49.47 (6) (a) 7. Beneficiaries eligible under sub. (4) (a) 2. (ag) 2. or (am) 1., for services under s. 49.46 (2) (a) and (b) that are related to pregnancy, including postpartum services and family planning services, as defined in s. 253.07 (1) (b), or related to other conditions which may complicate pregnancy.
16,1820
Section
1820. 49.472 (6) (a) of the statutes is amended to read:
49.472 (6) (a) Notwithstanding sub. (4) (a) 3., from the appropriation under s. 20.435 (4) (b) 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.
16,1821
Section
1821. 49.472 (6) (b) of the statutes is amended to read:
49.472 (6) (b) If federal financial participation is available, from the appropriation under s. 20.435 (4) (b) or (w), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under sub. (3).
16,1822
Section
1822. 49.473 of the statutes is created to read:
49.473 Medical assistance; women diagnosed with breast or cervical cancer. (1) In this section:
(a) "County department" means a county department under s. 46.215, 46.22, or 46.23.
(b) "Qualified entity" has the meaning given in
42 USC 1396r-1b (b) (2).
(2) A woman is eligible for medical assistance as provided under sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:
(a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, and 49.472, and is not eligible for health care coverage under s. 49.665.
(b) The woman is under 65 years of age.
(c) The woman is not eligible for health care coverage that qualifies as creditable coverage in
42 USC 300gg (c).
(d) The woman has been screened for breast or cervical cancer under a breast and cervical cancer early detection program that is authorized under a grant received under
42 USC 300k.
(e) The woman requires treatment for breast or cervical cancer.
(3) Prior to applying to the department or a county department for medical assistance, a woman is eligible for medical assistance as provided under sub. (5) beginning on the date on which a qualified entity determines, on the basis of preliminary information, that the women meets the requirements specified in sub. (2) and ending on one of the following dates:
(a) If the woman applies to the department or a county department for medical assistance within the time limit required under sub. (4), the day on which the department or county department determines whether the woman meets the requirements under sub. (2).
(b) If the woman does not apply to the department or county department for medical assistance within the time limit required under sub. (4), the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
(4) A woman who a qualified entity determines under sub. (3) is eligible for medical assistance shall apply to the department or county department no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
(5) The department shall audit and pay, from the appropriation accounts under s. 20.435 (4) (b) and (o), allowable charges to a provider who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under sub. (2) for all benefits and services specified under s. 49.46 (2).
(6) A qualified entity that determines under sub. (3) that a woman is eligible for medical assistance as provided under sub. (5) shall do all of the following:
(a) Notify the department of the determination no later than 5 days after the date on which the determination is made.
(b) Inform the woman at the of time the determination that she is required to apply to the department or a county department for medical assistance no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
(7) The department shall provide qualified entities with application forms for medical assistance and information on how to assist women in completing the form.
16,1835k
Section 1835k. Subchapter V (title) of chapter 49 [precedes 49.66] of the statutes is amended to read:
CHAPTER 49
SUBCHAPTER V
OTHER MEDICALLY RELATED SERVICES
AND SUPPORT and medical PROGRAMS
16,1836
Section
1836. 49.665 (4) (at) 1. a. of the statutes is amended to read:
49.665 (4) (at) 1. a. Except as provided in subd. 1. b., the department shall establish a lower maximum income level for the initial eligibility determination if funding under s. 20.435 (4) (bc), (jz) and, (p), and (x) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding.
16,1836g
Section 1836g. 49.665 (4) (at) 1. b. of the statutes is amended to read:
49.665 (4) (at) 1. b. The department may not lower the maximum income level for initial eligibility unless the department first submits to the joint committee on finance its plans a plan for lowering the maximum income level and the committee approves the plan. If, within 14 days after submitting the plan the date on which the plan is submitted to the joint committee on finance, the cochairpersons of the committee do not notify the secretary that the committee has scheduled a meeting for the purpose of reviewing the plan, the department shall implement the plan is considered approved by the committee as proposed. If within 14 days after the date on which the plan is submitted to the committee, the cochairpersons of the committee notify the secretary that the committee has scheduled a meeting to review the plan, the department may implement the plan only as approved by the committee.
16,1836r
Section 1836r. 49.665 (4) (at) 1. c. of the statutes is created to read:
49.665 (4) (at) 1. c. Notwithstanding s. 20.001 (3) (b), if, after reviewing the plan submitted under subd. 1. b., the joint committee on finance determines that the amounts appropriated under s. 20.435 (4) (bc), (jz), (p), and (x) are insufficient to accommodate the projected enrollment levels, the committee may transfer appropriated moneys from the general purpose revenue appropriation account of any state agency, as defined in s. 20.001 (1), other than a sum sufficient appropriation account, to the appropriation account under s. 20.435 (4) (bc) to supplement the health care program under this section if the committee finds that the transfer will eliminate unnecessary duplication of functions, result in more efficient and effective methods for performing programs or more effectively carry out legislative intent, and that legislative intent will not be changed by the transfer.
16,1837
Section
1837. 49.665 (4) (at) 2. of the statutes is amended to read:
49.665 (4) (at) 2. If, after the department has established a lower maximum income level under subd. 1., projections indicate that funding under s. 20.435 (4) (bc), (jz) and, (p), and (x) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185% of the poverty line.
16,1837p
Section 1837p. 49.68 (3) (b) of the statutes is amended to read:
49.68 (3) (b) The From the appropriation accounts under ss. 20.435 (4) (e) and (je), the state shall pay the cost of medical treatment required as a direct result of chronic renal disease of certified patients from the date of certification, including the cost of administering recombinant human erythropoietin to appropriate patients, whether the treatment is rendered in an approved facility in the state or in a dialysis or transplantation center which is approved as such by a contiguous state, subject to the conditions specified under par. (d). Approved facilities may include a hospital in-center dialysis unit or a nonhospital dialysis center which is closely affiliated with a home dialysis program supervised by an approved facility. Aid shall also be provided for all reasonable expenses incurred by a potential living-related donor, including evaluation, hospitalization, surgical costs and postoperative follow-up to the extent that these costs are not reimbursable under the federal medicare program or other insurance. In addition, all expenses incurred in the procurement, transportation and preservation of cadaveric donor kidneys shall be covered to the extent that these costs are not otherwise reimbursable. All donor-related costs are chargeable to the recipient and reimbursable under this subsection.
16,1837q
Section 1837q. 49.683 (2) of the statutes is amended to read:
49.683 (2) Approved costs for medical care under sub. (1) shall be paid from the appropriation accounts under s. 20.435 (4) (e) and (je).
16,1837r
Section 1837r. 49.685 (2) of the statutes is amended to read:
49.685 (2) Assistance program. The From the appropriation accounts under s. 20.435 (4) (e) and (je), the department shall establish a program of financial assistance to persons suffering from hemophilia and other related congenital bleeding disorders. The program shall assist such persons to purchase the blood derivatives and supplies necessary for home care. The program shall be administered through the comprehensive hemophilia treatment centers.
16,1837s
Section 1837s. 49.687 (title) of the statutes is amended to read:
49.687 (title) Disease aids; patient financial and liability requirements; rebate agreements.
16,1838
Section
1838. 49.687 (2) of the statutes is amended to read:
49.687 (2) The department shall develop and implement a sliding scale of patient liability for kidney disease aid under s. 49.68, cystic fibrosis aid under s. 49.683 and hemophilia treatment under s. 49.685, based on the patient's ability to pay for treatment. To ensure that the needs for treatment of patients with lower incomes receive priority within the availability of funds under s. 20.435 (4) (e) and (je), the department shall revise the sliding scale for patient liability by January 1, 1994, and shall, every 3 years thereafter by January 1, review and, if necessary, revise the sliding scale.
16,1838c
Section 1838c. 49.687 (3) of the statutes is created to read:
49.687
(3) The department or an entity with which the department contracts shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under
42 USC 1396r-8. The department or entity may enter into a rebate agreement under this subsection that shall include all of the following as requirements:
(a) That, as a condition of coverage for prescription drugs of a manufacturer under s. 49.68, 49.683, or 49.685, the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet eligibility criteria under s. 49.68, 49.683, or 49.685, to the state treasurer to be credited to the appropriation under s. 20.435 (4) (je), each calendar quarter or according to a schedule established by the department.
(b) That the amount of the rebate payment shall be determined by a method specified in
42 USC 1396r-8 (c)
, except that, if the average manufacturer price for a prescription drug exceeds the average manufacturer price of the drug as of December 31, 2000, or the first calendar quarter after the day on which the drug was first available, as adjusted for inflation, the rebate amount shall increase by the amount of the difference.
16,1838gb
Section 1838gb. 49.688 of the statutes is created to read:
49.688 Prescription drug assistance for elderly persons. (1) In this section:
(a) "Generic name" has the meaning given in s. 450.12 (1) (b).
(b) "Poverty line" means the nonfarm federal poverty line for the continental United States, as defined by the federal department of labor under
42 USC 9902 (2).
(c) "Prescription drug" means a prescription drug, as defined in s. 450.01 (20), that is included in the drugs specified under s. 49.46 (2) (b) 6. h. and that is manufactured by a drug manufacturer that enters into a rebate agreement in force under sub. (6).
(d) "Prescription order" has the meaning given in s. 450.01 (21).
(e) "Program payment rate" means the rate of payment made for the identical drug specified under s. 49.46 (2) (b) 6. h., plus 5%, plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h.
(2) (a) A person to whom all of the following applies is eligible to purchase a prescription drug for the amounts specified in sub. (5) (a) 1. and 2.:
1. The person is a resident, as defined in s. 27.01 (10) (a), of this state.
2. The person is at least 65 years of age.
3. The person is not a recipient of medical assistance.
4. The person's annual household income, as determined by the department, does not exceed 240% of the federal poverty line for a family the size of the person's eligible family.
5. The person pays the program enrollment fee specified in sub. (3) (a).
(b) A person to whom par. (a) 1. to 3. and 5. applies, but whose annual household income, as determined by the department, exceeds 240% of the federal poverty line for a family the size of the persons' eligible family, is eligible to purchase a prescription drug at the amounts specified in sub. (5) (a) 4. only during the remaining amount of any 12-month period in which the person has first paid the annual deductible specified in sub. (3) (b) 2. a. in purchasing prescription drugs at the retail price and has then paid the annual deductible specified in sub. (3) (b) 2. b.
(3) Program participants shall pay all of the following:
(a) For each 12-month benefit period, a program enrollment fee of $20.
(b) 1. For each 12-month benefit period, for a person specified in sub. (2) (a), a deductible for prescription drugs of $500, except that a person whose annual household income, as determined by the department, is 160% or less of the federal poverty line for a family the size of the person's eligible family pays no deductible.
2. For each 12-month benefit period, for a person specified in sub. (2) (b), a deductible for prescription drugs that equals all of the following:
a. The difference between the person's annual household income and 240% of the federal poverty line for a family the size of the person's eligible family.
b. Five hundred dollars.
(c) After payment of any applicable deductible under par. (b), all of the following:
1. A copayment of $5 for each prescription drug that bears only a generic name.
2. A copayment of $15 for each prescription drug that does not bear only a generic name.
(d) Notwithstanding s. 49.002, if a person who is eligible under this section has other available coverage for payment of a prescription drug, this section applies only to costs for prescription drugs for the persons that are not covered under the person's other available coverage.
(4) The department shall devise and distribute a form for application for the program under sub. (2), shall determine eligibility for each 12-month benefit period of applicants and shall issue to eligible persons a prescription drug card for use in purchasing prescription drugs, as specified in sub. (5). The department shall promulgate rules that specify the criteria to be used to determine household income under sub. (2) (a) 4. and (b) and (3) (b) 1.
(5) (a) Beginning on September 1, 2002, except as provided in sub. (7) (b), as a condition of participation by a pharmacy or pharmacist in the program under s. 49.45, 49.46, or 49.47, the pharmacy or pharmacist may not charge a person who presents a valid prescription order and a card indicating that he or she meets eligibility requirements under sub. (2) an amount for a prescription drug under the order that exceeds the following:
1. For a deductible, as specified in sub. (3) (b) 1. and 2. b., the program payment rate.
2. After any applicable deductible under subd. 1. is charged, the copayment, as applicable, that is specified in sub. (3) (c) 1. or 2. No dispensing fee may be charged to a person under this subdivision.
3. For a deductible, as specified in sub. (3) (b) 2. a., the retail price.
4. After the deductible under subd. 3. is charged, the copayment, as applicable, that is specified in sub. (3) (c) 1. or 2. No dispensing fee may be charged to a person under this subdivision.
(b) The department shall calculate and transmit to pharmacies and pharmacists that are certified providers of medical assistance amounts that may be used in calculating charges under par. (a). The department shall periodically update this information and transmit the updated amounts to pharmacies and pharmacists.
(6) The department, or an entity with which the department contracts, shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under
42 USC 1396r-8. A rebate agreement under this subsection shall include all of the following as requirements:
(a) That, except as provided in sub. (7) (b), the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet criteria under sub. (2) (a) and persons who meet criteria under sub. (2) (b) and have paid the deductible under sub. (3) (b) 2. a., to the state treasurer to be credited to the appropriation account under s. 20.435 (4) (j), each calendar quarter or according to a schedule established by the department.
(b) That, except as provided in sub. (7) (b), the amount of the rebate payment shall be determined by a method specified in
42 USC 1396r-8 (c).
(7) (a) Except as provided in par. (b), from the appropriation accounts under s. 20.435 (4) (bv) and (j), beginning on September 1, 2002, the department shall, under a schedule that is identical to that used by the department for payment of pharmacy provider claims under medical assistance, provide to pharmacies and pharmacists payments for prescription drugs sold by the pharmacies or pharmacists to persons eligible under sub. (2) who have paid the deductible specified under sub. (3) (b) 1. or 2. or who, under sub. (3) (b) 1., are not required to pay a deductible. The payment for each prescription drug under this paragraph shall be at the program payment rate, minus any copayment paid by the person under sub. (5) (a) 2. or 4., and plus, if applicable, incentive payments that are similar to those provided under s. 49.45 (8v). The department shall devise and distribute a claim form for use by pharmacies and pharmacists under this paragraph and may limit payment under this paragraph to those prescription drugs for which payment claims are submitted by pharmacists or pharmacies directly to the department. The department may apply to the program under this section the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under subch. IV of ch. 49.
(b) During any period in which funding under s. 20.435 (4) (bv) is completely expended for the payments specified in par. (a), the requirements of par. (a) and subs. (3) (c), (5), and (6) (a) and (b) do not apply to drugs purchased during that period, but the department shall continue to accept applications and determine eligibility under sub. (4) and shall indicate to applicants that the eligibility of program participants to purchase prescription drugs as specified in sub. (3), under the requirements of sub. (5), is conditioned on the availability of funding under s. 20.435 (4) (bv).
(8) The department shall, under methods promulgated by the department by rule, monitor compliance by pharmacies and pharmacists that are certified providers of medical assistance with the requirements of sub. (5) and shall annually report to the legislature under s. 13.172 (2) concerning the compliance. The report shall include information on any pharmacies or pharmacists that discontinue participation as certified providers of medical assistance and the reasons given for the discontinuance.
(9) (a) The department shall promulgate rules relating to prohibitions on fraud that are substantially similar to applicable provisions under s. 49.49 (1) (a).
(b) A person who is convicted of violating a rule promulgated by the department under par. (a) in connection with that person's furnishing of prescription drugs under this section may be fined not more than $25,000, or imprisoned for not more than 7 years and 6 months, or both.
(c) A person other than a person specified in par. (b) who is convicted of violating a rule promulgated by the department under par. (a) may be fined not more than $10,000, or imprisoned for not more than one year, or both.
