2005 Wisconsin Act 25

25,1124g Section 1124g. 49.45 (3) (m) of the statutes is created to read:

49.45 (3) (m) Reimbursement for services provided by a health maintenance organization, as defined in s. 609.01 (2), with a contract under sub. (2) (b) 2. to provide health care to recipients of Medical Assistance or Badger Care, shall be made under capitation rates that are actuarially sound.

25,1125s Section 1125s. 49.45 (6m) (a) 6. of the statutes is created to read:

49.45 (6m) (a) 6. "Resource Utilization Groupings III" means a comparative resource utilization grouping that classifies each facility resident based on information obtained from performing, for the resident, a minimum data set assessment developed by the federal Centers for Medicare and Medicaid Services.

25,1128m Section 1128m. 49.45 (6m) (ag) 3p. of the statutes is created to read:

49.45 (6m) (ag) 3p. For all costs specified under par. (am) 1. bm., an acuity-based payment rate system to which all of the following applies:

a. The system shall incorporate acuity measurements under the most recent Resource Utilization Groupings III methodology to determine factors for case-mix adjustment.

b. Four times annually, for each facility resident who is a Medical Assistance recipient on March 31, June 30, September 30, or December 31, as applicable, the system shall determine the average case-mix index by use of the factors specified under subd. 3p. a.

c. The system shall incorporate payment adjustments for dementia, behavioral needs, or other complex medical conditions.

d. The system may include incentives for providing high quality of care.

e. The system shall identify the extent to which payment is made to facilities, under the system, for facilities' direct care nursing costs allowable under Medical Assistance.

25,1132f Section 1132f. 49.45 (6m) (m) of the statutes is created to read:

49.45 (6m) (m) The department may not use the criteria for functional eligibility specified in s. 46.286 (1) (a) to determine rates of payment to facilities under this subsection.

25,1133 Section 1133. 49.45 (6t) of the statutes, as affected by 2003 Wisconsin Act 318, is repealed.

25,1135c Section 1135c. 49.45 (6x) (title) of the statutes is amended to read:

49.45 (6x) (title) Funding for essential access city hospital hospitals .

25,1135d Section 1135d. 49.45 (6x) (a) of the statutes is amended to read:

49.45 (6x) (a) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w), the department shall distribute not more than $4,748,000 in each fiscal year, to provide funds to an essential access city hospital hospitals, except that the department may not allocate funds to an essential access city hospital to the extent that the allocation would exceed any limitation under 42 USC 1396b (i) (3).

25,1135e Section 1135e. 49.45 (6x) (b) of the statutes is amended to read:

49.45 (6x) (b) The department shall develop procedures for solicitation and review of requests for funds and a method to distribute the funds under par. (a) to an individual hospital hospitals that shall include establishment of criteria for the designation as an essential access city hospital. Beginning on July 1, 2007, the criteria established by the department may not include reference to criteria that were required to have been met during July 1, 1995, to June 30, 1996, but shall include the requirement that more than 30 percent of a hospital's total inpatient days are reimbursable under Medical Assistance. No hospital that qualifies for a Medical Assistance pediatric inpatient supplement is eligible for funds under this subsection.

25,1144p Section 1144p. 49.45 (18) (ag) 1. of the statutes is amended to read:

49.45 (18) (ag) 1. A copayment of $1 $3 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b).

25,1146j Section 1146j. 49.45 (27) of the statutes is amended to read:

49.45 (27) Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v), subject to s. 49.46 (2) (f).

25,1147 Section 1147. 49.45 (39) (b) 1. of the statutes is amended to read:

49.45 (39) (b) 1. `Payment for school medical services.' If a school district or a cooperative educational service agency elects to provide school medical services and meets all requirements under par. (c), the department shall reimburse the school district or the cooperative educational service agency for 60% of the federal share of allowable charges for the school medical services that it provides and, as specified in subd. 2., for allowable administrative costs. If the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing elects to provide school medical services and meets all requirements under par. (c), the department shall reimburse the department of public instruction for 60% of the federal share of allowable charges for the school medical services that the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing provides and, as specified in subd. 2., for allowable administrative costs. A school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, claims for common carrier transportation costs as a school medical service unless the department receives notice from the federal health care financing administration that, under a change in federal policy, the claims are not allowed. If the department receives the notice, a school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, unreimbursed claims for common carrier transportation costs incurred before the date of the change in federal policy. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. Except as provided in subd. 1m., all All other expenses for the school medical services provided by a school district or a cooperative educational service agency shall be paid for by the school district or the cooperative educational service agency with funds received from state or local taxes. The school district, the Wisconsin Center for the Blind and Visually Impaired, the Wisconsin Educational Services Program for the Deaf and Hard of Hearing, or the cooperative educational service agency shall comply with all requirements of the federal department of health and human services for receiving federal financial participation.

25,1148 Section 1148. 49.45 (39) (b) 1m. of the statutes is repealed.

25,1149 Section 1149. 49.45 (39) (b) 2. of the statutes is amended to read:

49.45 (39) (b) 2. `Payment for school medical services administrative costs.' The department shall reimburse a school district or a cooperative educational service agency specified under subds. subd. 1. and 1m. and shall reimburse the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing for 90% of the federal share of allowable administrative costs, using time studies, beginning in fiscal year 1999-2000. A school district or a cooperative educational service agency may submit, and the department of health and family services shall allow, claims for administrative costs incurred during the period that is up to 24 months before the date of the claim, if allowable under federal law.

25,1149f Section 1149f. 49.45 (42m) of the statutes is created to read:

49.45 (42m) Physical and occupational therapy. (a) If, in authorizing the provision of physical or occupational therapy services under s. 49.46 (2) (b) 6. b., the department authorizes a reduced duration of services from the duration that the provider specifies in the authorization request, the department shall substantiate the reduction that the department made in the duration of the services if the provider of the services requests any additional authorizations for the provision of physical or occupational therapy services to the same individual.

(b) The division of the department that is responsible for health care financing shall monitor compliance with the requirement under par. (a) in concert with representatives of the Wisconsin Physical Therapy Association and the Wisconsin Occupational Therapy Association.

25,1150 Section 1150. 49.46 (1) (a) 5. of the statutes is amended to read:

49.46 (1) (a) 5. Any child in an adoption assistance, foster care, kinship care, long-term kinship care or, treatment foster care, or subsidized guardianship placement under ch. 48 or 938, as determined by the department.

25,1153 Section 1153. 49.46 (1) (a) 14. of the statutes is amended to read:

49.46 (1) (a) 14. Any person who would meet the financial and other eligibility requirements for home or community-based services under s. 46.27 (11) or, 46.277, or 46.2785 but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3), if a waiver under s. 49.45 (38) is in effect or federal law permits federal financial participation for medical assistance coverage of the person and if funding is available for the person under s. 46.27 (11) or, 46.277, or 46.2785.

25,1154 Section 1154. 49.46 (1) (a) 15. of the statutes is amended to read:

49.46 (1) (a) 15. Any individual who is infected with tuberculosis and meets the income and resource eligibility requirements for the federal supplemental security Supplemental Security Income program under 42 USC 1381 to 1383d.

25,1157 Section 1157. 49.46 (2) (b) 8. of the statutes is amended to read:

49.46 (2) (b) 8. Home or community-based services, if provided under s. 46.27 (11), 46.275, 46.277 or, 46.278, or 46.2785, under the family care benefit if a waiver is in effect under s. 46.281 (1) (c), or under a waiver requested under 2001 Wisconsin Act 16, section 9123 (16rs), or 2003 Wisconsin Act 33, section 9124 (8c).

25,1157j Section 1157j. 49.46 (2) (f) of the statutes is amended to read:

49.46 (2) (f) Benefits under this subsection or s. 49.45 (27) may not include payment for gastric bypass surgery or gastric stapling surgery unless it is performed because of a medical emergency the procedure is required to be covered under federal medicaid law, as interpreted by the federal centers for medicare and medicaid services.

25,1158 Section 1158. 49.47 (4) (as) 1. of the statutes is amended to read:

49.47 (4) (as) 1. The person would meet the financial and other eligibility requirements for home or community-based services under s. 46.27 (11) or, 46.277, or 46.2785 or under the family care benefit if a waiver is in effect under s. 46.281 (1) (c) but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3).

25,1159 Section 1159. 49.47 (4) (as) 3. of the statutes is amended to read:

49.47 (4) (as) 3. Funding is available for the person under s. 46.27 (11) or, 46.277, or 46.2785 or under the family care benefit if a waiver is in effect under s. 46.281 (1) (c).

25,1167 Section 1167. 49.497 (title) of the statutes is amended to read:

49.497 (title) Recovery of incorrect medical assistance Medical Assistance or Badger Care payments.

25,1168 Section 1168. 49.497 (1) of the statutes is renumbered 49.497 (1) (a) (intro.) and amended to read:

49.497 (1) (a) (intro.) The department may recover any payment made incorrectly for benefits specified under s. 49.46, 49.468 or 49.47 provided under this subchapter or s. 49.665 if the incorrect payment results from any of the following:

1. A misstatement or omission of fact by a person supplying information in an application for benefits under s. 49.46, 49.468 or 49.47 this subchapter or s. 49.665.

2. The department may also recover if a medical assistance failure of a Medical Assistance or Badger Care recipient or any other person responsible for giving information on the recipient's behalf fails to report the receipt of income or assets in an amount that would have affected the recipient's eligibility for benefits.

(b) The department's right of recovery is against any medical assistance Medical Assistance or Badger Care recipient to whom or on whose behalf the incorrect payment was made. The extent of recovery is limited to the amount of the benefits incorrectly granted. The county department under s. 46.215 or 46.22 or the governing body of a federally recognized American Indian tribe administering medical assistance Medical Assistance or Badger Care shall begin recovery actions on behalf of the department according to rules promulgated by the department.

25,1169 Section 1169. 49.497 (1) (a) 3. of the statutes is created to read:

49.497 (1) (a) 3. The failure of a Medical Assistance or Badger Care recipient or any other person responsible for giving information on the recipient's behalf to report any change in the recipient's financial or nonfinancial situation or eligibility characteristics that would have affected the recipient's eligibility for benefits or the recipient's cost-sharing requirements.

25,1170 Section 1170. 49.497 (1m) of the statutes is created 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. 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 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.

(b) If any recipient, or parent of a minor recipient, named in an order to compel payment issued under par. (a) fails to pay the department any amount due under the terms of the order and no contested case to review the order is pending and the time for filing for a contested case review has expired, the department may present a certified copy of the order to the circuit court for any county. The sworn statement of the secretary shall be evidence of the incorrect payment. The circuit court shall, without notice, render judgment in accordance with the order. A judgment rendered under this paragraph shall have the same effect and shall be entered in the judgment and lien docket and may be enforced in the same manner as if the judgment had been rendered in an action tried and determined by the circuit court.

(c) The recovery procedure under this subsection is in addition to any other recovery procedure authorized by law.

25,1171 Section 1171. 49.497 (2) of the statutes is amended to read:

49.497 (2) A county or governing body of a federally recognized American Indian tribe may retain 15% of benefits distributed under s. 49.46, 49.468 or 49.47 provided under this subchapter or s. 49.665 that are recovered under sub. (1) this section due to the efforts of an employee or officer of the county or tribe.

25,1172 Section 1172. 49.497 (4) of the statutes is created to read:

49.497 (4) The department may appear for the state in any and all collection matters under this section, and may commence suit in the name of the department to recover an incorrect payment from the recipient to whom or on whose behalf it was made.

