Wisconsin Legislature: 10,106

1. Increasing the cost effectiveness and efficiency of care and the care delivery system for Medical Assistance programs.

2. Limiting switching from private health insurance to Medical Assistance programs.

3. Ensuring the long-term viability and sustainability of Medical Assistance programs.

4. Advancing the accuracy and reliability of eligibility for Medical Assistance programs and claims determinations and payments.

5. Improving the health status of individuals who receive benefits under a Medical Assistance program.

6. Aligning Medical Assistance program benefit recipient and service provider incentives with health care outcomes.

7. Supporting responsibility and choice of medical assistance recipients.

(c) If the department determines, as a result of the study under par. (b), that revision of existing statutes or rules would be necessary to advance a purpose described in par. (b) 1. to 7., the department may promulgate rules that do any of the following related to Medical Assistance programs:

1. Require cost sharing from program benefit recipients up to the maximum allowed by federal law or a waiver of federal law.

2. Authorize providers to deny care or services if a program benefit recipient is unable to share costs, to the extent allowed by federal law or waiver.

3. Modify existing benefits or establish various benefit packages and offer different packages to different groups of recipients.

4. Revise provider reimbursement models for particular services.

5. Mandate that program benefit recipients enroll in managed care.

6. Restrict or eliminate presumptive eligibility.

7. To the extent permitted by federal law, impose restrictions on providing benefits to individuals who are not citizens of the United States.

8. Set standards for establishing and verifying eligibility requirements.

9. Develop standards and methodologies to assure accurate eligibility determinations and redetermine continuing eligibility.

10. Reduce income levels for purposes of determining eligibility to the extent allowed by federal law or waiver and subject to the limitations under par. (e) 2.

(e) 1. The department shall submit an amendment to the state Medical Assistance plan or request a waiver of federal laws related to medical assistance, if necessary, to the extent necessary to implement any rule promulgated under par. (c). If the federal department of health and human services does not allow the amendment or does not grant the waiver, the department may not put the rule into effect or implement the action described in the rule.

2. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to have in effect eligibility standards, methodologies, and procedures under the state Medical Assistance plan or waivers of federal laws related to medical assistance that are more restrictive than those in place on March 23, 2010. If the waiver request does not receive federal approval before December 31, 2011, the department shall reduce income levels on July 1, 2012, for the purposes of determining eligibility to 133 percent of the federal poverty line for adults who are not pregnant and not disabled, to the extent permitted under 42 USC 1396a (gg), if the department follows the procedures under 42 USC 1396a (gg) (3).

49.45 (3) (n) This subsection does not apply if the department promulgates a rule under sub. (2m) (c) 4., to the extent that the rule conflicts with this subsection.

49.45 (6m) (n) This subsection does not apply if the department promulgates a rule under sub. (2m) (c) 4., to the extent that the rule conflicts with this subsection.

49.45 (8) (b) Reimbursement Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), reimbursement under s. 20.435 (4) (b), (o), and (w) for home health services provided by a certified home health agency or independent nurse shall be made at the home health agency's or nurse's usual and customary fee per patient care visit, subject to a maximum allowable fee per patient care visit that is established under par. (c).

49.45 (8) (b) Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), reimbursement Reimbursement under s. 20.435 (4) (b), (o), and (w) for home health services provided by a certified home health agency or independent nurse shall be made at the home health agency's or nurse's usual and customary fee per patient care visit, subject to a maximum allowable fee per patient care visit that is established under par. (c).

49.45 (8) (c) The department shall establish a maximum statewide allowable fee per patient care visit, for each type of visit with respect to provider, that may be no greater than the cost per patient care visit, as determined by the department from cost reports of home health agencies, adjusted for costs related to case management, care coordination, travel, record keeping and supervision, unless otherwise provided by the department by rule promulgated under sub. (2m) (c).

49.45 (8r) Payment for certain obstetric and gynecological care. The Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), the rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in s. 36.60 (1) (cm), or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125% of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.

49.45 (8r) Payment for certain obstetric and gynecological care. Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), the The rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in s. 36.60 (1) (cm), or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125% of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.

49.45 (8v) Incentive-based pharmacy payment system. The department shall establish a system of payment to pharmacies for legend and over-the-counter drugs provided to recipients of medical assistance that has financial incentives for pharmacists who perform services that result in savings to the medical assistance program. Under this system, the department shall establish a schedule of fees that is designed to ensure that any incentive payments made are equal to or less than the documented savings unless otherwise provided by the department by rule promulgated under sub. (2m) (c). The department may discontinue the system established under this subsection if the department determines, after performance of a study, that payments to pharmacists under the system exceed the documented savings under the system.

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 Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), 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.

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. Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), no 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.

49.45 (18) (ag) (intro.) Except as provided in pars. (am), (b), and (c), and subject to par. (d), a recipient specified in par. (ac) shall pay all of the following, unless otherwise provided by the department by rule promulgated under sub. (2m) (c):

49.45 (18) (b) (intro.) The Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), the following services are not subject to recipient cost sharing under this subsection:

49.45 (18) (b) (intro.) Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), the The following services are not subject to recipient cost sharing under this subsection:

49.45 (18) (d) No person who designates a pharmacy or pharmacist as his or her sole provider of prescription drugs and who so uses that pharmacy or pharmacist is liable under this subsection for more than $12 per month for prescription drugs received, unless otherwise provided by the department by rule promulgated under sub. (2m) (c).

49.45 (23) (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. If the department promulgates a rule under sub. (2m) (c) 10., this paragraph does not apply to the extent that it conflicts with the rule.

49.45 (23) (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. Cost Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), cost sharing may include an annual enrollment fee, which may not exceed $75 per year. 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.

49.45 (23) (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. Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), cost Cost sharing may include an annual enrollment fee, which may not exceed $75 per year. 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.

49.45 (24g) (c) The department's proposal under par. (a) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or 2., and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than July 1, 2011. If the department promulgates a rule under sub. (2m) (c) 4., this paragraph does not apply to the extent that it conflicts with the rule.

49.45 (24r) (a) The department shall implement any waiver granted by the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide family planning, as defined in s. 253.07 (1) (a), under medical assistance to any woman between the ages of 15 and 44 whose family income does not exceed 200% of the poverty line for a family the size of the woman's family. If the department promulgates a rule under sub. (2m) (c) 10., this paragraph does not apply to the extent it conflicts with the rule.

49.45 (24r) (b) The department may request an amended waiver from the secretary to permit the department to conduct a demonstration project to provide family planning to any man between the ages of 15 and 44 whose family income does not exceed 200 percent of the poverty line for a family the size of the man's family. If the amended waiver is granted, the department may implement the waiver. If the department promulgates a rule under sub. (2m) (c) 10., this paragraph does not apply to the extent it conflicts with the rule.

49.45 (25g) (c) The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (b) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011. The increases in reimbursement rates and monthly per-patient care coordination fees that are not provided by the federal government shall be paid from the appropriation under. s. 20.435 (1) (am). If the department promulgates a rule under sub. (2m) (c) 4., this paragraph does not apply to the extent it conflicts with the rule.

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), unless otherwise provided by the department by rule promulgated under sub. (2m) (c).

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, unless otherwise provided by the department by rule promulgated under sub. (2m) (c), 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, unless otherwise provided by the department by rule promulgated under sub. (2m) (c), 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. 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.