Amendment CSA1-SB40

SB40-CSA1,762,3 (i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,6 (j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,10 (k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).

SB40-CSA1,762,13 (L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.

SB40-CSA1,762,16 (m) Transportation to obtain emergency medical care only, as medically necessary, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

SB40-CSA1,762,18 (n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.

SB40-CSA1,762,23 (o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.

SB40-CSA1,762,24 (p) Early childhood developmental services, for children under 6 years of age.

SB40-CSA1,762,25 (q) Smoking cessation treatment, for pregnant women only.

SB40-CSA1,763,1 (r) Prenatal care coordination, for pregnant women at high risk only.

SB40-CSA1,763,11 (11m) Provider payments and requirements. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs.

SB40-CSA1,763,14 (12) Rules; notice of effective date. (a) 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.

SB40-CSA1,763,22 2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.

SB40-CSA1,764,2 (b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is consistent with all of the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.

SB40-CSA1, s. 1608 Section 1608. 49.473 (2) (a) of the statutes is amended to read:

SB40-CSA1,764,6 49.473 (2) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.

SB40-CSA1, s. 1610 Section 1610. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).

SB40-CSA1, s. 1611 Section 1611. 49.475 (1) (ag) of the statutes is created to read:

SB40-CSA1,764,10 49.475 (1) (ag) "Covered entity" means any of the following that is not an insurer:

SB40-CSA1,764,11 1. A nonprofit hospital, as defined in s. 46.21 (2) (m).

SB40-CSA1,764,15 2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons organized in this state if the employer, labor union, or other group provides prescription drug coverage to covered individuals who reside or are employed in this state.

SB40-CSA1,764,17 3. A comprehensive or limited health care benefits program administered by the state that provides prescription drug coverage.

SB40-CSA1, s. 1612 Section 1612. 49.475 (1) (am) of the statutes is created to read:

SB40-CSA1,764,22 49.475 (1) (am) "Covered individual" means an individual who is a member, participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary of a covered entity, or a dependent of the individual, and who receives prescription drug coverage from or through the covered entity.

SB40-CSA1, s. 1613 Section 1613. 49.475 (1) (c) of the statutes is created to read:

SB40-CSA1,765,3 49.475 (1) (c) "Pharmacy benefits management" means the procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals; or any of the following services provided in the administration of pharmacy benefits:

SB40-CSA1,765,4 1. Dispensation of prescription drugs by mail.

SB40-CSA1,765,6 2. Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals.

SB40-CSA1,765,7 3. Clinical formulary development and management services.

SB40-CSA1,765,8 4. Rebate contracting and administration.

SB40-CSA1,765,10 5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.

SB40-CSA1, s. 1614 Section 1614. 49.475 (1) (d) of the statutes is created to read:

SB40-CSA1,765,13 49.475 (1) (d) "Pharmacy benefits manager" means a person that performs pharmacy benefits management functions.

SB40-CSA1, s. 1615 Section 1615. 49.475 (1) (e) of the statutes is created to read:

SB40-CSA1,765,16 49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:

SB40-CSA1,765,18 1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.

SB40-CSA1,765,19 2. An enrollee of family care.

SB40-CSA1,765,20 3. A recipient of the Badger Care health care program.

SB40-CSA1,765,21 4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.

SB40-CSA1,765,23 5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.

SB40-CSA1,765,24 6. A woman who receives services that are reimbursed under s. 255.06.

SB40-CSA1, s. 1616 Section 1616. 49.475 (1) (f) of the statutes is created to read:

SB40-CSA1,766,3 49.475 (1) (f) "Third party" means an entity that by statute, rule, or contract is responsible for payment of a claim for a health care item or service. "Third party" includes all of the following:

SB40-CSA1,766,4 1. An insurer.

SB40-CSA1,766,6 2. An employee benefit plan described in 29 USC 1003 (a) that is not exempt under 29 USC 1003 (b) and is not a multiple employer welfare arrangement.

SB40-CSA1,766,7 3. A service benefit plan, as specified in 42 USC 1396a (25) (I).

SB40-CSA1,766,8 4. A pharmacy benefits manager.

SB40-CSA1, s. 1617 Section 1617. 49.475 (2) of the statutes is repealed and recreated to read:

SB40-CSA1,766,11 49.475 (2) Requirements of 3rd parties. As a condition of doing business in this state, a 3rd party shall do all of the following:

SB40-CSA1,766,14 (a) Upon the department's request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:

SB40-CSA1,766,16 1. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.

SB40-CSA1,766,19 2. If subd. 1. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.

SB40-CSA1,766,23 (b) Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department's right to recover any 3rd-party payment made for which assignment has not been accepted.

SB40-CSA1,767,3 (c) Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.

SB40-CSA1,767,7 (d) If all of the following apply, agree not to deny a claim submitted by the department under par. (b) solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:

SB40-CSA1,767,9 1. The department submits the claim less than 36 months after the date on which the health care item or service was provided.

SB40-CSA1,767,12 2. Action by the department to enforce the department's rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.

SB40-CSA1, s. 1618 Section 1618. 49.475 (3) (intro.) of the statutes is amended to read:

SB40-CSA1,767,16 49.475 (3) Written agreement. (intro.) Upon requesting an insurer a 3rd party to provide the information under sub. (2) (a), the department and the 3rd party shall enter into a written agreement with the insurer that satisfies all of the following:

SB40-CSA1, s. 1619 Section 1619. 49.475 (3) (a) of the statutes is amended to read:

SB40-CSA1,767,19 49.475 (3) (a) Identifies in detail the detailed format of the information to be disclosed provided to the department.

SB40-CSA1, s. 1620 Section 1620. 49.475 (3) (c) of the statutes is amended to read:

SB40-CSA1,767,22 49.475 (3) (c) Specifies how the insurer's 3rd party's reimbursable costs under sub. (5) will be determined and specifies the manner of payment.

SB40-CSA1, s. 1621 Section 1621. 49.475 (4) (a) of the statutes is amended to read:

SB40-CSA1,768,2 49.475 (4) (a) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer 3rd party to disclose information under this section.

SB40-CSA1, s. 1622 Section 1622. 49.475 (4) (b) of the statutes is amended to read:

SB40-CSA1,768,7 49.475 (4) (b) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 30 days after receiving the department's request if the department has previously requested the insurer 3rd party to disclose information under this section.

SB40-CSA1, s. 1623 Section 1623. 49.475 (4) (d) of the statutes is created to read:

SB40-CSA1,768,10 49.475 (4) (d) If a 3rd party other than an insurer fails to comply with par. (a) or (b), the department may so notify the attorney general.

SB40-CSA1, s. 1624 Section 1624. 49.475 (5) of the statutes is amended to read:

SB40-CSA1,768,17 49.475 (5) From the appropriations under s. 20.435 (4) (bm) and (pa), the department shall reimburse an insurer A 3rd party that provides information under this section sub. (2) (a) for the insurer's 3rd party's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of the information under this section.

SB40-CSA1, s. 1625 Section 1625. 49.475 (6) of the statutes is created to read:

SB40-CSA1,769,3 49.475 (6) Sharing information. The department of health and family services shall provide to the department of workforce development, for purposes of the medical support liability program under s. 49.22, any information that the department of health and family services receives under this section. The department of workforce development may allow a county child support agency under s. 59.53 (5) or a tribal child support agency access to the information, subject to the use and disclosure restrictions under s. 49.83, and shall consult with the department of health and family services regarding procedures and methods to adequately safeguard the confidentiality of the information provided under this subsection.

SB40-CSA1, s. 1626 Section 1626. 49.475 (6) of the statutes, as created by 2007 Wisconsin Act .... (this act), is amended to read:

SB40-CSA1,769,15 49.475 (6) Sharing information. The department of health and family services shall provide to the department of workforce development children and families, for purposes of the medical support liability program under s. 49.22, any information that the department of health and family services receives under this section. The department of workforce development children and families may allow a county child support agency under s. 59.53 (5) or a tribal child support agency access to the information, subject to the use and disclosure restrictions under s. 49.83, and shall consult with the department of health and family services regarding procedures and methods to adequately safeguard the confidentiality of the information provided under this subsection.

SB40-CSA1, s. 1627 Section 1627. 49.48 (1m) of the statutes is amended to read:

SB40-CSA1,769,23 49.48 (1m) If an individual who applies for or to renew a certification under sub. (1) does not have a social security number, the individual, as a condition of obtaining the certification, shall submit a statement made or subscribed under oath or affirmation to the department that the applicant does not have a social security number. The form of the statement shall be prescribed by the department of workforce development children and families. A certification issued or renewed in reliance upon a false statement submitted under this subsection is invalid.

SB40-CSA1, s. 1628 Section 1628. 49.48 (2) of the statutes is amended to read:

SB40-CSA1,770,4 49.48 (2) The department of health and family services may not disclose any information received under sub. (1) to any person except to the department of workforce development children and families for the purpose of making certifications required under s. 49.857.

SB40-CSA1, s. 1629 Section 1629. 49.48 (3) of the statutes is amended to read:

SB40-CSA1,770,17 49.48 (3) The department of health and family services shall deny an application for the issuance or renewal of a certification specified in sub. (1), shall suspend a certification specified in sub. (1) or may, under a memorandum of understanding under s. 49.857 (2), restrict a certification specified in sub. (1) if the department of workforce development children and families certifies under s. 49.857 that the applicant for or holder of the certificate is delinquent in the payment of court-ordered payments of child or family support, maintenance, birth expenses, medical expenses or other expenses related to the support of a child or former spouse or fails to comply, after appropriate notice, with a subpoena or warrant issued by the department of workforce development children and families or a county child support agency under s. 59.53 (5) and related to paternity or child support proceedings.

SB40-CSA1, s. 1629m Section 1629m. 49.485 of the statutes is created to read:

SB40-CSA1,770,25 49.485 False claims. Whoever knowingly presents or causes to be presented to any officer, employee, or agent of this state a false claim for medical assistance shall forfeit not less than $5,000 nor more than $10,000, plus 3 times the amount of the damages that were sustained by the state or would have been sustained by the state, whichever is greater, as a result of the false claim. The attorney general may bring an action on behalf of the state to recover any forfeiture incurred under this section.

SB40-CSA1, s. 1630 Section 1630. 49.49 (3m) (a) (intro.) of the statutes is amended to read:

SB40-CSA1,771,5 49.49 (3m) (a) (intro.) No provider may knowingly impose upon a recipient charges in addition to payments received for services under ss. 49.45 to 49.47 49.471 or knowingly impose direct charges upon a recipient in lieu of obtaining payment under ss. 49.45 to 49.47 49.471 except under the following conditions:

SB40-CSA1, s. 1631 Section 1631. 49.49 (3m) (a) 1. of the statutes is amended to read:

SB40-CSA1,771,8 49.49 (3m) (a) 1. Benefits or services are not provided under s. 49.46 (2) or 49.471 (11) and the recipient is advised of this fact prior to receiving the service.

SB40-CSA1, s. 1632 Section 1632. 49.49 (3m) (a) 2. of the statutes is amended to read:

SB40-CSA1,771,20 49.49 (3m) (a) 2. If an applicant is determined to be eligible retroactively under s. 49.46 (1) (b) or 49.47 (4) (d) and a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider shall, upon notification of the applicant's retroactive eligibility, submit claims for reimbursement payment under s. 49.45 for covered services or benefits rendered to the recipient during the retroactive period. Upon receipt of payment under s. 49.45, the provider shall reimburse the applicant recipient or other person who has made prior payment to the provider. No provider may be required to reimburse the applicant or other person in excess of the amount reimbursed under s. 49.45 for services provided to the recipient during the retroactive eligibility period, by the amount of the prior payment made.