At the conclusion of any proceeding under Chapter 980, the court may inquire as to the person's ability to reimburse the state for the costs of representation. If the court determines that the person is able to make reimbursement, the court may order the person to reimburse the state. These reimbursements would be made to the clerk of courts where the proceedings took place, which would transmit payments to the county treasurer, who would be required to deposit 25 percent of the payment in the county treasury and transmit the remainder to the Department of Administration. Upon request, the State Public Defender must conduct a determination of indigency and report the results of the determination. Require the clerk of courts to report, by January 31 of each year, to the State Public Defender the total amount of reimbursements order for Chapter 980. While I understand the importance of updating the process for placing sexually violent persons in the community, the issues the Department of Health Services and communities face in completing placement plans and how critical it is that these individuals be placed in appropriate settings for the health and safety of the citizens in those counties, I am vetoing these provisions as nonfiscal policy. This policy eliminates current law provisions requiring that residential options be a specific distance from any school premises, child care facility, public park, place of worship or youth center and should therefore be thoroughly vetted through the regular legislative process, with input from the public and counties.
59. FoodShare Employment and Training – Universal Referrals
Section 964d
This provision requires income maintenance workers to provide all FoodShare applicants and participants information about the FoodShare Employment and Training program at least two times per year.
I am vetoing this provision because there is no additional funding or positions included in the bill to implement this unfunded mandate. However, I am directing the Department of Health Services to develop a protocol for better informing all FoodShare applicants and participants about the FoodShare Employment and Training Program because I agree with the intent of the provision.
60. FoodShare Employment and Training – Cost to Continue
Section 9120 (2s)
This section requires the Department of Health Services to submit a report to the Legislature regarding the outcomes related to the FoodShare Employment and Training program before February 1, 2018. The report shall include any proposed program improvements and contract modifications necessary based on the reported outcomes.
I am vetoing this section because I object to this administratively burdensome requirement.
61. FoodShare Employment and Training Pilot
Section 9120 (2)
This provision modifies the provision in the Governor's budget to increase the amount of job training and employment assistance services provided to individuals receiving FoodShare benefits by requiring able-bodied adults with school-age children to participate in the FoodShare Employment and Training Program. The provision is modified in the following ways: (a) require the pilot region selected by the Department of Health Services to be composed of no more than two FoodShare Employment and Training vendor regions; (b) require a pilot of the work requirement be run from April 2019 through June 30, 2020; and (c) require an evaluation of the pilot program and make statewide expansion contingent on that evaluation.
Further, this provision reduces funding in fiscal year 2017-18 by $29,000 GPR and increases funding by $42,300 GPR in fiscal year 2018-19. This provision also transfers the biennial funding of $4,236,400 GPR provided in the bill to the Joint Committee on Finance supplemental appropriation and requires that the Department of Health Services seek release of the funds through s. 13.10 by submitting a detailed plan for implementation of the pilot. I am partially vetoing this provision to remove the requirements that the regions be FoodShare Employment and Training vendor regions because I object to this arbitrary policy. I direct the department to determine which region or regions make the most sense for Wisconsin.
Second, I am partially vetoing the provision to remove the evaluation of the program because I object to requiring an evaluation of this provision before it can be expanded.
Lastly, I am partially vetoing the requirement that the department operate a pilot from April 2019 through June 30, 2020, because I object to this arbitrary and administratively burdensome timeline. The department requires flexibility in operating this program and an arbitrary timeline impedes on the administration's ability to successfully implement this provision.
62. Medical Assistance Coverage of Complex Rehabilitation Technology
Sections 926p, 931n and 9120 (5h)
This provision specifies that durable medical equipment that is considered complex rehabilitation technology is a covered service under the Medical Assistance program.
The provision defines a "complex needs patient" as an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation; "complex rehabilitation technology" as items classified within Medicare as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary; "individually configured" as having a combination of sizes, features, adjustments or modifications that a qualified complex rehabilitation technology supplier can customize to the specific individual by measuring, fitting, programming, adjusting or adapting as appropriate so that the device operates in accordance with an assessment or evaluation of the individual by a qualified health care professional and is consistent with the individual's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
The provision further defines "Medicare" as coverage under Part A or Part B of Title XVIII of the federal Social Security Act, 42 USC 1395 et seq. A "qualified complex rehabilitation technology professional" is defined as an individual who is certified as an assistive technology professional by the Rehabilitation Engineering and Assistive Technology Society of North America. The provision defines "qualified complex rehabilitation technology supplier" as a company or entity that meets all of the following criteria: (a) is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology; (b) is an enrolled supplier for purposes of Medicare reimbursement that meets the supplier and quality standards established for durable medical equipment suppliers, including those for complex rehabilitation technology under Medicare; (c) is an employer of at least one qualified complex rehabilitation technology professional to analyze the needs and capacities of the complex needs patient in consultation with qualified health care professionals, to participate in the selection of appropriate complex rehabilitation technology for those needs and capacities of the complex needs patient, and to provide training in the proper use of the complex rehabilitation technology; (d) requires a qualified complex rehabilitation technology professional to be physically present for the evaluation and determination of appropriate complex rehabilitation technology for a complex needs patient; (e) has the capability to provide service and repair by qualified technicians for all complex rehabilitation technology it sells; and (f) provides written information at the time of delivery of the complex rehabilitation technology to the complex needs patient stating how the complex needs patient may receive service and repair for the complex rehabilitation technology.
Further, the provision defines "qualified health care professional" as any of the following: (a) a licensed physician or physician assistant, (b) a licensed physical therapist, (c) a licensed occupational therapist, or (d) a licensed chiropractor.
The provision also requires the Department of Health Services to promulgate rules and other policies for the use of complex rehabilitation technology by recipients of Medical Assistance (MA). The provision stipulates that the rules shall include all of the following: (a) designation of billing codes as complex rehabilitation technology including creation of new billing codes or modification of existing billing codes and provisions allowing for quarterly updates to the designations; (b) establishment of specific supplier standards for companies or entities that provide complex rehabilitation technology and limiting reimbursement only to suppliers that are qualified complex rehabilitation technology suppliers; (c) a requirement that MA recipients who need a manual wheelchair, power wheelchair, or other seating component to be evaluated by a qualified health care professional who does not have a financial relationship with a qualified complex rehabilitation technology supplier and a qualified complex rehabilitation technology professional; (d) establishment and maintenance of payment rates for complex rehabilitation technology that are adequate to ensure complex needs patients have access to complex rehabilitation technology, taking into account the significant resources, infrastructure and staff needed to appropriately provide complex rehabilitation technology to meet the unique needs of complex needs patients; (e) a requirement for contracts with the department that managed care plans providing services to MA recipients comply with statutory requirements related to the provision of complex rehabilitation technology and with the related administrative rules; and (f) protection of access to complex rehabilitation technology for complex needs patients.
Lastly the provision specifies that the proposed rules must designate certain healthcare common procedure system codes, which are used under the federal Medicare program and certain mixed complex rehabilitation technology product and standard mobility and accessory product codes. Require the department to specify, in the proposed rules, that procurement of these codes shall be exempt from any bidding or selective contracting requirements.
I am vetoing this provision because I believe there may be unanticipated costs to the MA program and that the language presented may inadvertently limit availability for this service in rural areas of the state. I object to this policy item being placed in the budget without giving the department, MA recipients, health care providers and the public an opportunity to publicly debate its merits. While this provision may have merit, the Legislature should review the impact further and forward legislation when the impacts have been analyzed and such issues have been resolved.
63. Exemption from the Nursing Home Bed Assessment
This provision creates an exemption for county-owned institutions for mental diseases and state licensed nursing homes, which are not certified to participate in Medicaid and Medicare, from the state nursing home bed assessment. The Department of Health Services is required to seek approval from the U.S. Department of Health and Human Services.
I am vetoing this provision because the practice would violate a Centers for Medicare and Medicaid Services requirement that the assessment be "broad based" in design and is therefore not allowable.
64. Childless Adult Employment and Training Waiver
Section 928d
This section requires the Department of Health Services to submit a report to the Joint Committee on Finance no later than three months following final approval of the proposed Medicaid Childless Adult waiver, including the following: (a) a description of each component of the approved waiver, including information on the department's plan to implement; and (b) an estimate of the impact on Medical Assistance enrollment and the Medical Assistance budget.
The section further specifies that that the department may not implement the waiver unless the Joint Committee on Finance meets under s. 13.10 of the statutes to review the report and approves the waiver. Lastly, the Joint Committee on Finance may modify the waiver by removing certain components. The department is required to implement the waiver as approved by the Joint Committee on Finance and the department must submit a waiver amendment to the federal government with any changes made by the committee. I am vetoing this section because I believe these requirements will infringe on the Department of Health Services' ability to negotiate a successful waiver with the Centers for Medicare and Medicaid Services. Further, I object to the creation of unnecessary and burdensome reporting requirements that could delay approval of the waiver, jeopardizing these reforms from being implemented.
65. Family Care Funding
This provision provides funding in the Joint Committee on Finance supplemental GPR appropriation and requires the Department of Health Services to work with both the Centers for Medicare and Medicaid Services as well as Family Care Managed Care Organizations to develop a payment mechanism to increase the direct care and services portion of the capitation rates paid to the managed care organizations.
The provision further requires the department to seek release of the funds under s. 13.10 upon the Centers for Medicare and Medicaid Services approval of such a payment mechanism and lastly requires the department to seek any required federal approval no later than December 31, 2017. I support efforts aimed at increasing rates paid to direct care service providers. However, I believe the requirements of this provision to be administratively burdensome and am vetoing it in two ways. I am partially vetoing the provision to remove the date by which the department must seek federal approval for the rate methodology because I object to this burdensome timeline and believe the department should seek federal approval when it is appropriate to do so, and not at an arbitrary time.
Further, I am partially vetoing the provision to remove the requirement for the department to seek funds under s. 13.10 because I believe it is administratively burdensome. As a result, the supplement of funds to implement this provision will be made from the appropriation under s. 20.865 (4) (a) without the approval of the Joint Committee on Finance. 66. Family Care Partnership Program
This section directs the Department of Health Services to submit a waiver to the Centers for Medicare and Medicaid Services to expand the Family Care Partnership Program statewide. The department is further required to submit a plan to expand the program to the Joint Committee on Finance within 60 days of federal approval. Lastly, should the waiver request be denied by the federal government, the section requires the department to submit a report to the Joint Committee on Finance detailing the reasons why the waiver request was denied.
I am vetoing this section because a waiver request is not necessary to expand the Family Care Partnership Program and I object to the creation of this unnecessary and burdensome process. However, I support expansion of the Family Care Partnership Program and am directing the department to explore expansion opportunities throughout the state.
67. Self-Directed Services Waiver for Postsecondary Education
Section 747w
This section requires the Department of Health Services to request a federal home and community-based services waiver to provide Medicaid coverage for services provided to individuals with developmental disabilities receiving postsecondary education on the grounds of a health care institution. If the waiver is approved, the department shall limit the coverage to 100 individuals per month and shall determine the funding for each participant based on the benefit levels for the Include, Respect, I Self-Direct (IRIS) waiver program.
I am vetoing this section because these requirements are substantially similar to current law provisions directing the department to request a waiver. The federal government has indicated the provisions are not permitted under federal regulations and law regarding Medicaid home and community-based services.
68. Nursing Home Bed Licenses
This provision requires the Department of Health Services to increase by 18 the number of licensed nursing home beds for a nursing facility that meets the following requirements: (a) has a bed capacity of no more than 30 on the effective date of the bill, (b) is in a county with a population of at least 27,000 with the population of the county seat no more than 9,200 and the home county is adjacent to a county with a population of at least 20,000 on the effective date of the bill, and (c) has requested the increase in its licensed beds through a notice to the department that includes the applicant's per diem and operating and capital rates. The provision further requires the department to approve an application from a nursing home under this provision within one month of receiving the application. The provision also requires the department to develop a policy which nursing homes may use to apply for, and receive approval of, the transfer of available and licensed nursing home beds. Lastly, the provision requires the department to report to the Joint Committee on Finance no later than July 1, 2018, with details of the developed policies.
