1995 Wisconsin Act 27

(d) Reimbursement to an agency may be based on total costs agreed to by the parties regardless of the actual number of service units to be furnished, when the agency is entering into a contract for a new or expanded service that the purchaser recognizes will require a start-up period not to exceed 180 days. This reimbursement applies only if identified client needs necessitate the establishment of a new service or expansion of an existing service.

(e) If the purchaser finds it necessary to terminate a contract prior to the contract expiration date for reasons other than nonperformance by the provider, the actual cost incurred by the provider may be reimbursed in an amount determined by mutual agreement of the parties.

(f) Advance payments of up to one-twelfth of an annual contract may be allowed under the contract. If the advance payment exceeds $10,000, the provider shall supply a surety bond in an amount equal to the amount of the advance payment applied for. No surety bond is required if the provider is a state agency. The cost of the surety bond shall be allowable as an expense.

(4) For purposes of this section and as a condition of reimbursement, each provider under contract shall:

(a) Except as provided in this subsection, maintain a uniform double entry accounting system and a management information system which are compatible with cost accounting and control systems prescribed by the department.

(b) Cooperate with the department and purchaser in establishing costs for reimbursement purposes.

(c) Unless waived by the department, biennially, or annually if required under federal law, provide the purchaser with a certified financial and compliance audit report if the care and services purchased exceed $25,000. The audit shall follow standards that the department prescribes.

(d) Transfer a client from one category of care or service to another only with the approval of the purchaser.

(e) Charge a uniform schedule of fees as specified under s. 49.32 (1) unless waived by the purchaser with the approval of the department. Whenever providers recover funds attributed to the client, such funds shall offset the amount paid under the contract.

(5) Except as provided in sub. (5m), the purchaser shall recover from provider agencies money paid in excess of the conditions of the contract from subsequent payments made to the provider.

(5m) (a) In this subsection:

1. “Provider" means a nonprofit, nonstock corporation organized under ch. 181 that contracts under this section to provide client services on the basis of a unit rate per client service.

2. “Rate-based service" means a service or a group of services, as determined by the department, that is reimbursed through a prospectively set rate and that is distinguishable from other services or groups of services by the purpose for which funds are provided for that service or group of services and by the source of funding for that service or group of services.

(b) 1. Subject to subds. 2. and 3., if revenue under a contract for the provision of a rate-based service exceeds allowable costs incurred in the contract period, the provider may retain from the surplus generated by that rate-based service up to 5% of the contract amount. A provider that retains a surplus under this subdivision shall use that retained surplus to cover a deficit between revenue and allowable costs incurred in any preceding or future contract period for the same rate-based service that generated the surplus or to address the programmatic needs of clients served by the same rate-based service that generated the surplus.

2. Subject to subd. 3., a provider may accumulate funds from more than one contract period under this paragraph, except that, if at the end of a contract period the amount accumulated from all contract periods for a rate-based service exceeds 10% of the amount of all current contracts for that rate-based service, the provider shall, at the request of a purchaser, return to that purchaser the purchaser's proportional share of that excess and use any of that excess that is not returned to a purchaser to reduce the provider's unit rate per client for that rate-based service in the next contract period. If a provider has held for 4 consecutive contract periods an accumulated reserve for a rate-based service that is equal to or exceeds 10% of the amount of all current contracts for that rate-based service, the provider shall apply 50% of that accumulated amount to reducing its unit rate per client for that rate-based service in the next contract period.

3. If on December 31, 1995, the amount accumulated by a provider from all contract periods ending on or before that date for all rate-based services provided by the provider exceeds 10% of the provider's total contract amount for all rate-based services provided by the provider in 1995, the provider shall, at the request of a purchaser, return to that purchaser the purchaser's proportional share of that excess.

(f) All providers that are subject to this subsection shall comply with any financial reporting and auditing requirements that the department may prescribe. Those requirements shall include a requirement that a provider provide to any purchaser and the department any information that the department needs to claim federal reimbursement for the cost of any services purchased from the provider and a requirement that a provider provide audit reports to any purchaser and the department according to standards specified in the provider's contract and any other standards that the department may prescribe.

(6) Contracts may be renegotiated by the purchaser under conditions specified in the contract.

(7) The service provider under this section may appeal decisions of the purchaser in accordance with terms and conditions of the contract and ch. 68 or 227.

27,2938 Section 2938 . 49.35 of the statutes is created to read:

49.35 Public assistance; supervisory functions of department. (1) (a) The department shall supervise the administration of programs under this subchapter. The department shall submit to the federal authorities state plans for the administration of programs under this subchapter in such form and containing such information as the federal authorities require, and shall comply with all requirements prescribed to ensure their correctness.

(b) All records of the department and all county records relating to programs under this subchapter and aid under s. 49.18, 1971 stats., s. 49.20, 1971 stats., and s. 49.61, 1971 stats., as affected by chapter 90, laws of 1973, shall be open to inspection at all reasonable hours by authorized representatives of the federal government. Notwithstanding s. 48.396 (2), all county records relating to the administration of the services and public assistance specified in this paragraph shall be open to inspection at all reasonable hours by authorized representatives of the department.

(bm) All records of the department relating to aid provided under s. 49.19 are open to inspection at reasonable hours by members of the legislature who require the information contained in the records in pursuit of a specific state legislative purpose. All records of any county relating to aid provided under s. 49.19 are open to inspection at reasonable hours by members of the board of supervisors of the county or the governing body of a city, village or town located in the county who require the information contained in the records in pursuit of a specific county or municipal legislative purpose. The right to records access provided by this paragraph does not apply if access is prohibited by federal law or regulation or if this state is required to prohibit such access as a condition precedent to participation in a federal program in which this state participates.

(c) The department may at any time audit all county records relating to the administration of the services and public assistance specified in this section and may at any time conduct administrative reviews of county departments under ss. 46.215, 46.22 and 46.23. If the department conducts such an audit or administrative review in a county, the department shall furnish a copy of the audit or administrative review report to the chairperson of the county board of supervisors and the county clerk in a county with a single-county department or to the county boards of supervisors and the county clerks in counties with a multicounty department, and to the director of the county department under s. 46.215, 46.22 or 46.23.

(2) The county administration of all laws relating to programs under this subchapter shall be vested in the officers and agencies designated in the statutes.

27,2939 Section 2939 . 49.41 of the statutes is amended to read:

49.41 Assistance grants exempt from levy. All grants of aid to families with dependent children, payments made for social services, cash benefits paid by counties under s. 59.07 (154), and benefits under ss. 49.032, 49.046 and s. 49.177 or federal Title XVI, are exempt from every tax, and from execution, garnishment, attachment and every other process and shall be inalienable.

27,2940 Section 2940 . 49.41 of the statutes, as affected by 1995 Wisconsin Act .... (this act), is renumbered 49.96 and amended to read:

49.96 Assistance grants exempt from levy. All grants of aid to families with dependent children, payments made for social services, cash benefits paid by counties under s. 59.07 (154), and benefits under s. 49.177 49.77 or federal Title XVI, are exempt from every tax, and from execution, garnishment, attachment and every other process and shall be inalienable.

27,2941 Section 2941 . Subchapter IV (title) of chapter 49 [precedes 49.43] of the statutes is created to read:

Chapter 49

Subchapter IV
Medical assistance

27,2942 Section 2942 . The unnumbered subchapter title preceding 49.43 of the statutes is repealed.

27,2943 Section 2943 . 49.43 (1) of the statutes is renumbered 49.43 (1m).

27,2944 Section 2944 . 49.43 (3e) of the statutes is created to read:

49.43 (3e) “Department" means the department of health and social services.

27,2945 Section 2945 . 49.43 (10) of the statutes is amended to read:

49.43 (10) “Provider" means a person, corporation, limited liability company, partnership, unincorporated business or professional association and any agent or employe thereof who provides medical assistance under ss. 49.45 to 49.47, 49.49 and 49.495.

27,2946 Section 2946 . 49.43 (10s) of the statutes is created to read:

49.43 (10s) “Secretary" means the secretary of health and social services.

27,2947 Section 2947 . 49.45 (2) (a) 15. of the statutes is amended to read:

49.45 (2) (a) 15. Routinely provide notification to persons eligible for medical assistance under ss. 49.46 to 49.47, or such persons' guardians, of the department's access to provider records.

27,2949 Section 2949 . 49.45 (2) (a) 23. of the statutes is created to read:

49.45 (2) (a) 23. Promulgate rules that define “supportive services", “personal services" and “nursing services" provided in a certified assisted living facility, as defined under s. 50.01 (1d), for purposes of reimbursement under ss. 46.27 (11) (c) 7. and 46.277 (5) (e).

27,2950 Section 2950 . 49.45 (2) (b) 4. of the statutes is amended to read:

49.45 (2) (b) 4. Audit claims filed by any provider of medical assistance, and as part of that audit, request of any such provider, and review, medical records of individuals who have received benefits under the medical assistance program, or under s. 49.046.

27,2951 Section 2951 . 49.45 (3) (a) of the statutes is amended to read:

49.45 (3) (a) Reimbursement shall be made to each county department under ss. 46.215, 46.22 and 46.23 for the administrative services performed in the medical assistance program on the basis of s. 49.52 49.33 (8). For purposes of reimbursement under this paragraph, assessments completed under s. 46.27 (6) (a) are administrative services performed in the medical assistance program.

27,2952g Section 2952g. 49.45 (3) (e) 7m. of the statutes is created to read:

49.45 (3) (e) 7m. Notwithstanding subd. 7., the daily reimbursement or payment rate for services at a hospital established under s. 45.375 (1) provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to the facility created under s. 45.365 (1).

27,2953 Section 2953 . 49.45 (5) of the statutes is amended to read:

49.45 (5) Appeal. Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined may file an appeal with the department pursuant to s. 49.50 (8) 49.21 (1).

27,2954 Section 2954 . 49.45 (5m) (a) of the statutes is amended to read:

49.45 (5m) (a) Notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (1) (b) and (o) the department shall distribute not more than $2,256,000 in each of fiscal years 1993-94 and 1994-95 year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under 42 USC 1396b (i) (3).

27,2955 Section 2955 . 49.45 (6b) (a) of the statutes is amended to read:

49.45 (6b) (a) Beginning in fiscal year 1994-95 1995-96, for relocations from the central Wisconsin center for the developmentally disabled, by $55.77 $205 per day.

27,2956 Section 2956 . 49.45 (6b) (b) of the statutes is amended to read:

49.45 (6b) (b) Beginning in fiscal year 1994-95 1995-96, for relocations from the northern Wisconsin center for the developmentally disabled, by $49.06 $199 per day.

27,2957 Section 2957 . 49.45 (6b) (c) of the statutes is amended to read:

49.45 (6b) (c) Beginning in fiscal year 1994-95 1995-96, for relocations from the southern Wisconsin center for the developmentally disabled, by $48.37 $149 per day.

27,2960 Section 2960 . 49.45 (6m) (ag) 3m. of the statutes is amended to read:

49.45 (6m) (ag) 3m. For state fiscal year 1993-94 1995-96, rates that shall be set by the department based on information from cost reports for the 1992 1994 fiscal year of the facility and for state fiscal year 1994-95 1996-97, rates that shall be set by the department based on information from cost reports for the 1993 1995 fiscal year of the facility.

27,2961 Section 2961 . 49.45 (6m) (ag) 8. of the statutes is amended to read:

49.45 (6m) (ag) 8. Calculation of total payments and supplementary payments to facilities that permits an increase in funds allocated under s. 20.435 (1) (b) and (o) for nursing home care provided medical assistance recipients over that paid for services provided in state fiscal year 1992-93 1994-95 of no more than 3.58% 4.25% during state fiscal year 1993-94 1995-96 and over that paid for services provided in state fiscal year 1993-94 1995-96 of no more than 3.57% 3.5% during state fiscal year 1994-95 1996-97, excluding increases in total payments attributable to increases in recipient utilization of facility care, payments for the provision of active treatment to facility residents with developmental disability or chronic mental illness and payments for preadmission screening of facility applicants and annual reviews of facility residents required under 42 USC 1396r (e).

27,2962 Section 2962 . 49.45 (6m) (am) 5. of the statutes is amended to read:

49.45 (6m) (am) 5. Allowable administrative and general costs, including costs related to the facility's overall management and administration and allowable expenses that are not recognized or reimbursed in other cost centers and including the costs of commercial estimators approved by the department under par. (ar) 6.

27,2963 Section 2963 . 49.45 (6m) (am) 5m. of the statutes is created to read:

49.45 (6m) (am) 5m. Allowable interest expense of the facility, less interest income of the facility and less interest income of affiliated entities, to the extent required under the approved state plan for services under 42 USC 1396.

27,2964 Section 2964 . 49.45 (6m) (ar) 1. c. of the statutes is amended to read:

49.45 (6m) (ar) 1. c. If a facility has an approved program for provision of service to emotionally disturbed or mentally retarded residents, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under subd. 1. b. may be made to that facility according to a method developed by the department.

27,2965 Section 2965 . 49.45 (6m) (ar) 6. of the statutes is amended to read:

49.45 (6m) (ar) 6. Capital payment shall be based on a replacement value for a facility, as. The replacement value shall be determined by a commercial estimator with which contracted for by the department has contracted for service, and paid for by the facility. The replacement value shall be subject to limitations determined by the department, except that the department may not reduce final capital payment of a facility by more than $3.50 per patient day.

27,2966 Section 2966 . 49.45 (6m) (av) 2. of the statutes is amended to read:

49.45 (6m) (av) 2. The department shall compile an average payment rate for each facility based on that facility's rates for cost centers described under par. (am) 1. to 5. that were in effect on June 30 of the previous year , 1994. The department may develop a method for adjusting the facility's rate for the cost center under par. (am) 1. in compiling the average payment rate under this subdivision.

27,2967 Section 2967 . 49.45 (6m) (av) 4. of the statutes is amended to read:

49.45 (6m) (av) 4. If the facility's payment rate under subd. 1. is a decrease from its average payment rate from the previous year under subd. 2., and if the figure calculated under subd. 3. exceeds the payment rate for the facility under subd. 1., the facility's average payment rate shall be the greater of its average payment rate under subd. 2. or its rate under subd. 1.

27,2968 Section 2968 . 49.45 (6m) (bm) 4. of the statutes is repealed.

27,2969 Section 2969 . 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 (3) (cd), (4) (de) or (eb) (1) (bt) or (bu) or (7) (b) or 20.445 (3) (de), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriations under s. 20.410 (3) (cd) or 20.435 (3) (cd), (4) (de) or (eb) (1) (bt) or (bu) or (7) (b), or the department shall direct the department of industry, labor and human relations to reduce allocations of funds to counties in the amount of the disallowance from the appropriation under s. 20.445 (3) (de), in accordance with s. 16.544 to the extent applicable.

27,2970 Section 2970 . 49.45 (6m) (c) 6. of the statutes is created to read:

49.45 (6m) (c) 6. Provide, upon request, such information as the department considers necessary to determine allowable interest expenses under par. (am) 5m.

27,2971 Section 2971 . 49.45 (6m) (h) of the statutes is amended to read:

49.45 (6m) (h) The department may require by rule that all claims for payment of services provided facility residents under this chapter subchapter be submitted or countersigned by the respective facility administrator. The department may specify those categories of services for which payment will be made only if the services are rendered or authorized in writing by a primary health care provider designated by the recipient for the particular category of services.

27,2974b Section 2974b. 49.45 (6m) (L) of the statutes is created to read:

49.45 (6m) (L) For purposes of ss. 46.27 (11) (c) 7. and 46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under s. 46.27 (11) (c) 7. or 46.277 (5) (e).

27,2975 Section 2975 . 49.45 (6t) of the statutes is created to read:

49.45 (6t) County department operating deficit reduction. From the appropriation under s. 20.435 (1) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a county department under s. 46.215, 46.22, 46.23 or 51.42 for services provided under s. 49.46 (2) (a) 4. d. and (b) 6. f., the department shall allocate up to $4,500,000 in each fiscal year to these county departments, as determined by the department, and shall perform all of the following:

(a) For the reduction of operating deficits incurred by the county departments, estimate the availability of federal medicaid funds that may be matched to county funds that are expended for costs in excess of reimbursement for services provided under s. 49.46 (2) (a) 4. d. and (b) 6. f.

(b) Based on the amount estimated to be available under par. (a), develop a method, which need not be promulgated as rules under ch. 227, to distribute this allocation to the individual county departments under s. 46.215, 46.22, 46.23 or 51.42 that have incurred operating deficits that shall include all of the following: