Amendment SSA1-SB44

SB44-SSA1,542,3 (f) During the first meeting of the prescription drug prior authorization and therapeutics committee in each calendar year, the committee shall elect a member to serve as the chairperson of the committee for a one-year term. The committee shall meet at least once annually and on the call of the chairperson. A majority of the committee constitutes a quorum to do business. Recommendations of the committee shall be determined by majority vote.

SB44-SSA1,542,7 (h) The department shall consider all relevant recommendations of the prescription drug prior authorization and therapeutics committee before requiring prior authorization for a prescription drug under the Medical Assistance program or under s. 49.665 or 49.668.

SB44-SSA1,542,13 (i) By January 1 annually, the department shall submit a report to the governor, the members of the joint committee on finance, and the appropriate standing committees of the legislature under s. 13.172 (3), on any changes that the department made in the previous 12 months to department policies related to prior authorization for prescription drugs under the Medical Assistance program or the program under s. 49.665 or 49.668, and shall include all of the following in the report:

SB44-SSA1,542,15 1. The name and therapeutic class for each prescription drug for which the department changed prior authorization policies.

SB44-SSA1,542,17 2. The criteria for approving a prior authorization request for any prescription drug identified under subd. 1.

SB44-SSA1,542,21 3. Identification of any differences between the policies adopted by the department and relevant recommendations of the prescription drug prior authorization and therapeutics committee and, if applicable, the clinical and scientific reasons for diverging from the committee's recommendations.

SB44-SSA1, s. 1393 Section 1393. 49.45 (49m) of the statutes is created to read:

SB44-SSA1,542,24 49.45 (49m) Prescription drug cost controls; purchasing agreements. (a) In this section:

SB44-SSA1,542,25 1. "Brand name" has the meaning given in s. 450.12 (1) (a).

SB44-SSA1,543,1 2. "Generic name" has the meaning given in s. 450.12 (1) (b).

SB44-SSA1,543,2 3. "Prescription drug" has the meaning given in s. 450.01 (20).

SB44-SSA1,543,6 (b) The department may enter into a multi-state purchasing agreement with another state or a purchasing agreement with a purchaser of prescription drugs if the other state or purchaser agrees to participate in one or more of the activities specified in par. (c) 1. to 4.

SB44-SSA1,543,9 (c) The department may design and implement a program to reduce the cost of prescription drugs and to maintain high quality in prescription drug therapies, which shall include all of the following:

SB44-SSA1,543,12 1. A list of the prescription drugs that are included as a benefit under s. 49.46 (2) (b) 6. h. that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.

SB44-SSA1,543,18 2. Establishing supplemental rebates under agreements with prescription drug manufacturers for prescription drugs provided to recipients under Medical Assistance and Badger Care and to eligible persons under s. 49.688 and, if it is possible to implement the program without adversely affecting supplemental rebates for Medical Assistance, Badger Care, and prescription drug assistance under s. 49.688, to beneficiaries of participants under par. (b).

SB44-SSA1,543,19 3. Utilization management and fraud and abuse controls.

SB44-SSA1,543,21 4. Any other activity to reduce the cost of or expenditures for prescription drugs and maintain high quality in prescription drug therapies.

SB44-SSA1,543,24 (cg) The department shall consider all relevant recommendations of the prescription drug prior authorization and therapeutics committee before including a prescription drug on, or excluding a prescription drug from, a list under par. (c) 1.

SB44-SSA1,544,3 (cr) 1. Except as provided in subd. 2., the department may not require prior authorization for a prescription drug under s. 49.46 (2) (b) 6. h. that is prescribed to treat a mental illness.

SB44-SSA1,544,5 2. The department may require prior authorization for a selective serotonin reuptake inhibitor that is first prescribed for a person on or after March 15, 2004.

SB44-SSA1,544,7 (d) The department may enter into a contract with an entity to perform any of the duties and exercise any of the powers of the department under this subsection.

SB44-SSA1, s. 1393c Section 1393c. 49.45 (51) of the statutes is created to read:

SB44-SSA1,544,16 49.45 (51) Medical care transportation services. (a) By November 1 annually, the department shall provide to the department of revenue information concerning the estimated amounts of supplements payable from the appropriation under s. 20.435 (4) (b) to specific local governmental units for the provision of transportation for medical care, as specified under s. 49.46 (2) (b) 3., during the fiscal year. Beginning November 1, 2004, the information that the department provides under this paragraph shall include any adjustments necessary to reflect actual claims submitted by service providers in the previous fiscal year.

SB44-SSA1,544,19 (b) On the date that is the 3rd Monday in November, the department shall annually pay to specific local governmental units the estimated net amounts specified in par. (a).

SB44-SSA1, s. 1401 Section 1401. 49.46 (2) (a) 4. c. of the statutes is amended to read:

SB44-SSA1,544,22 49.46 (2) (a) 4. c. Skilled nursing home services other than in an institution for mental diseases, except as limited under s. 49.45 (6c) and (30m) (b) and (c).

SB44-SSA1, s. 1402 Section 1402. 49.46 (2) (b) 6. a. of the statutes is amended to read:

SB44-SSA1,544,25 49.46 (2) (b) 6. a. Intermediate care facility services other than in an institution for mental diseases, except as limited under s. 49.45 (30m) (b) and (c).

SB44-SSA1, s. 1403d Section 1403d. 49.46 (2) (b) 8. of the statutes is amended to read:

SB44-SSA1,545,5 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, 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 .... (this act), section 9124 (8c).

SB44-SSA1, s. 1404 Section 1404. 49.472 (6) (a) of the statutes is amended to read:

SB44-SSA1,545,12 49.472 (6) (a) Notwithstanding sub. (4) (a) 3., from the appropriation account under s. 20.435 (4) (b), (gp), 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.

SB44-SSA1, s. 1405 Section 1405. 49.472 (6) (b) of the statutes is amended to read:

SB44-SSA1,545,17 49.472 (6) (b) If federal financial participation is available, from the appropriation account under s. 20.435 (4) (b), (gp), 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).

SB44-SSA1, s. 1406 Section 1406. 49.473 (title) of the statutes is amended to read:

SB44-SSA1,545,20 49.473 (title) Medical assistance; women diagnosed with breast or cervical cancer or precancerous conditions.

SB44-SSA1, s. 1407 Section 1407. 49.473 (2) (c) of the statutes is amended to read:

SB44-SSA1,545,24 49.473 (2) (c) The woman is not eligible for health care coverage that qualifies as creditable coverage in 42 USC 300gg (c), excluding the coverage specified in 42 USC 300gg (c) (1) (F).

SB44-SSA1, s. 1408 Section 1408. 49.473 (2) (e) of the statutes is amended to read:

SB44-SSA1,546,2 49.473 (2) (e) The woman requires treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix.

SB44-SSA1, s. 1409 Section 1409. 49.473 (5) of the statutes is amended to read:

SB44-SSA1,546,8 49.473 (5) The department shall audit and pay, from the appropriation accounts under s. 20.435 (4) (b), (gp), 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).

SB44-SSA1, s. 1410 Section 1410. 49.473 (6) (b) of the statutes is amended to read:

SB44-SSA1,546,13 49.473 (6) (b) Inform the woman at the of time of 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.

SB44-SSA1, s. 1412 Section 1412. 49.496 (4) of the statutes is amended to read:

SB44-SSA1,547,4 49.496 (4) Administration. The department may require a county department under s. 46.215, 46.22, or 46.23 or the governing body of a federally recognized American Indian tribe administering medical assistance to gather and provide the department with information needed to recover medical assistance under this section. The department shall pay to a county department or tribal governing body an amount equal to 5% of the recovery collected by the department relating to a beneficiary for whom the county department or tribal governing body made the last determination of medical assistance eligibility. A county department or tribal governing body may use funds received under this subsection only to pay costs incurred under this subsection and, if any amount remains, to pay for improvements to functions required under s. 49.33 49.78 (2). The department may withhold payments under this subsection for failure to comply with the department's requirements under this subsection. The department shall treat payments made under this subsection as costs of administration of the medical assistance Medical Assistance program.

SB44-SSA1, s. 1413 Section 1413. 49.498 (16) (g) of the statutes is amended to read:

SB44-SSA1,547,14 49.498 (16) (g) All forfeitures, penalty assessments , and interest, if any, shall be paid to the department within 10 days of receipt of notice of assessment or, if the forfeiture, penalty assessment, and interest, if any, are contested under par. (f), within 10 days of receipt of the final decision after exhaustion of administrative review, unless the final decision is appealed and the order is stayed by court order under sub. (19) (b). The department shall remit all forfeitures paid to the state treasurer secretary of administration for deposit in the school fund. The department shall deposit all penalty assessments and interest in the appropriation under s. 20.435 (6) (g).

SB44-SSA1, s. 1414 Section 1414. 49.665 (2) (title) of the statutes is amended to read:

SB44-SSA1,547,16 49.665 (2) (title) Waiver Waivers.

SB44-SSA1, s. 1415 Section 1415. 49.665 (2) of the statutes is renumbered 49.665 (2) (a) and amended to read:

SB44-SSA1,548,3 49.665 (2) (a) 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., is granted and in effect, the department of health and family services shall implement the program under this section. 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., is granted and in effect.

SB44-SSA1, s. 1416 Section 1416. 49.665 (2) (b) of the statutes is created to read:

SB44-SSA1,548,14 49.665 (2) (b) If the department of health and family services determines that it needs a waiver to require the verification specified in sub. (4) (a) 3m., the department shall request a waiver from the secretary of the federal department of health and human services and may not implement the verification requirement under sub. (4) (a) 3m. unless the waiver is granted. If a waiver is required and is granted, the department of health and family services may implement the verification requirement under sub. (4) (a) 3m. as appropriate. If a waiver is not required, the department of health and family services may require the verification specified in sub. (4) (a) 3m. for eligibility determinations and annual review eligibility determinations made by the department, beginning on January 1, 2004.

SB44-SSA1, s. 1417 Section 1417. 49.665 (4) (a) 3m. of the statutes is created to read:

SB44-SSA1,548,21 49.665 (4) (a) 3m. Each member of the family who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings, of whether the employer provides health care coverage for which the family is eligible, and of the amount that the employer pays, if any, towards the cost of the health care coverage, excluding any deductibles or copayments required under the coverage.

SB44-SSA1, s. 1419 Section 1419. 49.665 (5) (a) of the statutes is renumbered 49.665 (5) (ag) and amended to read:

SB44-SSA1,549,19 49.665 (5) (ag) Except as provided in pars. (am), (b), and (bm), a family, or child who does not reside with his or her parent, who receives health care coverage under this section shall pay a percentage of the cost of that coverage in accordance with a schedule established by the department by rule. If the schedule established by the department requires a family, or child who does not reside with his or her parent, to contribute more than 3% of the family's or child's income towards the cost of the health care coverage provided under this section, the department shall submit the schedule to the joint committee on finance for review and approval of the schedule. If the cochairpersons of the joint committee on finance do not notify the department within 14 working days after the date of the department's submittal of the schedule that the committee has scheduled a meeting to review the schedule, the department may implement the schedule. If, within 14 days after the date of the department's submittal of the schedule, the cochairpersons of the committee notify the department that the committee has scheduled a meeting to review the schedule, the department may not require a family, or child who does not reside with his or her parent, to contribute more than 3% of the family's or child's income unless the joint committee on finance approves the schedule. The joint committee on finance may not approve and the department may not implement a schedule that requires a family or child to contribute, including the amounts required under par. (am), more than 3.5% of the family's or child's income towards the cost of the health care coverage provided under this section.

SB44-SSA1, s. 1420 Section 1420. 49.665 (5) (ac) of the statutes is created to read:

SB44-SSA1,549,23 49.665 (5) (ac) In this subsection, "cost" means total cost-sharing charges, including premiums, copayments, coinsurance, deductibles, enrollment fees, and any other cost-sharing charges.

SB44-SSA1, s. 1421 Section 1421. 49.665 (5) (ag) of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB44-SSA1,550,21 49.665 (5) (ag) Except as provided in pars. (am), (b), and (bm), a family, or child who does not reside with his or her parent, who receives health care coverage under this section shall pay a percentage of the cost of that coverage in accordance with a schedule established by the department by rule. If the schedule established by the department requires a family, or child who does not reside with his or her parent, to contribute more than 3% of the family's or child's income towards the cost of the health care coverage provided under this section, the department shall submit the schedule to the joint committee on finance for review and approval of the schedule. If the cochairpersons of the joint committee on finance do not notify the department within 14 working days after the date of the department's submittal of the schedule that the committee has scheduled a meeting to review the schedule, the department may implement the schedule. If, within 14 days after the date of the department's submittal of the schedule, the cochairpersons of the committee notify the department that the committee has scheduled a meeting to review the schedule, the department may not require a family, or child who does not reside with his or her parent, to contribute more than 3% of the family's or child's income unless the joint committee on finance approves the schedule. The joint committee on finance may not approve and the The department may not establish or implement a schedule that requires a family or child to contribute, including the amounts required under par. (am), more than 3.5% 5% of the family's or child's income towards the cost of the health care coverage provided under this section.

SB44-SSA1, s. 1422 Section 1422. 49.665 (5) (am) of the statutes is created to read:

SB44-SSA1,550,25 49.665 (5) (am) Except as provided in pars. (b) and (bm), a child or family member who receives health care coverage under this section shall pay the following cost-sharing amounts:

SB44-SSA1,551,2 1. A copayment of $1 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b).

SB44-SSA1,551,4 2. A copayment of $3 for each prescription of a drug that bears a brand name, as defined in s. 450.12 (1) (a).

SB44-SSA1, s. 1423 Section 1423. 49.68 (3) (a) of the statutes is amended to read:

SB44-SSA1,551,9 49.68 (3) (a) Any Subject to s. 49.687 (1m), any permanent resident of this state who suffers from chronic renal disease may be accepted into the dialysis treatment phase of the renal disease control program if the resident meets standards set by rule under sub. (2) and s. 49.687.

SB44-SSA1, s. 1424 Section 1424. 49.68 (3) (d) 1. of the statutes is amended to read:

SB44-SSA1,551,24 49.68 (3) (d) 1. No aid may be granted under this subsection unless the recipient has no other form of aid available from the federal medicare program or, from private health, accident, sickness, medical, and hospital insurance coverage, or from other health care coverage specified by rule under s. 49.687 (1m) (b). If insufficient aid is available from other sources and if the recipient has paid an amount equal to the annual medicare deductible amount specified in subd. 2., the state shall pay the difference in cost to a qualified recipient. If at any time sufficient federal or private insurance aid or other health care coverage becomes available during the treatment period, state aid under this subsection shall be terminated or appropriately reduced. Any patient who is eligible for the federal medicare program shall register and pay the premium for medicare medical insurance coverage where permitted, and shall pay an amount equal to the annual medicare deductible amounts required under 42 USC 1395e and 1395L (b), prior to becoming eligible for state aid under this subsection.

SB44-SSA1, s. 1425 Section 1425. 49.68 (3) (d) 3. of the statutes is created to read:

SB44-SSA1,552,5 49.68 (3) (d) 3. No payment shall be made under this subsection for any portion of medical treatment costs or other expenses that are payable under any state, federal, or other health care coverage program, including a health care coverage program specified by rule under s. 49.687 (1m) (b), or under any grant, contract, or other contractual arrangement.

SB44-SSA1, s. 1426 Section 1426. 49.68 (3) (e) of the statutes is amended to read:

SB44-SSA1,552,19 49.68 (3) (e) State aids for services any service provided under this section shall be equal to the lower of the allowable charges charge under the Medical Assistance program under subch. IV or the federal medicare program Medicare program. In no case shall state rates for individual service elements exceed the federally defined allowable costs. The rate of charges for services not covered by public and private insurance shall not exceed the reasonable charges as established by medicare fee determination procedures. A person that provides to a patient a service for which aid is provided under this section shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section. The state may not pay for the cost of travel, lodging, or meals for persons who must travel to receive inpatient and outpatient dialysis treatment for kidney disease. This paragraph shall not apply to donor related costs as defined in par. (b).

SB44-SSA1, s. 1428 Section 1428. 49.683 (1) of the statutes is amended to read:

SB44-SSA1,552,24 49.683 (1) The Subject to s. 49.687 (1m), the department may provide financial assistance for costs of medical care of persons over the age of 18 years with the diagnosis of cystic fibrosis who meet financial requirements established by the department by rule under s. 49.687 (1).

SB44-SSA1, s. 1429 Section 1429. 49.683 (3) of the statutes is created to read:

SB44-SSA1,553,4 49.683 (3) No payment shall be made under this section for any portion of medical care costs that are payable under any state, federal, or other health care coverage program, including a health care coverage program specified by rule under s. 49.687 (1m) (b), or under any grant, contract, or other contractual arrangement.

SB44-SSA1, s. 1430 Section 1430. 49.685 (6) (b) of the statutes is amended to read:

SB44-SSA1,553,13 49.685 (6) (b) Reimbursement shall not be made under this section for any blood products or supplies which that are not purchased from or provided by a comprehensive hemophilia treatment center, or a source approved by the treatment center. Reimbursement shall not be made under this section for any portion of the costs of blood products or supplies which that are payable under any other state or, federal program, or other health care coverage program, including a health care coverage program specified by rule under s. 49.687 (1m) (b), or under any grant, contract and any, or other contractual arrangement.

SB44-SSA1, s. 1431 Section 1431. 49.687 (title) of the statutes is amended to read:

SB44-SSA1,553,16 49.687 (title) Disease aids; patient requirements; rebate agreements; cost containment.

SB44-SSA1, s. 1432 Section 1432. 49.687 (1) of the statutes is amended to read:

SB44-SSA1,554,8 49.687 (1) The department shall promulgate rules that require a person who is eligible for benefits under s. 49.68, 49.683, or 49.685 and whose current estimated total family income exceeds specified limits for the current year is at or above 200% of the poverty line to obligate or expend specified portions of the income for medical care for treatment of kidney disease, cystic fibrosis, or hemophilia before receiving benefits under s. 49.68, 49.683, or 49.685. The rules shall require a person to pay 0.50% of his or her total family income for the cost of medical treatment covered under s. 49.68, 49.683, or 49.685 if that income is from 200% to 250% of the federal poverty line, 0.75% if that income is more than 250% but not more than 275% of the federal poverty line, 1% if that income is more than 275% but not more than 300% of the federal poverty line, 1.25% if that income is more than 300% but not more than 325% of the federal poverty line, 2% if that income is more than 325% but not more than 350% of the federal poverty line, 2.75% if that income is more than 350% but not more than 375% of the federal poverty line, 3.5% if that income is more than 375% but not more than 400% of the federal poverty line, and 4.5% if that income is more than 400% of the federal poverty line.

SB44-SSA1, s. 1433 Section 1433. 49.687 (1m) of the statutes is created to read:

SB44-SSA1,554,14 49.687 (1m) (a) A person is not eligible to receive benefits under s. 49.68 or 49.683 unless before the person applies for benefits under s. 49.68 or 49.683, the person first applies for benefits under all other health care coverage programs specified by the department by rule under par. (b) for which the person reasonably may be eligible.