I am vetoing this provision because there is a current law process by which nursing homes can transfer licensed beds and I object to the creation of this redundant process. I further object to the increase in the number of licensed nursing home beds which is a deviation from the department's long-standing nursing home bed moratorium and the decades-long trend toward community-based long-term care. However, I understand the issues facing the nursing home industry and direct the department to work with stakeholders to identify any alternatives available to increase a nursing home's licensed bed count.
Sections 928g, 2249e and 2249g
These provisions provide one-time funding for the Department of Health Services to fund an intensive care coordination pilot project. The pilot would reimburse hospitals and health care systems for intensive care coordination services provided to Medical Assistance (MA) recipients.
The department is required to select eligible hospitals and health care systems to receive reimbursement under the program that submit a description of their programs to the department that meets the following: (a) the entity uses emergency department utilization data to identify MA recipients in order to reduce the use of the emergency department; (b) the entity identifies MA recipients who frequently visit the emergency room; (c) the entity has an intensive care coordination team; (d) the entity provides MA recipients with discharge instructions, referral information, appointment scheduling and intensive care coordination by a coordination individual to connect the MA recipient to a primary care provider; and (e) the intensive care coordination by the entity is designed to result in outcomes during the six-month or 12-month period.
The department is required to respond to the entity if additional information is required to determine eligibility and provide a description for enrolling MA recipients. The department is also required to reimburse the entity for enrollment in the program at $500 per MA recipient with an option for one additional six-month period for additional $500 reimbursement payment.
Entities that are eligible for reimbursement under this program are required to report, for each of the two years of the pilot program, to the department all of the following: (a) the number of MA recipients served by intensive care coordination; (b) for each MA recipient, the number of emergency department visits for a time period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination; and (c) any demonstrated outcomes.
The department is required to calculate the costs saved to the MA program by avoiding emergency department visits and distribute half the amount to the hospital or health care system if the calculation is positive.
The department is required to submit a report to the Joint Committee on Finance no later than 24 months after the date on which the first hospital or health care system is able to enroll individuals.
Finally, the department is required to obtain any necessary approval from the federal Department of Health and Human Services.
Overuse of the emergency room system leads to needless expense, crowding and reduced access to those individuals in need of true emergency services. I support efforts to reduce emergency overuse. However, I am vetoing this provision because I believe efforts to address this systemic problem should be broad-based and not aimed at one or two health care systems. Further, I believe that incentives of this nature should be tied to performance in order to best utilize taxpayer dollars and ensure the best outcomes for program participants. Lastly, Wisconsin has a strong history of managed care and a pilot of this nature reverts back to a fee-for-service and more costly payment model.
70. Clinical Consultations
This provision requires the Department of Health Services to provide reimbursement for clinical consultations under the Medical Assistance program. This provision defines "clinical consultation" as, for a student up to age 21, communication from a mental health professional, or qualified treatment trainee working under the supervision of a mental health professional, to another individual who is working with the client to inform, inquire and instruct regarding all of the following and to direct and coordinate clinical service components: (a) the client's symptoms, (b) strategies for effective engagement, care and intervention for the client, and (c) treatment expectations for the client across service settings. The department is required to report on utilization of these services, to the Joint Committee on Finance, by March 31, 2019. This provision is repealed effective June 30, 2019.
I am partially vetoing this provision to remove the report on utilization of services because I believe this report is administratively burdensome.
71. Emergency Physician Services and Reimbursement Workgroup
This provision establishes a workgroup to examine and make recommendations regarding medical services provided in hospital emergency departments to Medical Assistance recipients. The workgroup is to focus on aspects of the healthcare system involving emergency care, specifically patient care practices, medication use and prescribing practices, billing and coding administration, organization of health care delivery systems, care coordination, patient financial incentives, and any other aspects the workgroup finds appropriate.
This provision specifies the workgroup to include: (a) two physicians practicing in Wisconsin representing a statewide physician-member organization of emergency physicians; (b) two representatives of the Division of Medicaid Services, with experience in emergency physician services, codes and payment; (c) one representative who is a hospital emergency department administrator employed by a Wisconsin hospital or hospital-based health system; and (d) one coding/billing specialist from an organization with expertise in the business of emergency medicine that contracts with emergency physicians practicing in Wisconsin.
The provision requires the workgroup to meet no later than 60 days after the effective date of the bill and at least every 45 days following until a consensus of the workgroup has established a set of recommendations. The workgroup is to report its finding to the Joint Committee on Finance no later than September 1, 2018.
I am vetoing this provision because it is duplicative of current managed care and care coordination efforts in the Department of Health Services. I direct the department to continue its efforts.
72. Youth Crisis Stabilization Facility
These provisions create two new facilities for serving individuals with mental health needs. First, these provisions modify the Governor's budget initiative to allow the Department of Health Services to make transfers from its program revenue appropriation that funds the general operations of the state mental health institutes by transferring $450,000 PR in fiscal year 2018-19 on a one-time basis to a new program revenue, all moneys received appropriation for the purpose of contracting for a peer-run respite center for veterans in the Milwaukee area.
Further, these provisions modify language included in the Governor's budget to establish a youth crisis stabilization facility eliminating funding from the department and requiring the department to submit a request under s. 13.10 to the Joint Committee on Finance for release of funds allocated for youth crisis stabilization grants. The provisions require the department to submit any such request to the Joint Committee on Finance prior to the department soliciting proposals and allows the Committee to approve or modify and approve any plan submitted for review. A new sum certain appropriation is created in the department to receive any approved transfer of authority from the Committee and fund the costs of the facility. These provisions also require the department to include in its 2019-21 budget request, a proposal to provide ongoing GPR funding for both the peer-run respite center for veterans as well as the youth crisis stabilization facility.
Finally, both the new appropriation for the peer-run respite center for veterans as well as the appropriation for the crisis stabilization facility are repealed at the end of the biennium, as is the authority to transfer any balances from the state operations for the mental health institutes appropriation for these purposes.
I believe both a youth crisis stabilization facility and a peer-run respite center for veterans are important tools for the department to support and treat individuals with complex mental health needs and potentially significant mental health crises. I object to the overly burdensome requirements laid out in the bill and believe they will impede the ability for the department to negotiate and enter into contracts for both services, thereby delaying critical treatment options for some of Wisconsin's most vulnerable citizens. In order to give the department full flexibility in implementing these important programs, I am partially vetoing the provisions in the following ways.
First, I am partially vetoing section 183 [as it relates to s. 20.435 (5) (kd)] and vetoing section 379j to remove the appropriation for the youth crisis stabilization facility. Further, I am vetoing section 9120 (1b) to remove any requirements for the department to seek funding from the Joint Committee on Finance to implement this program. I object to this overly burdensome process and believe this type of treatment center should be implemented as soon as the department believes it is feasible to do so. I am also partially vetoing section 183 [as it relates to s. 20.865 (4) (g)] by lining out the appropriation and writing in a smaller amount that reduces the appropriation by $1,245,500 in fiscal year 2017-18. I am also requesting the Department of Administration secretary to not allot these funds. Next, I am partially vetoing section 183 [as it relates to s. 20.435 (5) (kp)] related to the peer-run respite center for veterans by striking the words "veterans peer-run respite" from the title of the appropriation to broaden its scope in order to fund both the peer-run respite center for veterans and a youth crisis stabilization center. I am also partially vetoing section 379p to further broaden the scope of the appropriation. However, I direct the department to expend at least $450,000 PR for a peer-run respite center for veterans and at least $1,245,500 PR for a youth crisis stabilization facility, consistent with the amounts approved for each by the Legislature. Further, I am partially vetoing section 377 to allow sufficient funding to be transferred from the appropriation funding operations of the mental health institutes to fund the youth crisis stabilization facility and the peer-run respite center for veterans.
Lastly, I am vetoing the remaining provisions to ensure ongoing funding for both the peer-run respite center and the youth crisis stabilization facility.
I believe these changes will allow the department to implement these important mental health treatment options in the most efficient manner possible.
73. Disposition of Surplus Revenue Balance in the Mental Health Institutes Appropriation
