I am vetoing this provision because I believe there may be unanticipated costs to the MA program and that the language presented may inadvertently limit availability for this service in rural areas of the state. I object to this policy item being placed in the budget without giving the department, MA recipients, health care providers and the public an opportunity to publicly debate its merits. While this provision may have merit, the Legislature should review the impact further and forward legislation when the impacts have been analyzed and such issues have been resolved.
63. Exemption from the Nursing Home Bed Assessment
This provision creates an exemption for county-owned institutions for mental diseases and state licensed nursing homes, which are not certified to participate in Medicaid and Medicare, from the state nursing home bed assessment. The Department of Health Services is required to seek approval from the U.S. Department of Health and Human Services.
I am vetoing this provision because the practice would violate a Centers for Medicare and Medicaid Services requirement that the assessment be "broad based" in design and is therefore not allowable.
64. Childless Adult Employment and Training Waiver
Section 928d
This section requires the Department of Health Services to submit a report to the Joint Committee on Finance no later than three months following final approval of the proposed Medicaid Childless Adult waiver, including the following: (a) a description of each component of the approved waiver, including information on the department's plan to implement; and (b) an estimate of the impact on Medical Assistance enrollment and the Medical Assistance budget.
The section further specifies that that the department may not implement the waiver unless the Joint Committee on Finance meets under s. 13.10 of the statutes to review the report and approves the waiver. Lastly, the Joint Committee on Finance may modify the waiver by removing certain components. The department is required to implement the waiver as approved by the Joint Committee on Finance and the department must submit a waiver amendment to the federal government with any changes made by the committee. I am vetoing this section because I believe these requirements will infringe on the Department of Health Services' ability to negotiate a successful waiver with the Centers for Medicare and Medicaid Services. Further, I object to the creation of unnecessary and burdensome reporting requirements that could delay approval of the waiver, jeopardizing these reforms from being implemented.
65. Family Care Funding
This provision provides funding in the Joint Committee on Finance supplemental GPR appropriation and requires the Department of Health Services to work with both the Centers for Medicare and Medicaid Services as well as Family Care Managed Care Organizations to develop a payment mechanism to increase the direct care and services portion of the capitation rates paid to the managed care organizations.
The provision further requires the department to seek release of the funds under s. 13.10 upon the Centers for Medicare and Medicaid Services approval of such a payment mechanism and lastly requires the department to seek any required federal approval no later than December 31, 2017. I support efforts aimed at increasing rates paid to direct care service providers. However, I believe the requirements of this provision to be administratively burdensome and am vetoing it in two ways. I am partially vetoing the provision to remove the date by which the department must seek federal approval for the rate methodology because I object to this burdensome timeline and believe the department should seek federal approval when it is appropriate to do so, and not at an arbitrary time.
Further, I am partially vetoing the provision to remove the requirement for the department to seek funds under s. 13.10 because I believe it is administratively burdensome. As a result, the supplement of funds to implement this provision will be made from the appropriation under s. 20.865 (4) (a) without the approval of the Joint Committee on Finance. 66. Family Care Partnership Program
This section directs the Department of Health Services to submit a waiver to the Centers for Medicare and Medicaid Services to expand the Family Care Partnership Program statewide. The department is further required to submit a plan to expand the program to the Joint Committee on Finance within 60 days of federal approval. Lastly, should the waiver request be denied by the federal government, the section requires the department to submit a report to the Joint Committee on Finance detailing the reasons why the waiver request was denied.
I am vetoing this section because a waiver request is not necessary to expand the Family Care Partnership Program and I object to the creation of this unnecessary and burdensome process. However, I support expansion of the Family Care Partnership Program and am directing the department to explore expansion opportunities throughout the state.
67. Self-Directed Services Waiver for Postsecondary Education
Section 747w
This section requires the Department of Health Services to request a federal home and community-based services waiver to provide Medicaid coverage for services provided to individuals with developmental disabilities receiving postsecondary education on the grounds of a health care institution. If the waiver is approved, the department shall limit the coverage to 100 individuals per month and shall determine the funding for each participant based on the benefit levels for the Include, Respect, I Self-Direct (IRIS) waiver program.
I am vetoing this section because these requirements are substantially similar to current law provisions directing the department to request a waiver. The federal government has indicated the provisions are not permitted under federal regulations and law regarding Medicaid home and community-based services.
68. Nursing Home Bed Licenses
This provision requires the Department of Health Services to increase by 18 the number of licensed nursing home beds for a nursing facility that meets the following requirements: (a) has a bed capacity of no more than 30 on the effective date of the bill, (b) is in a county with a population of at least 27,000 with the population of the county seat no more than 9,200 and the home county is adjacent to a county with a population of at least 20,000 on the effective date of the bill, and (c) has requested the increase in its licensed beds through a notice to the department that includes the applicant's per diem and operating and capital rates. The provision further requires the department to approve an application from a nursing home under this provision within one month of receiving the application. The provision also requires the department to develop a policy which nursing homes may use to apply for, and receive approval of, the transfer of available and licensed nursing home beds. Lastly, the provision requires the department to report to the Joint Committee on Finance no later than July 1, 2018, with details of the developed policies.
I am vetoing this provision because there is a current law process by which nursing homes can transfer licensed beds and I object to the creation of this redundant process. I further object to the increase in the number of licensed nursing home beds which is a deviation from the department's long-standing nursing home bed moratorium and the decades-long trend toward community-based long-term care. However, I understand the issues facing the nursing home industry and direct the department to work with stakeholders to identify any alternatives available to increase a nursing home's licensed bed count.
Sections 928g, 2249e and 2249g
These provisions provide one-time funding for the Department of Health Services to fund an intensive care coordination pilot project. The pilot would reimburse hospitals and health care systems for intensive care coordination services provided to Medical Assistance (MA) recipients.
The department is required to select eligible hospitals and health care systems to receive reimbursement under the program that submit a description of their programs to the department that meets the following: (a) the entity uses emergency department utilization data to identify MA recipients in order to reduce the use of the emergency department; (b) the entity identifies MA recipients who frequently visit the emergency room; (c) the entity has an intensive care coordination team; (d) the entity provides MA recipients with discharge instructions, referral information, appointment scheduling and intensive care coordination by a coordination individual to connect the MA recipient to a primary care provider; and (e) the intensive care coordination by the entity is designed to result in outcomes during the six-month or 12-month period.
The department is required to respond to the entity if additional information is required to determine eligibility and provide a description for enrolling MA recipients. The department is also required to reimburse the entity for enrollment in the program at $500 per MA recipient with an option for one additional six-month period for additional $500 reimbursement payment.
Entities that are eligible for reimbursement under this program are required to report, for each of the two years of the pilot program, to the department all of the following: (a) the number of MA recipients served by intensive care coordination; (b) for each MA recipient, the number of emergency department visits for a time 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; and (c) any demonstrated outcomes.
The department is required to calculate the costs saved to the MA program by avoiding emergency department visits and distribute half the amount to the hospital or health care system if the calculation is positive.
The department is required to submit a report to the Joint Committee on Finance no later than 24 months after the date on which the first hospital or health care system is able to enroll individuals.
Finally, the department is required to obtain any necessary approval from the federal Department of Health and Human Services.
Overuse of the emergency room system leads to needless expense, crowding and reduced access to those individuals in need of true emergency services. I support efforts to reduce emergency overuse. However, I am vetoing this provision because I believe efforts to address this systemic problem should be broad-based and not aimed at one or two health care systems. Further, I believe that incentives of this nature should be tied to performance in order to best utilize taxpayer dollars and ensure the best outcomes for program participants. Lastly, Wisconsin has a strong history of managed care and a pilot of this nature reverts back to a fee-for-service and more costly payment model.
70. Clinical Consultations
This provision requires the Department of Health Services to provide reimbursement for clinical consultations under the Medical Assistance program. This provision defines "clinical consultation" as, for a student up to age 21, communication from a mental health professional, or 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: (a) the client's symptoms, (b) strategies for effective engagement, care and intervention for the client, and (c) treatment expectations for the client across service settings. The department is required to report on utilization of these services, to the Joint Committee on Finance, by March 31, 2019. This provision is repealed effective June 30, 2019.
I am partially vetoing this provision to remove the report on utilization of services because I believe this report is administratively burdensome.
71. Emergency Physician Services and Reimbursement Workgroup
This provision establishes a workgroup to examine and make recommendations regarding medical services provided in hospital emergency departments to Medical Assistance recipients. The workgroup is to focus on aspects of the healthcare system involving emergency care, specifically patient care practices, medication use and prescribing practices, billing and coding administration, organization of health care delivery systems, care coordination, patient financial incentives, and any other aspects the workgroup finds appropriate.
This provision specifies the workgroup to include: (a) two physicians practicing in Wisconsin representing a statewide physician-member organization of emergency physicians; (b) two representatives of the Division of Medicaid Services, with experience in emergency physician services, codes and payment; (c) one representative who is a hospital emergency department administrator employed by a Wisconsin hospital or hospital-based health system; and (d) one coding/billing specialist from an organization with expertise in the business of emergency medicine that contracts with emergency physicians practicing in Wisconsin.
The provision requires the workgroup to meet no later than 60 days after the effective date of the bill and at least every 45 days following until a consensus of the workgroup has established a set of recommendations. The workgroup is to report its finding to the Joint Committee on Finance no later than September 1, 2018.
I am vetoing this provision because it is duplicative of current managed care and care coordination efforts in the Department of Health Services. I direct the department to continue its efforts.
72. Youth Crisis Stabilization Facility
These provisions create two new facilities for serving individuals with mental health needs. First, these provisions modify the Governor's budget initiative to allow the Department of Health Services to make transfers from its program revenue appropriation that funds the general operations of the state mental health institutes by transferring $450,000 PR in fiscal year 2018-19 on a one-time basis to a new program revenue, all moneys received appropriation for the purpose of contracting for a peer-run respite center for veterans in the Milwaukee area.
Further, these provisions modify language included in the Governor's budget to establish a youth crisis stabilization facility eliminating funding from the department and requiring the department to submit a request under s. 13.10 to the Joint Committee on Finance for release of funds allocated for youth crisis stabilization grants. The provisions require the department to submit any such request to the Joint Committee on Finance prior to the department soliciting proposals and allows the Committee to approve or modify and approve any plan submitted for review. A new sum certain appropriation is created in the department to receive any approved transfer of authority from the Committee and fund the costs of the facility. These provisions also require the department to include in its 2019-21 budget request, a proposal to provide ongoing GPR funding for both the peer-run respite center for veterans as well as the youth crisis stabilization facility.
Finally, both the new appropriation for the peer-run respite center for veterans as well as the appropriation for the crisis stabilization facility are repealed at the end of the biennium, as is the authority to transfer any balances from the state operations for the mental health institutes appropriation for these purposes.
I believe both a youth crisis stabilization facility and a peer-run respite center for veterans are important tools for the department to support and treat individuals with complex mental health needs and potentially significant mental health crises. I object to the overly burdensome requirements laid out in the bill and believe they will impede the ability for the department to negotiate and enter into contracts for both services, thereby delaying critical treatment options for some of Wisconsin's most vulnerable citizens. In order to give the department full flexibility in implementing these important programs, I am partially vetoing the provisions in the following ways.
First, I am partially vetoing section 183 [as it relates to s. 20.435 (5) (kd)] and vetoing section 379j to remove the appropriation for the youth crisis stabilization facility. Further, I am vetoing section 9120 (1b) to remove any requirements for the department to seek funding from the Joint Committee on Finance to implement this program. I object to this overly burdensome process and believe this type of treatment center should be implemented as soon as the department believes it is feasible to do so. I am also partially vetoing section 183 [as it relates to s. 20.865 (4) (g)] by lining out the appropriation and writing in a smaller amount that reduces the appropriation by $1,245,500 in fiscal year 2017-18. I am also requesting the Department of Administration secretary to not allot these funds. Next, I am partially vetoing section 183 [as it relates to s. 20.435 (5) (kp)] related to the peer-run respite center for veterans by striking the words "veterans peer-run respite" from the title of the appropriation to broaden its scope in order to fund both the peer-run respite center for veterans and a youth crisis stabilization center. I am also partially vetoing section 379p to further broaden the scope of the appropriation. However, I direct the department to expend at least $450,000 PR for a peer-run respite center for veterans and at least $1,245,500 PR for a youth crisis stabilization facility, consistent with the amounts approved for each by the Legislature. Further, I am partially vetoing section 377 to allow sufficient funding to be transferred from the appropriation funding operations of the mental health institutes to fund the youth crisis stabilization facility and the peer-run respite center for veterans.
Lastly, I am vetoing the remaining provisions to ensure ongoing funding for both the peer-run respite center and the youth crisis stabilization facility.
I believe these changes will allow the department to implement these important mental health treatment options in the most efficient manner possible.
73. Disposition of Surplus Revenue Balance in the Mental Health Institutes Appropriation
This provision requires the Department of Health Services, at the close of each even-numbered fiscal year, to provide county and tribal human services agencies with the unencumbered balance in the program revenue appropriation account for the state mental health institutes. If this amount exceeds 17 percent of the expenditures from the appropriation in the even-numbered year, the department must include a spending plan for the balance in its next biennial budget request. The department is required to consult with county human services agencies in developing the proposal.
While consultation between the Department of Health Services and counties is an integral part to setting policy, I am vetoing this provision as I believe it is overly burdensome for the agency and encroaches on the executive branch's responsibility to manage state agency programs within the statutes and funding levels set by the Legislature. In addition, these consultations already occur without a statutory requirement.
74. Office of Children's Mental Health Travel Reimbursement
Section 392c
This provision requires the Department of Health Services to fund, from within its base resources in its GPR general administration appropriation, travel reimbursements for individuals with firsthand mental health experience to participate in Office of Children's Mental Health meetings.
I am vetoing this provision because the Department of Health Services has the ability to provide funding for this purpose and so the authorization in statute for the department to fund these costs is duplicative and unnecessary.
Department of Veterans Affairs
75. Veterans Trust Fund and State Veterans Homes
Sections 739qg, 739qm, 9149 (1f) and 9149 (1g)
These provisions make a series of changes to the Wisconsin Department of Veterans Affairs veterans trust fund and State Veterans Homes. Under these provisions, the Department of Veterans Affairs is prohibited from making any transfer from the unencumbered program revenue balance of the Veterans Homes to the veterans trust fund unless the transfer has been approved by the Joint Committee on Finance.
The Department of Veterans Affairs is required to prepare a report that contains all of the following: (a) a description and analysis of the administrative costs supported by the veterans trust fund and veterans home revenue; (b) proposes any changes to the department's programs, administrative structure or position level and salaries to increase efficiency or lower administrative costs; and (c) proposes two long-term plans to maintain solvency of the veterans trust fund, one of which allows for transfers from the homes and one of which uses no such transfers.
Further, these sections require the department to submit proposed changes to VA 6 of the Administrative Code to include a formula for calculating private pay rates for nursing home and assisted living care at Veterans Homes and to clearly define rate-setting terms. Further, the department is required to submit a report to the Joint Legislative Audit Committee and the Joint Committee on Finance by January 1, 2018, on the cash balance in the Veterans Home program revenue appropriation it believes is appropriate to maintain, and its efforts to develop, and routinely update, a detailed plan for the management and proposed use of the cash balance.
Finally, under these sections the department is required to submit a report to the Joint Legislative Audit Committee and the Joint Committee on Finance by January 1, 2018, on its efforts to (a) establish a systematic process for comprehensively identifying and assessing the capital-related project needs for the State Veterans Homes, and (b) the use of this information to complete a ten-year facilities plan for the Veterans Homes and to help develop its required six-year facilities plans in the future.
I am vetoing these provisions because I object to the creation of a series of additional mandated reports which are administratively burdensome and redirects valuable staff time away from care for veterans. Further, I believe these requirements encroach on the executive branch's responsibility to manage state agency programs within the statutes and funding levels set by the Legislature.
Budget Management
76. General Fund Structural Balance
Section 140k
This section prohibits general fund net appropriations from exceeding general fund revenues in the second year of the fiscal biennium for every future Governor's budget bill submitted to the Legislature.
I am vetoing this section for several important reasons.
First, I am vetoing this section because I object to the unnecessary constraint that this provision places upon the Governor's budget recommendations. Prudent budgeting can, and has been, undertaken without this constraint. This unnecessary limitation would prohibit the Governor from recommending the return of excess funds at the beginning of the second year of a fiscal biennium to the people of Wisconsin through reduced taxes, increases in state aid or enhanced state programs.
Second, I am vetoing this section because it is poorly placed in the budget process and, consequently, can be expected to create unnecessary uncertainty for the funding of state programs. It is poorly placed because the Governor's budget recommendations are made prior to the final general fund revenue estimates used for budget passage that the Legislative Fiscal Bureau typically makes in May of each odd-numbered year. As a result, this section may generate unneeded angst regarding the funding of a wide variety of state aids and programs despite an expected excess balance in the state's general fund.
Third, I am vetoing this section because it establishes a standard contradictory to legislative action. This requirement would submit the Governor's budget to a constraint that the Legislature has explicitly excluded itself from in recent budgets, including this 2017-19 budget act.
Finally, I am vetoing this section because it forces the Executive Budget Bill to be incomplete, in that it cannot be fully tailored to address the state's fiscal circumstances. By prohibiting all Governors, both current and future, from having the current level of budget flexibility in making gubernatorial budget recommendations, it gives the Legislature an incomplete outline, direction and vision to move the state forward in the best manner possible just as the Legislature begins its budget deliberations.
General Fund Taxes
77. Refundable Business Tax Credit Claims
