Amendment AA1-ASA1-SB55

SB55-ASA1-AA1,436,13 49.45 (2) (a) 11. Establish criteria for the certification of eligible providers of services under Title XIX of the social security act medical assistance and, except as provided in par. (b) 6m. and s. 49.48, and subject to par. (b) 7. and 8., certify such eligible providers who meet the criteria.

SB55-ASA1-AA1, s. 1750j Section 1750j. 49.45 (2) (a) 12. of the statutes is amended to read:

SB55-ASA1-AA1,437,4 49.45 (2) (a) 12. Decertify or suspend under this subdivision a provider from or restrict a provider's participation in the medical assistance program, if after giving reasonable notice and opportunity for hearing, the department finds that the provider has violated a federal statute or regulation or a state law statute or administrative rule and such violations are by law the violation is by statute, regulation, or rule grounds for decertification or suspension restriction. The department shall suspend the provider pending the hearing under this subdivision if the department includes in its decertification notice findings that the provider's continued participation in the medical assistance program pending hearing is likely to lead to the irretrievable loss of public funds and is unnecessary to provide adequate access to services to medical assistance recipients. As soon as practicable after the hearing, the department shall issue a written decision. No payment may be made under the medical assistance program with respect to any service or item furnished by the provider subsequent to decertification or during the period of suspension.

SB55-ASA1-AA1, s. 1750L Section 1750L. 49.45 (2) (b) 6m. of the statutes is created to read:

SB55-ASA1-AA1,437,9 49.45 (2) (b) 6m. Limit the number of providers of particular services that may be certified under par. (a) 11. or the amount of resources, including employees and equipment, that a certified provider may use to provide particular services to medical assistance recipients, if the department finds all of the following:

SB55-ASA1-AA1,437,12 a. That existing certified providers and resources provide services that are adequate in quality and amount to meet the need of medical assistance recipients for the particular services.

SB55-ASA1-AA1,437,14 b. That the potential for medical assistance fraud or abuse exists if additional providers are certified or additional resources are used by certified providers.

SB55-ASA1-AA1, s. 1750n Section 1750n. 49.45 (2) (b) 7. of the statutes is created to read:

SB55-ASA1-AA1,438,2 49.45 (2) (b) 7. Require, as a condition of certification under par. (a) 11., all providers of a specific service that is among those enumerated under s. 49.46 (2) or 49.47 (6) (a), as specified in this subdivision, to file with the department a surety bond issued by a surety company licensed to do business in this state. Providers subject to this subdivision provide those services specified under s. 49.46 (2) or 49.47 (6) (a) for which providers have demonstrated significant potential to violate s. 49.49 (1) (a), (2) (a) or (b), (3), (3m) (a), (3p), (4) (a), or (4m) (a), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13. The surety bond shall be payable to the department in an amount that the department determines is reasonable in view of amounts of former recoveries against providers of the specific service and the department's costs to pursue those recoveries. The department shall promulgate rules under this subdivision that specify all of the following:

SB55-ASA1-AA1,438,6 a. Services under medical assistance for which providers have demonstrated significant potential to violate s. 49.49 (1) (a), (2) (a) or (b), (3), (3m) (a), (3p), (4) (a), or (4m) (a), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13.

SB55-ASA1-AA1,438,7 b. The amount or amounts of the surety bonds.

SB55-ASA1-AA1,438,10 c. Terms of the surety bond, including amounts, if any, without interest to be refunded to the provider upon withdrawal or decertification from the medical assistance program.

SB55-ASA1-AA1, s. 1750p Section 1750p. 49.45 (2) (b) 8. of the statutes is created to read:

SB55-ASA1-AA1,438,16 49.45 (2) (b) 8. Require a person who takes over the operation, as defined in sub. (21) (ag), of a provider, to first obtain certification under par. (a) 11. for the operation of the provider, regardless of whether the person is currently certified. The department may withhold the certification required under this subdivision until any outstanding repayment under sub. (21) is made.

SB55-ASA1-AA1, s. 1750r Section 1750r. 49.45 (2) (b) 9. of the statutes is created to read:

SB55-ASA1-AA1,439,12 49.45 (2) (b) 9. After providing reasonable notice and opportunity for a hearing, charge an assessment to a provider that repeatedly has been subject to recoveries under par. (a) 10. a. because of the provider's failure to follow identical or similar billing procedures or to follow other identical or similar program requirements. The assessment shall be used to defray in part the costs of audits and investigations by the department under sub. (3) (g) and may not exceed $1,000 or 200% of the amount of any such repeated recovery made, whichever is greater. The provider shall pay the assessment to the department within 10 days after receipt of notice of the assessment or the final decision after administrative hearing, whichever is later. The department may recover any part of an assessment not timely paid by offsetting the assessment against any medical assistance payment owed to the provider and may refer any such unpaid assessments not collected in this manner to the attorney general, who may proceed with collection under this subdivision. Failure to timely pay in any manner an assessment charged under this subdivision, other than an assessment that is offset against any medical assistance payment owed to the provider, is grounds for decertification under subd. 12. A provider's payment of an assessment does not relieve the provider of any other legal liability incurred in connection with the recovery for which the assessment is charged, but is not evidence of violation of a statute or rule. The department shall credit all assessments received under this subdivision to the appropriation account under s. 20.435 (4) (iL).

SB55-ASA1-AA1, s. 1750t Section 1750t. 49.45 (3) (g) of the statutes is amended to read:

SB55-ASA1-AA1,440,10 49.45 (3) (g) The secretary may appoint authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of laws statutes, regulations, or rules applicable to Title XIX of the federal social security act or the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees appointed authorized by the secretary under this paragraph shall be issued, and shall possess at all times during which while they are performing their investigatory or audit functions under this section, identification, signed by the secretary which, that specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Pursuant to Under the request of a designated person and upon presentation of that the person's authorization, providers and medical assistance recipients shall accord such the person access to any provider personnel, records, books, recipient medical records, or documents or other information needed. Under the written request of a designated person and upon presentation of the person's authorization, providers and recipients shall accord the person access to any needed patient health care records of a recipient. Authorized employees shall have authority to may hold hearings, administer oaths, take testimony, and perform all other duties necessary to bring such the matter before the department for final adjudication and determination.

SB55-ASA1-AA1, s. 1750v Section 1750v. 49.45 (3) (h) 1. of the statutes is repealed.

SB55-ASA1-AA1, s. 1750x Section 1750x. 49.45 (3) (h) 2. of the statutes is repealed.

SB55-ASA1-AA1, s. 1750z Section 1750z. 49.45 (3) (h) 3. of the statutes is renumbered 49.45 (3) (h) and amended to read:

SB55-ASA1-AA1,440,24 49.45 (3) (h) The failure or refusal of a person to purge himself or herself of contempt found under s. 885.12 and perform the act as required by law shall constitute provider to accord department auditors or investigators access as required under par. (g) to any provider personnel, records, books, patient health care records of medical assistance recipients, or documents or other information requested constitutes grounds for decertification or suspension of that person the provider from participation in the medical assistance program and no. No payment may be made for services rendered by that person subsequent to the provider following decertification or, during the period of suspension, or during any period of provider failure or refusal to accord access as required under par. (g).".

SB55-ASA1-AA1,441,1 815. Page 621, line 12: after that line insert:

SB55-ASA1-AA1,441,2 " Section 1750w. 49.45 (2) (a) 24. of the statutes is created to read:

SB55-ASA1-AA1,441,12 49.45 (2) (a) 24. Promulgate rules that require that the written plan of care for persons receiving personal care services under medical assistance be reviewed by a registered nurse at least every 60 days. The rules shall provide that the written plan of care shall designate intervals for visits to the recipient's home by a registered nurse as part of the review of the plan of care. The designated intervals for visits shall be based on the individual recipient's needs, and each recipient shall be visited in his or her home by a registered nurse at least once in every 12-month period. The rules shall also provide that a visit to the recipient is also required if, in the course of the nurse's review of the plan of care, there is evidence that a change in the recipient's condition has occurred that may warrant a change in the plan of care.".

SB55-ASA1-AA1,441,13 816. Page 622, line 8: delete ", or (w)" and substitute ", (w), or (wm)".

SB55-ASA1-AA1,441,14 817. Page 622, line 14: delete lines 14 to 21.

SB55-ASA1-AA1,441,15 818. Page 624, line 21: delete "and (w)" and substitute ", (w), and (wm)".

SB55-ASA1-AA1,441,16 819. Page 628, line 21: after that line insert:

SB55-ASA1-AA1,441,17 " Section 1783g. 49.45 (18) (d) of the statutes is amended to read:

SB55-ASA1-AA1,441,23 49.45 (18) (d) A person is liable for a copayment of $1 for each prescription drug that bears only a generic name, as defined in s. 450.12 (1) (b), and is liable for a copayment of $2 for each prescription drug that does not bear only a generic name. 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 $5 per month for prescription drugs received.".

SB55-ASA1-AA1,441,24 820. Page 628, line 21: after that line insert:

SB55-ASA1-AA1,442,1 " Section 1786g. 49.45 (21) (title) of the statutes is amended to read:

SB55-ASA1-AA1,442,3 49.45 (21) (title) Transfer of business, liability for Taking over provider's operation; repayments required.

SB55-ASA1-AA1, s. 1786h Section 1786h. 49.45 (21) (a) of the statutes is renumbered 49.45 (21) (ar) and amended to read:

SB55-ASA1-AA1,442,14 49.45 (21) (ar) If any provider Before a person may take over the operation of a provider that is liable for repayment of improper or erroneous payments or overpayments under ss. 49.43 to 49.497 sells or otherwise transfers ownership of his or her business or all or substantially all of the assets of the business, the transferor and transferee are each liable for the repayment. Prior to final transfer, the transferee is responsible for contacting the department and ascertaining if the transferor, full repayment shall be made. Upon request, the department shall notify the provider or the person that intends to take over the operation of the provider as to whether the provider is liable under this paragraph.

SB55-ASA1-AA1, s. 1786i Section 1786i. 49.45 (21) (ag) of the statutes is created to read:

SB55-ASA1-AA1,442,18 49.45 (21) (ag) In this subsection, "take over the operation" means obtain, with respect to an aspect of a provider's business for which the provider has filed claims for medical assistance reimbursement, any of the following:

SB55-ASA1-AA1,442,20 1. Ownership of the provider's business or all or substantially all of the assets of the business.

SB55-ASA1-AA1,442,21 2. Majority control over decisions.

SB55-ASA1-AA1,442,22 3. The right to any profits or income.

SB55-ASA1-AA1,442,24 4. The right to contact and offer services to patients, clients, or residents served by the provider.

SB55-ASA1-AA1,443,3 5. An agreement that the provider will not compete with the person at all or with respect to a patient, client, resident, service, geographical area, or other part of the provider's business.

SB55-ASA1-AA1,443,5 6. The right to perform services that are substantially similar to services performed by the provider at the same location as those performed by the provider.

SB55-ASA1-AA1,443,7 7. The right to use any distinctive name or symbol by which the provider is known in connection with services to be provided by the person.

SB55-ASA1-AA1, s. 1786j Section 1786j. 49.45 (21) (b) of the statutes is amended to read:

SB55-ASA1-AA1,443,18 49.45 (21) (b) If a transfer occurs If, notwithstanding the prohibition under par. (ar), a person takes over the operation of a provider and the applicable amount under par. (a) (ar) has not been repaid, the department may, in addition to withholding certification as authorized under sub. (2) (b) 8., proceed against either the transferor or the transferee the provider or the person. Within 30 days after receiving the certified provider receives notice from the department, the transferor or the transferee shall pay the amount shall be repaid in full. Upon failure to comply If the amount is not repaid in full, the department may bring an action to compel payment. If a transferor fails to pay within 90 days after receiving notice from the department, the department, may proceed under sub. (2) (a) 12. , or may do both.".

SB55-ASA1-AA1,443,19 821. Page 630, line 20: after that line insert:

SB55-ASA1-AA1,443,20 " Section 1792g. 49.45 (49) of the statutes is created to read:

SB55-ASA1-AA1,444,2 49.45 (49) Prior authorization for legend drugs. If, after June 30, 2002, and before July 1, 2004, a manufacturer has in force a rebate agreement under s. 49.688 (7), the department may not during that period expand the prior authorization requirements for prescription drugs manufactured by the manufacturer for which coverage is provided under s. 49.46 (2) (b) 6. h. beyond those prior authorization requirements that are in effect on July 1, 2002.".

