.47 (4) (c) 1. Except To the extent approved by the federal government and except as provided in par. (am), eligibility exists if income does not exceed 133 1/3 100 percent of the maximum aid to families with dependent children payment under s. 49.19 (11) poverty line for the applicant's family size or the combined benefit amount available under supplemental security income under 42 USC 1381 to 1383c and state supplemental aid under s. 49.77 whichever is lower. In this subdivision “income" includes earned or unearned income that would be included in determining eligibility for the individual or family under s. 49.19 or 49.77, or for the aged, blind or disabled under 42 USC 1381 to 1385. “Income" does not include earned or unearned income which would be excluded in determining eligibility for the individual or family under s. 49.19 or 49.77, or for the aged, blind or disabled individual under 42 USC 1381 to 1385.

59,933n Section 933n. 49.47 (6) (c) 4. of the statutes is amended to read:

49.47 (6) (c) 4. Services Except as provided under s. 49.45 (53m), services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this subdivision, the department shall define “convalescent leave" and “conditional release" by rule.

59,934 Section 934 . 49.472 (3) (a) of the statutes is amended to read:

49.472 (3) (a) The individual's family's net income is less than 250 percent of the poverty line for a family the size of the individual's family. In calculating the net income, the department shall apply all of the exclusions specified under 42 USC 1382a (b) and to the extent approved by the federal government shall exclude medical and remedial expenditures and long-term care costs in excess of $500 per month that would be incurred by the individual in absence of coverage under the medical assistance purchase plan or a Medicaid long-term care program.

59,935 Section 935 . 49.472 (3) (b) of the statutes is amended to read:

49.472 (3) (b) The individual's assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under 42 USC 1382b (a) or, assets accumulated in an independence account, and, to the extent approved by the federal government, assets from retirement benefits accumulated from income or employer contributions while employed and receiving medical assistance under this section or state-funded benefits under s. 46.27. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.

59,936 Section 936 . 49.472 (3) (f) of the statutes is amended to read:

49.472 (3) (f) The individual maintains premium payments under sub. (4) (am) and, if applicable and to the extent approved by the federal government, premium payments calculated by the department in accordance with sub. (4) (bm), unless the individual is exempted from premium payments under sub. (4) (b) (dm) or (5).

59,937 Section 937 . 49.472 (3) (g) of the statutes is amended to read:

49.472 (3) (g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals. To the extent approved by the federal government, an individual shall prove gainful employment and earned income to the department by providing wage income or prove in-kind work income by federal tax filing documentation. To qualify as gainful income, the amount of in-kind income shall be equal to or greater than the minimum amount for which federal income tax reporting is required.

59,938 Section 938 . 49.472 (4) (a) (intro.) of the statutes is renumbered 49.472 (4) (am) and amended to read:

49.472 (4) (am) Except To the extent approved by the federal government and except as provided in par. (b) pars. (dm) and (em) and sub. (5), an individual who is eligible for medical assistance under sub. (3) and receives medical assistance under this section shall pay a monthly premium of $25 to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:

59,939 Section 939 . 49.472 (4) (a) 1. of the statutes is repealed.

59,940 Section 940 . 49.472 (4) (a) 2. of the statutes is repealed.

59,941 Section 941 . 49.472 (4) (a) 2m. of the statutes is repealed.

59,942 Section 942 . 49.472 (4) (a) 3. of the statutes is repealed.

59,943 Section 943 . 49.472 (4) (b) of the statutes is repealed.

59,944 Section 944 . 49.472 (4) (bm) of the statutes is created to read:

49.472 (4) (bm) To the extent approved by the federal government, in addition to the $25 monthly premium under par. (am), an individual who receives medical assistance under this section and whose individual income exceeds 100 percent of the poverty line for a single-person household shall pay 3 percent of his or her adjusted earned and unearned monthly income under par. (cm) that is in excess of 100 percent of the poverty line.

59,945 Section 945 . 49.472 (4) (cm) of the statutes is created to read:

49.472 (4) (cm) For the purposes of par. (bm), an individual's adjusted earned and unearned monthly income is calculated by subtracting from the individual's earned and unearned monthly income his or her actual out-of-pocket medical and remedial expenses, long-term care costs, and impairment-related work expenses.

59,946 Section 946 . 49.472 (4) (dm) of the statutes is created to read:

49.472 (4) (dm) The department shall temporarily waive an individual's monthly premium under par. (am) and, if applicable, par. (bm) when the department determines that paying the premium would be an undue hardship on the individual.

59,947 Section 947 . 49.472 (4) (em) of the statutes is created to read:

49.472 (4) (em) If the department determines that a state plan amendment or waiver of federal Medicaid law is necessary to implement the premium methodology under this subsection and changes to the income and asset eligibility under sub. (3) and s. 49.47 (4) (c) 1., the department shall submit a state plan amendment or waiver request to the federal department of health and human services requesting those changes. If a state plan amendment or waiver is not necessary or if the federal department of health and human services does not disapprove the state plan amendment or waiver request, the department may implement subs. (3) and (4) and s. 49.47 (4) (c) 1. with any adjustments from the federal department of health and human services. If the federal department of health and human services disapproves the state plan amendment or waiver request in whole or in part, the department may implement the income and asset eligibility requirements and premium methodology under subs. (3) and (4), 2015 stats., and s. 49.47 (4) (c) 1., 2015 stats.

59,948 Section 948 . 49.472 (5) of the statutes is amended to read:

49.472 (5) Community options participants. From the appropriation under s. 20.435 (4) (bd), the department may pay all or a portion of the monthly premium calculated under sub. (4) (a) for an individual who is a participant in the community options program under s. 46.27 (11).

59,949 Section 949 . 49.472 (6) (a) of the statutes is amended to read:

49.472 (6) (a) Notwithstanding sub. (4) (a) 3., from the appropriation accounts under s. 20.435 (4) (b), (gm), or (w), the department shall, on the part of an individual who is eligible for medical assistance under sub. (3), pay premiums for or purchase individual coverage offered by the individual's employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.

59,950 Section 950 . 49.497 (1m) (a) of the statutes is amended to read:

49.497 (1m) (a) If, after notice that an incorrect payment was made, a recipient, or parent of a minor recipient, who is liable for repayment of an incorrect payment fails to repay the incorrect payment or enter into, or comply with, an agreement for repayment, the department may bring an action to enforce the liability or may issue an order to compel payment of the liability. The department shall issue the order to compel payment personally or by any type of mail service that requires a signature of acceptance from the recipient at the address of the person who is liable for repayment as it appears on the records of the department. The refusal or failure to accept or receive the order to compel payment by the person who is liable for repayment does not prevent the department from enforcing the order to compel repayment. Any person aggrieved by an order issued by the department under this paragraph may appeal the order as a contested case under ch. 227 by filing with the department a request for a hearing within 30 days after the date of the order. The only issue at the hearing shall be the determination by the department that the person has not repaid the incorrect payment or entered into, or complied with, an agreement for repayment.

59,951 Section 951 . 49.497 (1m) (b) of the statutes is amended to read: