49.45 (3) (b) 1. The contractor, if any, administering benefits or providing prepaid health care under s. 49.46, 49.465, 49.468 or, 49.47, or 49.471 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in sub. (2) (a) 4., but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
20,1520
Section
1520. 49.45 (3) (b) 2. of the statutes is amended to read:
49.45 (3) (b) 2. The contractor, if any, insuring benefits under s. 49.46, 49.465, 49.468 or, 49.47, or 49.471 shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the persons eligible to receive them and for its services as insurer.
20,1521
Section
1521. 49.45 (3) (dm) of the statutes is amended to read:
49.45
(3) (dm) After distribution of computer software has been made under
1993 Wisconsin Act 16, section
9126 (13h), no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under s. 49.46
or, 49.47
, or 49.471 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under
42 USC 1395.
20,1522
Section
1522. 49.45 (3) (f) 2. of the statutes is amended to read:
49.45 (3) (f) 2. The department may deny any provider claim for reimbursement which cannot be verified under subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in s. 49.46 (2) or 49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
20,1523
Section
1523. 49.45 (3) (L) 2. of the statutes is amended to read:
49.45
(3) (L) 2. The department may not pay a provider for a designated health service that is authorized under this section or s. 49.46
or, 49.47
, or 49.471, that is provided as the result of a referral made to the provider by a physician and that, under
42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of
42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under
42 USC 1395nn.
20,1524
Section
1524. 49.45 (3) (m) of the statutes is amended to read:
49.45 (3) (m) To be certified under sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in s. 340.01 (23g), that satisfies the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under s. 49.46 (2) (b) 3. or 49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.
20,1526
Section
1526. 49.45 (6c) (d) 1. of the statutes is amended to read:
49.45 (6c) (d) 1. No payment may be made under sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46 or, 49.47, or 49.471, who has developmental disability or mental illness and for whom under par. (b) or (c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.
20,1527
Section
1527. 49.45 (6c) (d) 2. of the statutes is amended to read:
49.45 (6c) (d) 2. Payment may be made under sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46 or, 49.47
, or 49.471 and who has developmental disability or mental illness and is determined under par. (b) or (c) to need facility care, regardless of whether it is determined under par. (b) or (c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.
20,1530h
Section 1530h. 49.45 (6m) (ar) 1. a. of the statutes is amended to read:
49.45
(6m) (ar) 1. a. The department shall establish standards for payment of allowable direct care costs under par. (am) 1. bm., for facilities that do not primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state and separate standards for payment of allowable direct care costs, for facilities that primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state. The standards shall be adjusted by the department for regional labor cost variations. The department shall treat as a single labor region the counties of Dane, Iowa, Columbia,
and Sauk
, and Rock and shall adjust payment so that the direct care cost targets of facilities in Dane, Iowa, Columbia, and Sauk counties are not reduced as a result of including facilities in Rock County in this labor region. For facilities in Douglas, Pierce, and St. Croix counties, the department shall perform the adjustment by use of the wage index that is used by the federal department of health and human services for hospital reimbursement under
42 USC 1395 to
1395ggg.
20,1532
Section
1532
. 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 (4) (bt) or (7) (b) or 20.445 (3) 20.437 (2) (dz), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.435 (4) (bt) or (7) (b), or the department shall direct the department of workforce development children and families to reduce allocations of funds to counties or Wisconsin works Works agencies in the amount of the disallowance from the appropriation account under s. 20.445 (3) 20.437 (2) (dz) or direct the department of corrections to reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.410 (3) (cd), in accordance with s. 16.544 to the extent applicable.
20,1533
Section
1533. 49.45 (6m) (m) of the statutes is created to read:
49.45 (6m) (m) To hold a bed in a facility, the department may pay the full payment rate under this subsection for up to 30 days for services provided to a person during the pendency of an undue hardship determination, as provided in s. 49.453 (8) (b) 3.
20,1538
Section
1538
. 49.45 (6z) (a) (intro.) of the statutes is amended to read:
49.45
(6z) (a) (intro.) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w), the department
shall may distribute funding in each fiscal year to supplement payment for services to hospitals that enter into
a contract under s. 49.02 (2) to provide health care services funded by a relief block grant under this chapter indigent care agreements, in accordance with the approved state plan for services under 42 USC 1396a, with relief agencies that administer the medical relief block grant under this chapter, if the department determines that the hospitals serve a disproportionate number of low-income patients with special needs. If no medical relief block grant under this chapter is awarded or if the allocation of funds to such hospitals would exceed any limitation under
42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into
a contract under s. 49.02 (2) indigent care agreements. The department may not distribute funds under this subsection to the extent that the distribution would do any of the following:
20,1539
Section
1539. 49.45 (8) (a) 4. of the statutes is amended to read:
49.45 (8) (a) 4. "Patient care visit" means a personal contact with a patient in a patient's home that is made by a registered nurse, licensed practical nurse, home health aide, physical therapist, occupational therapist, or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under s. 49.46 or, 49.47, or 49.471. "Patient care visit" does not include time spent by a nurse, therapist, or home health aide on case management, care coordination, travel, record keeping, or supervision that is related to the patient care visit.
20,1541
Section
1541. 49.45 (9) of the statutes is amended to read:
49.45 (9) Free choice. Any person eligible for medical assistance under ss. s. 49.46, 49.468 and, 49.47, or 49.471 may use the physician, chiropractor, dentist, pharmacist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist or dentist may be required to practice exclusively in the medical assistance program.
20,1542
Section
1542. 49.45 (18) (ac) of the statutes is amended to read:
49.45
(18) (ac) Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47
, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under
42 CFR 447.53 to
447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.
20,1543
Section
1543. 49.45 (18) (am) of the statutes is amended to read:
49.45 (18) (am) No person is liable under this subsection for services provided through prepayment contracts. This paragraph does not apply to a person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.
20,1546
Section
1546. 49.45 (23) of the statutes is created to read:
49.45
(23) Assistance for childless adults demonstration project. (a) The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide health care coverage for basic primary and preventive care to adults who are under the age of 65, who have family incomes not to exceed 200 percent of the poverty line, and who are not otherwise eligible for medical assistance under this subchapter, the Badger Care health care program under s. 49.665, or Medicare under
42 USC 1395 et seq.
(b) If the waiver is granted and in effect, the department may promulgate rules defining the health care benefit plan, including more specific eligibility requirements and cost-sharing requirements. Notwithstanding s. 227.24 (3), the plan details under this subsection may be promulgated as an emergency rule under s. 227.24 without a finding of emergency. If the waiver is granted and in effect, the demonstration project under this subsection shall begin on January 1, 2009, or on the effective date of the waiver, whichever is later.
20,1547
Section
1547. 49.45 (24g) of the statutes is repealed.
20,1549m
Section 1549m. 49.45 (24r) of the statutes is amended to read:
49.45 (24r) Family planning demonstration project. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide family planning services, as defined in s. 253.07 (1) (b) (a), under medical assistance to any woman between the ages of 15 and 44 whose family income does not exceed 185% 200% of the poverty line for a family the size of the woman's family. If the waiver is granted and in effect, the The department shall implement the any waiver no later than July 1, 1998, or on the effective date of the waiver, whichever is later granted.
20,1550
Section
1550. 49.45 (29) of the statutes is amended to read:
49.45 (29) Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46 and, 49.47, and 49.471.
20,1551c
Section 1551c. 49.45 (31) of the statutes is repealed and recreated to read:
49.45 (31) Long-Term Care Partnership Program. (a) The department shall submit to the federal department of health and human services, not later than 3 months after the effective date of this paragraph .... [revisor inserts date], an amendment to the state medical assistance plan that establishes in this state a Long-Term Care Partnership Program, as described in this subsection, and shall implement the program if the amendment to the state plan is approved. Under the program, the department shall exclude an amount equal to the amount of benefits that an individual receives under a qualifying long-term care insurance policy, as described in par. (b), when determining any of the following:
1. The individual's resources for purposes of determining the individual's eligibility for medical assistance.
2. The amount to be recovered from the individual's estate if the individual receives medical assistance.
(b) To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:
1. The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.
2. The policy meets the definition of a qualified long-term care insurance policy under
26 USC 7702B (b).
3. The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in
42 USC 1396p (b) (5).
4. The policy includes the applicable inflation protection specified in
42 USC 1396p (b) (1) (C) (iii) (IV).
5. The commissioner of insurance certifies to the department that the policy meets the criteria under subds. 2. to 4.
(c) 1. The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.
2. The training program approved under this paragraph shall include initial training that is not less than 8 hours long and ongoing training sessions that are not less than 4 hours long per session. Individuals who sell long-term care insurance policies shall be required to attend an ongoing training session every 24 months after the initial training. The commissioner may approve the initial and ongoing training sessions for continuing education requirements under s. 628.04 (3).
3. The training under this paragraph shall cover at a minimum long-term care insurance, long-term care services, qualified partnerships, and the relationship between qualified partnerships and other public and private coverage of long-term care costs.
(d) An insurer that issues a long-term care insurance policy described in par. (b) shall be required to submit reports to the secretary of the federal department of health and human services, in accordance with regulations developed by the secretary, that include notice of when benefits are paid under the policy, the amount of the benefits, notice of the termination of the policy, and any other information required by the secretary.
20,1552
Section
1552. 49.45 (35) of the statutes is repealed.
20,1553
Section
1553. 49.45 (40) of the statutes is amended to read:
49.45 (40) Periodic record matches. If the department contracts with the department of workforce development children and families under s. 49.197 (5), the department shall cooperate with the department of workforce development children and families in matching records of medical assistance recipients under s. 49.32 (7).
20,1554
Section
1554. 49.45 (42m) (a) of the statutes is amended to read:
49.45 (42m) (a) If, in authorizing the provision of physical or occupational therapy services under s. 49.46 (2) (b) 6. b. or 49.471 (11) (i), 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.
20,1554m
Section 1554m. 49.45 (44m) of the statutes is created to read:
49.45 (44m) Extension of parent eligibility when child dies. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to extend the eligibility of a parent, for up to 90 days, under the Medical Assistance program under this subchapter or the Badger Care health care program under s. 49.665 if the parent's child dies while both the parent and the child are covered under the Medical Assistance program or the Badger Care health care program and the parent would lose eligibility solely due to the death of the child. The department shall implement any waiver that is granted.
20,1555
Section
1555. 49.45 (48) of the statutes is amended to read:
49.45 (48) Payment of medicare part B outpatient hospital services coinsurances. The department shall include in the state plan for medical assistance a methodology for payment of the medicare part B outpatient hospital services coinsurance amounts that are authorized under ss. 49.46 (2) (c) 2., 4., and 5m., 49.468 (1) (b), and 49.47 (6) (a) 6. b., d., and f., and 49.471 (6) (j) 1.
20,1556
Section
1556. 49.45 (49m) (c) 1. of the statutes is amended to read:
49.45 (49m) (c) 1. A list of the prescription drugs that are included as a benefit under s. ss. 49.46 (2) (b) 6. h. and 49.471 (11) (a) that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.
20,1558
Section
1558. 49.45 (53) of the statutes is amended to read:
49.45 (53) Payments for certain services. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under s. ss. 49.46 (2) (a) 4. d. and (b) 6. j. and m. and 49.471 (11) (f).
20,1559e
Section 1559e. 49.45 (55) of the statutes is created to read:
49.45
(55) Health Opportunity Accounts Demonstration Program. The department shall request from the federal Centers for Medicare and Medicaid Services approval to participate in a demonstration program under
42 USC 1396u-8, under which Badger Care recipients may voluntarily enroll to contribute to health opportunity accounts and receive certain alternative benefits under medical assistance. If the Centers for Medicare and Medicaid Services approve the department's request, the department shall submit a proposed plan for implementation of the demonstration program to the joint committee on finance. The department may not implement the plan until it is approved by the committee, as submitted or as modified.
20,1559g
Section 1559g. 49.45 (56) of the statutes is created to read:
49.45
(56) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57), the department shall develop and implement, for Medical Assistance recipients, disease management programs
that are similar to that developed and followed by the Marshfield Clinic in this state under the Physician Group Practice Demonstration Program authorized under 42 USC 1315 (e) and (f) . These programs shall have at least the following characteristics:
(a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
(b) Educating health care providers on health care process improvement by developing best practice models.
(c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
(d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
(e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
20,1559h
Section 1559h. 49.45 (57) of the statutes is created to read:
49.45 (57) Physical health risk assessment. The department shall encourage each individual who is determined on or after the effective date of this subsection .... [revisor inserts date], to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.
20,1560
Section
1560. 49.453 (1) (a) of the statutes is amended to read:
49.453
(1) (a) "Assets" has the meaning given in
42 USC 1396p (e) (h) (1).
20,1561
Section
1561. 49.453 (1) (ar) of the statutes is created to read:
49.453 (1) (ar) "Community spouse" means the spouse of either the institutionalized person or the noninstitutionalized person.
20,1562
Section
1562. 49.453 (1) (d) of the statutes is amended to read:
49.453
(1) (d) "Income" has the meaning given in
42 USC 1396p (e) (h) (2).
20,1563
Section
1563. 49.453 (1) (e) of the statutes is amended to read:
49.453
(1) (e) "Institutionalized individual" has the meaning given in
42 USC 1396p (e) (h) (3).
20,1564
Section
1564. 49.453 (1) (f) (intro.) of the statutes is amended to read:
49.453 (1) (f) (intro.) "Look-back date" means
for a covered individual, either of the following:
1m. For transfers made before February 8, 2006, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under s. 49.454 (2) (c) or (3) (b) the date that is 60 months before:
20,1565
Section
1565. 49.453 (1) (f) 1. of the statutes is renumbered 49.453 (1) (f) 1m. a.