25,1173 Section 1173. 49.497 (5) of the statutes is created to read:

49.497 (5) The department may make an agreement with a recipient, or parent of a minor recipient, who is liable under sub. (1), providing for repayment of an incorrect payment at a specified rate or amount.

25,1174 Section 1174. 49.665 (1) (b) of the statutes is amended to read:

49.665 (1) (b) "Child" means a person who is born and who is under the age of 19.

25,1175 Section 1175. 49.665 (1) (g) of the statutes is created to read:

49.665 (1) (g) "Unborn child" means a person from the time of conception until it is born alive.

25,1176 Section 1176. 49.665 (2) (a) of the statutes is renumbered 49.665 (2) (a) 1. and amended to read:

49.665 (2) (a) 1. The department of health and family services shall request a waiver from the secretary of the federal department of health and human services to permit the department of health and family services to implement, beginning not later than July 1, 1998, or the effective date of the waiver, whichever is later, a health care program under this section. If a waiver that is consistent with all of the provisions of this section, excluding sub. (4) (a) 3m. and (ap) and provisions related to sub. (4) (ap), is granted and in effect, the department of health and family services shall implement the program under this section, subject to subd. 2. The department of health and family services may not implement the program under this section unless a waiver that is consistent with all of the provisions of this section, excluding sub. (4) (a) 3m. and (ap) and provisions related to sub. (4) (ap), is granted and in effect.

25,1177 Section 1177. 49.665 (2) (a) 2. of the statutes is created to read:

49.665 (2) (a) 2. The department may not implement sub. (4) (ap) or provisions related to the coverage under sub. (4) (ap) unless a state plan amendment authorizing the coverage under sub. (4) (ap) is approved by the federal department of health and human services.

25,1178 Section 1178. 49.665 (3) of the statutes is amended to read:

49.665 (3) Administration. The Subject to sub. (2) (a) 2., the department shall administer a program to provide the health services and benefits described in s. 49.46 (2) to persons that meet the eligibility requirements specified in sub. (4). The department shall promulgate rules setting forth the application procedures and appeal and grievance procedures. The department may promulgate rules limiting access to the program under this section to defined enrollment periods. The department may also promulgate rules establishing a method by which the department may purchase family coverage offered by the employer of a member of an eligible family or by of a member of a an eligible child's household, or family or individual coverage offered by the employer of an eligible unborn child's mother or her spouse, under circumstances in which the department determines that purchasing that coverage would not be more costly than providing the coverage under this section.

25,1179 Section 1179. 49.665 (4) (ap) of the statutes is created to read:

49.665 (4) (ap) An unborn child whose mother is not eligible for health care coverage under par. (a) or (am) or for medical assistance under s. 49.46 or 49.47, except that she may be eligible for benefits under s. 49.45 (27), is eligible for health care coverage under this section, which shall be limited to coverage for prenatal care, if all of the following requirements are met:

1. The income of the unborn child's mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 185 percent of the poverty line, except as provided in par. (at) and except that, if an unborn child is already receiving health care coverage under this section, the applicable specified person or persons may have an income that does not exceed 200 percent of the poverty line. The department shall establish by rule the criteria to be used to determine income.

2. Each of the following applicable persons who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings:

a. The unborn child's mother.

b. The spouse of the unborn child's mother.

c. Members of the unborn child's mother's family.

3. The unborn child's mother provides medical verification of her pregnancy, in the manner specified by the department.

4. The unborn child and the mother of the unborn child meet all other requirements established by the department by rule except for any of the following:

a. The mother is not a U.S. citizen or an alien qualifying for medicaid under 8 USC 1612.

b. The mother is an inmate of a public institution.

c. The mother does not provide a social security number, but only if subd. 4. a. applies.

25,1180 Section 1180. 49.665 (4) (at) 3. of the statutes is amended to read:

49.665 (4) (at) 3. The department may not adjust the maximum income level of 200% of the poverty line for persons already receiving health care coverage under this section or for applicable persons specified in par. (ap) 1. with respect to an unborn child already receiving health care coverage under this section.