SB55-ASA1-AA1,444,3 822. Page 630, line 20: after that line insert:

SB55-ASA1-AA1,444,4 " Section 1792r. 49.45 (53) of the statutes is created to read:

SB55-ASA1-AA1,444,15 49.45 (53) Refund of medical relief and general relief. (a) If a service provider receives reimbursement under this section for a claim submitted by or on behalf of the service provider under the circumstance specified under s. 49.45 (2) (a) 2m. b., the service provider shall, as a condition of certification under sub. (2) (a) 11., refund to the county that initially reimbursed the services as general relief or as medical relief, any medical relief under a relief block grant or any general relief paid to the service provider for the medical assistance-reimbursable services rendered. The county shall separately identify this refund and remit to the department for deposit in the appropriation account under s. 20.435 (4) (ib) an amount that represents the state's contribution toward the original medical relief or general relief paid.

SB55-ASA1-AA1,444,21 (b) If the federal department of health and human services disallows payment to the state of federal financial participation for a claim submitted by or on behalf of a service provider under the circumstance specified under sub. (2) (a) 2m. b., the county shall remit to the department for deposit in the appropriation account under s. 20.435 (4) (ib) an amount that is equal to the amount of federal financial participation paid by the department to the service provider under par. (a).

SB55-ASA1-AA1,444,22 (c) This subsection does not apply after June 30, 2005.".

SB55-ASA1-AA1,444,23 823. Page 631, line 5: delete lines 5 to 17.

SB55-ASA1-AA1,445,2 824. Page 631, line 23: delete the material beginning with that line and ending with page 632, line 4.

SB55-ASA1-AA1,445,3 825. Page 632, line 10: delete lines 10 to 16.

SB55-ASA1-AA1,445,4 826. Page 633, line 13: delete lines 13 to 24.

SB55-ASA1-AA1,445,5 827. Page 634, line 8: delete lines 8 to 15.

SB55-ASA1-AA1,445,6 828. Page 637, line 6: after that line insert:

SB55-ASA1-AA1,445,7 " Section 1814L. 49.47 (4) (aq) of the statutes is created to read:

SB55-ASA1-AA1,445,12 49.47 (4) (aq) 1. Subject to subd. 2., an individual who does not meet the limitation on income under par. (c) is eligible for medical assistance if the individual's income does not exceed 100% of the federal poverty level, and the individual is 65 years of age or older or is blind or totally and permanently disabled, as defined under federal Title XVI.

SB55-ASA1-AA1,445,16 2. If a federal waiver is necessary to provide medical assistance to individuals specified in subd. 1., the department shall request a waiver from the secretary of the federal department of health and human services before providing medical assistance under this paragraph.".

SB55-ASA1-AA1,445,17 829. Page 637, line 13: after that line insert:

SB55-ASA1-AA1,445,18 " Section 1815cb. 49.47 (4) (b) 2m. b. of the statutes is amended to read:

SB55-ASA1-AA1,445,21 49.47 (4) (b) 2m. b. For persons who are eligible under par. (a) 3. or 4. or (aq), motor vehicles are exempt from consideration as an asset to the same extent as provided under 42 USC 1381 to 1385.

SB55-ASA1-AA1, s. 1815cc Section 1815cc. 49.47 (4) (b) 2r. of the statutes is amended to read:

SB55-ASA1-AA1,446,2 49.47 (4) (b) 2r. For a person who is eligible under par. (a) 3. or 4. or (aq), the value of any burial space or agreement representing the purchase of a burial space held for the purpose of providing a place for the burial of the person or any member of his or her immediate family.

SB55-ASA1-AA1, s. 1815cd Section 1815cd. 49.47 (4) (b) 2w. of the statutes is amended to read:

SB55-ASA1-AA1,446,6 49.47 (4) (b) 2w. For a person who is eligible under par. (a) 3. or 4. or (aq), life insurance with cash surrender values if the total face value of all life insurance policies is not more than $1,500.

SB55-ASA1-AA1, s. 1815ce Section 1815ce. 49.47 (4) (b) 3. of the statutes is amended to read:

SB55-ASA1-AA1,446,12 49.47 (4) (b) 3. For a person who is eligible under par. (a) 3. or 4. or (aq), funds set aside to meet the burial and related expenses of the person and his or her spouse in an amount not to exceed $1,500 each, minus the sum of the cash value of any life insurance excluded under subd. 2w. and the amount in any irrevocable burial trust under s. 445.125 (1) (a).

SB55-ASA1-AA1, s. 1815cf Section 1815cf. 49.47 (4) (c) 1. of the statutes is amended to read:

SB55-ASA1-AA1,446,25 49.47 (4) (c) 1. Except as provided in par. pars. (am) and (aq) and as limited by subd. 3., eligibility exists if income does not exceed 133 1/3% 133.33% of the maximum aid to families with dependent children payment under s. 49.19 (11) for the applicant's family size or the combined benefit amount available under supplemental security income under 42 USC 1381 to 1383c and state supplemental aid under s. 49.77 whichever is higher. In this subdivision "income" includes earned or unearned income that would be included in determining eligibility for the individual or family under s. 49.19 or 49.77, or for the aged, blind or disabled under 42 USC 1381 to 1385. "Income" does not include earned or unearned income which would be excluded in determining eligibility for the individual or family under s. 49.19 or 49.77, or for the aged, blind or disabled individual under 42 USC 1381 to 1385.".

SB55-ASA1-AA1,447,2 830. Page 637, line 14: delete the material beginning with that line and ending with page 638, line 16.

SB55-ASA1-AA1,447,3 831. Page 638, line 16: after that line insert:

SB55-ASA1-AA1,447,4 " Section 1815L. 49.47 (4) (c) 3. of the statutes is amended to read:

SB55-ASA1-AA1,447,8 49.47 (4) (c) 3. Except as provided in par. pars. (am) and (aq), no person is eligible for medical assistance under this section if the person's income exceeds the maximum income levels that the U.S. department of health and human services sets for federal financial participation under 42 USC 1396b (f).

SB55-ASA1-AA1, s. 1815p Section 1815p. 49.47 (4) (i) 2. (intro.) of the statutes is amended to read:

SB55-ASA1-AA1,447,12 49.47 (4) (i) 2. (intro.) Notwithstanding par. (b) 2r. and 3., a person who is described in par. (a) 3. or 4. or (aq) is not eligible for benefits under this section if any of the following criteria is met:".

SB55-ASA1-AA1,447,13 832. Page 642, line 20: after that line insert:

SB55-ASA1-AA1,447,14 " Section 1823r. 49.4981 of the statutes is created to read:

SB55-ASA1-AA1,447,20 49.4981 Comprehensive quality assessment pilot project. (1) If the department receives a waiver of federal medical assistance laws, as requested under 2001 Wisconsin Act .... (this act), section 9123 (19g), the department shall conduct a pilot project in the counties of Brown, Grant, Polk, and Waukesha under which nursing facilities shall apply to the department, under requirements specified by the department, to participate in the pilot project.

SB55-ASA1-AA1,448,10 (2) If participation for a nursing facility is approved by the department under subsection (1), and if the nursing facility contracts to receive a comprehensive quality assessment, under standards and principles of comprehensive assessments of the quality of care provided to residents of nursing facilities, the nursing facility shall provide to the department a copy of a report by the assessment provider of each such assessment that is conducted. Each report shall include any findings of violations of state statutes or rules by the nursing facility that are discovered in the course of performance of the assessment. The nursing facility shall provide information that the department requests concerning any violations noted. The department may use the assessment report and information provided by the nursing facility as evidence to which s. 50.04 (4) applies or upon which an applicable forfeiture under s. 49.498 (16) or 50.04 (5) may be assessed. Upon receipt of the assessment report, the department may, but is not required to, waive the requirement under s. 49.498 (13) for an annual survey of the nursing facility.".

SB55-ASA1-AA1,448,11 833. Page 642, line 20: after that line insert:

SB55-ASA1-AA1,448,12 " Section 1835h. 49.496 (3) (f) of the statutes is amended to read:

SB55-ASA1-AA1,448,15 49.496 (3) (f) The department may contract with or employ an attorney to probate estates to recover under this subsection the costs of care. Any such contract is subject to the requirements of s. 20.930 (2) to (5).".

SB55-ASA1-AA1,448,16 834. Page 644, line 14: after that line insert: