Amendment CSA1-SB40

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.

SB40-CSA1, s. 1633 Section 1633 . 49.49 (3m) (a) 2. of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:

SB40-CSA1,772,6 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), or 49.471 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 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 recipient or other person who has made prior payment to the provider for services provided to the recipient during the retroactive eligibility period, by the amount of the prior payment made.

SB40-CSA1, s. 1634 Section 1634 . 49.49 (3m) (a) 3. of the statutes is amended to read:

SB40-CSA1,772,11 49.49 (3m) (a) 3. Benefits or services for which recipient copayment, coinsurance, or deductible is required under s. 49.45 (18), not to exceed maximum amounts allowable under 42 CFR 447.53 to 447.58, or for which recipient copayment or coinsurance is required under s. 49.471 (11).

SB40-CSA1, s. 1634r Section 1634r. 49.496 (3) (a) (intro.) of the statutes is amended to read:

SB40-CSA1,772,16 49.496 (3) (a) (intro.) Except as provided in par. (b), the department shall file a claim against the estate of a recipient for all of the following , subject to the exclusion of any amounts under the Long-Term Care Partnership Program established under s. 49.45 (31), unless already recovered by the department under this section:

SB40-CSA1, s. 1635 Section 1635. 49.497 (title) of the statutes is amended to read:

SB40-CSA1,772,19 49.497 (title) Recovery of incorrect Medical Assistance or Badger Care payments and of unpaid employer penalties.

SB40-CSA1, s. 1636 Section 1636. 49.497 (1r) of the statutes is created to read:

SB40-CSA1,773,6 49.497 (1r) (a) The department may recover any penalty assessment not paid under s. 49.471 (9) (c) from the employer against which the penalty was assessed. If, after notice that payment of a penalty is overdue, the employer who is liable fails to pay the penalty amount, or enter into or comply with an agreement for payment, the department may bring an action to enforce the liability or may issue an order to compel payment of the liability. Any person aggrieved by an order issued by the department under this paragraph may appeal the order as a contested case under ch. 227 by filing with the department a request for a hearing within 30 days after the date of the order. The only issue at the hearing shall be the determination by the department that the person has not paid the penalty or entered into, or complied with, an agreement for payment.

SB40-CSA1,773,16 (b) If any employer named in an order to compel payment issued under par. (a) fails to pay the department any amount due under the terms of the order and no contested case to review the order is pending and the time for filing for a contested case review has expired, the department may present a certified copy of the order to the circuit court for any county. The sworn statement of the secretary shall be evidence of the failure to pay the penalty. The circuit court shall, without notice, render judgment in accordance with the order. A judgment rendered under this paragraph shall have the same effect and shall be entered in the judgment and lien docket and may be enforced in the same manner as if the judgment had been rendered in an action tried and determined by the circuit court.

SB40-CSA1,773,18 (c) The recovery procedure under this subsection is in addition to any other recovery procedure authorized by law.

SB40-CSA1, s. 1637 Section 1637. 49.497 (4) of the statutes is amended to read:

SB40-CSA1,773,24 49.497 (4) The department may appear for the state in any and all collection matters under this section, and may commence suit in the name of the department to recover an incorrect payment from the recipient to whom or on whose behalf it was made or to recover an unpaid penalty from the employer against which the penalty was assessed.

SB40-CSA1, s. 1638 Section 1638. 49.665 (4) (ap) 2. of the statutes is repealed.

SB40-CSA1, s. 1639 Section 1639. 49.665 (4) (at) 1. a. of the statutes is amended to read:

SB40-CSA1,774,6 49.665 (4) (at) 1. a. Except as provided in subd. 1. b., the department shall establish a lower maximum income level for the initial eligibility determination if funding under s. 20.435 (4) (bc), (jz), (p), and (x) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding.

SB40-CSA1, s. 1640 Section 1640. 49.665 (4) (at) 1. cm. of the statutes is amended to read:

SB40-CSA1,774,18 49.665 (4) (at) 1. cm. Notwithstanding s. 20.001 (3) (b), if, after reviewing the plan submitted under subd. 1. b., the joint committee on finance determines that the amounts appropriated under s. 20.435 (4) (bc), (jz), (p), and (x) are insufficient to accommodate the projected enrollment levels, the committee may transfer appropriated moneys from the general purpose revenue appropriation account of any state agency, as defined in s. 20.001 (1), other than a sum sufficient appropriation account, to the appropriation account under s. 20.435 (4) (bc) (b) to supplement the health care program under this section if the committee finds that the transfer will eliminate unnecessary duplication of functions, result in more efficient and effective methods for performing programs, or more effectively carry out legislative intent, and that legislative intent will not be changed by the transfer.

SB40-CSA1, s. 1641 Section 1641. 49.665 (4) (at) 2. of the statutes is amended to read:

SB40-CSA1,774,24 49.665 (4) (at) 2. If, after the department has established a lower maximum income level under subd. 1., projections indicate that funding under s. 20.435 (4) (bc), (jz), (p), and (x) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185% of the poverty line.

SB40-CSA1, s. 1641d Section 1641d. 49.665 (4g) of the statutes is created to read:

SB40-CSA1,775,7 49.665 (4g) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (4m), the department shall develop and implement, for individuals who are eligible under sub. (4), 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: