Amendment ASA1-AB40

AB40-ASA1, s. 1408m Section 1408m. 49.197 (4) of the statutes is amended to read:

AB40-ASA1,569,21 49.197 (4) County and tribal error reduction. If the department of health services contracts with the department under sub. (5), the department shall provide funds from the appropriation under s. 20.437 (2) (kx) to counties, multicounty consortia, as defined in s. 49.78 (1) (br), and governing bodies of federally recognized American Indian tribes administering Medical Assistance under subch. IV, the food stamp program under 7 USC 2011 to 2036, the supplemental security income payments program under s. 49.77, the program providing payments for the support of children of supplemental security income recipients under s. 49.775, and the Badger Care health care program under s. 49.665 to offset administrative costs of reducing payment errors in those programs.

AB40-ASA1, s. 1415 Section 1415. 49.265 (4) (a) of the statutes is amended to read:

AB40-ASA1,569,25 49.265 (4) (a) The department shall distribute the federal community services block grant funds received under 42 USC 9903 and deposited in credited to the appropriations appropriation account under s. 20.437 (1) (mc) and (md) (2) (mg).

AB40-ASA1, s. 1420m Section 1420m. 49.43 (2r) of the statutes is created to read:

AB40-ASA1,570,4 49.43 (2r) "County," "county department," and "county department under s. 46.215, 46.22, or 46.23" includes a multicounty consortium in accordance with a contract under s. 49.78 (2).

AB40-ASA1, s. 1422m Section 1422m. 49.43 (8m) of the statutes is created to read:

AB40-ASA1,570,6 49.43 (8m) "Multicounty consortium" has the meaning given in s. 49.78 (1) (br).

AB40-ASA1, s. 1423k Section 1423k. 49.45 (2m) of the statutes, as created by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,570,13 49.45 (2m) Authorization for modifications to programs; study. (a) In this subsection, "Medical Assistance program" includes any program operated under this subchapter, demonstration program operated under 42 USC 1315, and program operated under a waiver of federal law relating to medical assistance that is granted by the federal department of health and human services.

AB40-ASA1,570,17 (b) The department shall study potential changes to the Medical Assistance state plan and to waivers of federal law relating to medical assistance obtained from the federal department of health and human services for all of the following purposes:

AB40-ASA1,570,19 1. Increasing the cost effectiveness and efficiency of care and the care delivery system for Medical Assistance programs.

AB40-ASA1,570,21 2. Limiting switching from private health insurance to Medical Assistance programs.

AB40-ASA1,570,23 3. Ensuring the long-term viability and sustainability of Medical Assistance programs.

AB40-ASA1,570,25 4. Advancing the accuracy and reliability of eligibility for Medical Assistance programs and claims determinations and payments.

AB40-ASA1,571,2 5. Improving the health status of individuals who receive benefits under a Medical Assistance program.

AB40-ASA1,571,4 6. Aligning Medical Assistance program benefit recipient and service provider incentives with health care outcomes.

AB40-ASA1,571,5 7. Supporting responsibility and choice of medical assistance recipients.

AB40-ASA1,571,9 (c) Subject to par. (d), 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 propose a policy that makes any of the following changes related to Medical Assistance programs:

AB40-ASA1,571,11 1. Requires cost sharing from program benefit recipients up to the maximum allowed by federal law or a waiver of federal law.

AB40-ASA1,571,13 2. Authorizes 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.

AB40-ASA1,571,15 3. Modifies existing benefits or establishes various benefit packages and offers different packages to different groups of recipients.

AB40-ASA1,571,16 4. Revises provider reimbursement models for particular services.

AB40-ASA1,571,17 5. Mandates that program benefit recipients enroll in managed care.

AB40-ASA1,571,18 6. Restricts or eliminates presumptive eligibility.

AB40-ASA1,571,20 7. To the extent permitted by federal law, imposes restrictions on providing benefits to individuals who are not citizens of the United States.

AB40-ASA1,571,21 8. Sets standards for establishing and verifying eligibility requirements.

AB40-ASA1,571,23 9. Develops standards and methodologies to assure accurate eligibility determinations and redetermines continuing eligibility.

AB40-ASA1,571,25 10. Reduces 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.

AB40-ASA1,572,14 (d) Before implementing a policy proposed under par. (c) that conflicts with a statute, and before submitting any amendment or waiver request under par. (e) that is necessary to implement any such policy, the department shall submit to the joint committee on finance the proposed amendment or waiver request and estimates of the projected cost savings associated with that amendment or waiver request. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department's submittal that the committee has scheduled a meeting for the purpose of reviewing the proposed amendment or waiver request, the proposed amendment or waiver request may be submitted to the federal department of health and human services. If, within 14 working days after the date of the department's submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed amendment or waiver request, the proposed amendment or waiver requested may be submitted only on approval of the committee.

AB40-ASA1,572,20 (e) 1. Subject to par. (d), 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 policy created 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 implement the policy.

AB40-ASA1,573,5 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).

AB40-ASA1,573,8 (f) Within 90 days after the effective date of this paragraph .... [LRB inserts date], and every 90 days thereafter, the department shall submit to the joint committee on finance a report that contains all of the following information:

AB40-ASA1,573,11 1. An updated description of any Medical Assistance program changes implemented by the department, including any amendments to the Medical Assistance state plan.

AB40-ASA1,573,13 2. An updated estimate of the projected savings associated with any changes described under subd. 1.

AB40-ASA1,573,16 3. An updated projection of the total Medical Assistance program benefit expenditures during the fiscal biennium and an analysis of how these projected expenditures compare to the funding provided in the 2011-13 biennial budget act.

AB40-ASA1, s. 1423m Section 1423m. 49.45 (2m) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

AB40-ASA1, s. 1424p Section 1424p. 49.45 (3) (n) of the statutes, as created by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,573,22 49.45 (3) (n) This subsection does not apply if the department creates a policy under sub. (2m) (c) 4., to the extent that the policy conflicts with this subsection.

AB40-ASA1, s. 1424q Section 1424q. 49.45 (3) (n) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

AB40-ASA1, s. 1427 Section 1427. 49.45 (5m) (am) of the statutes is amended to read:

AB40-ASA1,574,7 49.45 (5m) (am) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), (w) and (xc), the department shall distribute not more than $5,000,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under 42 USC 1396b (i) (3).

AB40-ASA1, s. 1428 Section 1428. 49.45 (6m) (a) 6. of the statutes is amended to read:

AB40-ASA1,574,12 49.45 (6m) (a) 6. "Resource Utilization Groupings III" means a comparative resource utilization grouping that classifies each facility resident based on information obtained from performing, for the resident, a minimum data set assessment developed by the federal Centers for Medicare and Medicaid Services.

AB40-ASA1, s. 1429 Section 1429. 49.45 (6m) (ag) (intro.) of the statutes is amended to read:

AB40-ASA1,574,20 49.45 (6m) (ag) (intro.) Payment for care provided in a facility under this subsection made under s. 20.435 (4) (b), (gm), (o), (pa), or (w) shall, except as provided in pars. (bg), (bm), and (br), be determined according to a prospective payment system updated annually by the department. The payment system shall implement standards that are necessary and proper for providing patient care and that meet quality and safety standards established under subch. II of ch. 50 and ch. 150. The payment system shall reflect all of the following:

AB40-ASA1, s. 1430 Section 1430. 49.45 (6m) (ag) 3p. a. of the statutes is amended to read:

AB40-ASA1,574,24 49.45 (6m) (ag) 3p. a. The system shall may incorporate acuity measurements under the most recent Resource Utilization Groupings III methodology to determine factors for case-mix adjustment.

AB40-ASA1, s. 1430c Section 1430c. 49.45 (6m) (ar) 1. a. of the statutes is amended to read:

AB40-ASA1,575,15 49.45 (6m) (ar) 1. a. The department shall establish standards for payment of allowable direct care costs under par. (am) 1. bm., for facilities that do not primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state and separate standards for payment of allowable direct care costs, for facilities that primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state. The standards shall be adjusted by the department for regional labor cost variations. The department shall treat as a single labor region the counties of Dane, Dodge, Iowa, Columbia, Sauk, and Rock and shall adjust payment so that the direct care cost targets of facilities in Dane, Iowa, Columbia, and Sauk counties are not reduced as a result of including facilities in Dodge and Rock County Counties in this labor region. For facilities in Douglas, Dunn, Pierce, and St. Croix counties, the department shall perform the adjustment by use of the wage index that is used by the federal department of health and human services for hospital reimbursement under 42 USC 1395 to 1395ggg.

AB40-ASA1, s. 1430d Section 1430d. 49.45 (6m) (n) of the statutes, as created by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,575,19 49.45 (6m) (n) This subsection does not apply if the department creates a policy under sub. (2m) (c) 4., to the extent that the policy conflicts with this subsection.

AB40-ASA1, s. 1430e Section 1430e. 49.45 (6m) (n) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is repealed.

AB40-ASA1, s. 1431 Section 1431. 49.45 (6tw) of the statutes is amended to read:

AB40-ASA1,576,4 49.45 (6tw) Payments to city health departments. From the appropriation account under s. 20.435 (7) (b), if the department selects the payment procedure under s. 49.45 (52) (a), the department may make payments to local health departments, as defined under s. 250.01 (4) (a) 3. Payment under this subsection to such a local health department may not exceed on an annualized basis payment made by the department to the local health department under s. 49.45 (6t), 2003 stats., for services provided by the local health department in 2002.

AB40-ASA1, s. 1432 Section 1432. 49.45 (6v) (b) of the statutes is amended to read:

AB40-ASA1,576,11 49.45 (6v) (b) The department shall, each year, submit to the joint committee on finance a report for the previous fiscal year, except for the 1997-98 fiscal year, that provides information on the utilization of beds by recipients of medical assistance in facilities and a discussion and detailed projection of the likely balances, expenditures, encumbrances and carry over of currently appropriated amounts in the appropriation accounts under s. 20.435 (4) (b), (gm), and (o).

AB40-ASA1, s. 1433d Section 1433d. 49.45 (6x) (a) of the statutes is renumbered 49.45 (6x) (a) (intro.) and amended to read:

AB40-ASA1,576,19 49.45 (6x) (a) (intro.) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department shall distribute not more than $4,748,000 in each fiscal year, to provide funds to an essential access city hospital all of the following, except that the department may not allocate funds to an essential access city a hospital to the extent that the allocation would exceed any limitation under 42 USC 1396b (i) (3).:

AB40-ASA1, s. 1433f Section 1433f. 49.45 (6x) (a) 1. to 3. of the statutes are created to read:

AB40-ASA1,576,24 49.45 (6x) (a) 1. Not more than $2,997,700 in fiscal year 2011-12 and not more than $2,988,700 in each fiscal year after fiscal year 2011-12 to an essential access city hospital that has previously received the supplemental payment for being an essential access city hospital.

AB40-ASA1,577,5 2. Not more than $999,200 in fiscal year 2011-12 and not more than $996,200 in each fiscal year after fiscal year 2011-12 to a hospital that would qualify for an essential access city hospital supplemental payment, under the criteria described in the 2010-11 inpatient hospital state plan, except that the hospital did not meet the criteria to be an essential access city hospital during fiscal year 1995-96.

AB40-ASA1,577,8 3. If the federal department of health and human services allows the payment, $300,000 from the appropriation account under s. 20.435 (4) (b) annually to a hospital that meets all of the following criteria:

AB40-ASA1,577,10 a. The hospital is located in a city that has a municipal border that is also a state border.

AB40-ASA1,577,12 b. The hospital has a Medical Assistance recipient patient mix that consists of at least 25 percent of residents from a state that borders this state.

AB40-ASA1,577,14 c. The hospital is located in a city with a poverty level, as determined from the 2000 U.S. census, that is greater than 5 percent.

AB40-ASA1,577,15 d. The hospital is located in a city with a population of less than 15,000 people.

AB40-ASA1, s. 1434 Section 1434. 49.45 (6y) (a) of the statutes is amended to read:

AB40-ASA1,578,2 49.45 (6y) (a) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department may distribute funding in each fiscal year to provide supplemental payment to hospitals that enter into a contract under s. 49.02 (2) to provide health care services funded by a relief block grant, as determined by the department, for hospital services that are not in excess of the hospitals' customary charges for the services, as limited under 42 USC 1396b (i) (3). If no relief block grant is awarded under this chapter or if the allocation of funds to such hospitals would exceed any limitation under 42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into a contract under s. 49.02 (2).

AB40-ASA1, s. 1435 Section 1435. 49.45 (6z) (a) (intro.) of the statutes is amended to read:

AB40-ASA1,578,15 49.45 (6z) (a) (intro.) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department may distribute funding in each fiscal year to supplement payment for services to hospitals that enter into indigent care agreements, in accordance with the approved state plan for services under 42 USC 1396a, with relief agencies that administer the medical relief block grant under this chapter, if the department determines that the hospitals serve a disproportionate number of low-income patients with special needs. If no medical relief block grant under this chapter is awarded or if the allocation of funds to such hospitals would exceed any limitation under 42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into indigent care agreements. The department may not distribute funds under this subsection to the extent that the distribution would do any of the following:

AB40-ASA1, s. 1435y Section 1435y. 49.45 (8) (b) of the statutes, as affected by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,578,23 49.45 (8) (b) Unless otherwise provided by the department by a policy created under sub. (2m) (c), reimbursement under s. 20.435 (4) (b), (gm), (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).

AB40-ASA1, s. 1436b Section 1436b. 49.45 (8) (b) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB40-ASA1,579,6 49.45 (8) (b) Unless otherwise provided by the department by a policy created under sub. (2m) (c), reimbursement Reimbursement under s. 20.435 (4) (b), (gm), (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).

AB40-ASA1, s. 1436h Section 1436h. 49.45 (8) (c) of the statutes, as affected by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,579,14 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 a policy created under sub. (2m) (c).

AB40-ASA1, s. 1436i Section 1436i. 49.45 (8) (c) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB40-ASA1,579,22 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 a policy created under sub. (2m) (c).

AB40-ASA1, s. 1436y Section 1436y. 49.45 (8r) of the statutes, as affected by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,580,8 49.45 (8r) Payment for certain obstetric and gynecological care. Unless otherwise provided by the department by a policy created 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.

AB40-ASA1, s. 1437b Section 1437b. 49.45 (8r) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB40-ASA1,580,18 49.45 (8r) Payment for certain obstetric and gynecological care. Unless otherwise provided by the department by a policy created 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.

AB40-ASA1, s. 1437e Section 1437e. 49.45 (8v) of the statutes, as affected by 2011 Wisconsin Act 10, is repealed and recreated to read:

AB40-ASA1,581,6 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 a policy created 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.

AB40-ASA1, s. 1437f Section 1437f. 49.45 (8v) of the statutes, as affected by 2011 Wisconsin Act .... (this act), is amended to read:

AB40-ASA1,581,19 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 a policy created 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.

AB40-ASA1, s. 1437h Section 1437h. 49.45 (9p) of the statutes is created to read:

AB40-ASA1,581,23 49.45 (9p) Prior authorization prohibited for wheelchair repairs. (a) In this subsection, "recipient of medical assistance" means an individual who receives medical assistance under any of the following: