OC7 SB1: Bill Text

SB1,703,19 49.45 (9) Free choice. Any person eligible for medical assistance under ss. s. 49.46, 49.468 and, 49.47, or 49.471 may use the physician, chiropractor, dentist, pharmacist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist or dentist may be required to practice exclusively in the medical assistance program.

SB1, s. 1542 Section 1542. 49.45 (18) (ac) of the statutes is amended to read:

SB1,704,7 49.45 (18) (ac) Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.

SB1, s. 1543 Section 1543. 49.45 (18) (am) of the statutes is amended to read:

SB1,704,11 49.45 (18) (am) No person is liable under this subsection for services provided through prepayment contracts. This paragraph does not apply to a person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.

SB1, s. 1546 Section 1546. 49.45 (23) of the statutes is created to read:

SB1,704,23 49.45 (23) Assistance for childless adults demonstration project. (a) The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide health care coverage for basic primary and preventive care to adults who are under the age of 65, who have family incomes not to exceed 200 percent of the poverty line, and who are not otherwise eligible for medical assistance under this subchapter, the Badger Care health care program under s. 49.665, or Medicare under 42 USC 1395 et seq. Any individual who had coverage under the Health Insurance Risk-Sharing Plan under subch. II of ch. 149 within 6 months before applying for the project under this subsection is not eligible to participate in the project under this subsection.

SB1,705,5 (b) If the waiver is granted and in effect, the department may promulgate rules defining the health care benefit plan, including more specific eligibility requirements and cost-sharing requirements. Notwithstanding s. 227.24 (3), the plan details under this subsection may be promulgated as an emergency rule under s. 227.24 without a finding of emergency. If the waiver is granted and in effect, the demonstration project under this subsection shall begin on January 1, 2009, or on the effective date of the waiver, whichever is later.

SB1, s. 1547 Section 1547. 49.45 (24g) of the statutes is repealed.

SB1, s. 1548 Section 1548. 49.45 (24m) (intro.) of the statutes is amended to read:

SB1,705,12 49.45 (24m) (intro.) From the appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w), and (xd), in order to test the feasibility of instituting a system of reimbursement for providers of home health care and personal care services for medical assistance recipients that is based on competitive bidding, the department shall:

SB1, s. 1549 Section 1549. 49.45 (24r) of the statutes is amended to read:

SB1,705,23 49.45 (24r) Family planning demonstration project. The department shall request a an amended waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide family planning services, as defined in s. 253.07 (1) (b) (a), under medical assistance to any woman or man between the ages of 15 and 44 whose family income does not exceed 185% 200 percent of the poverty line for a family the size of the woman's or man's family. If The department shall implement any waiver granted and, if the amendment to the waiver is granted and in effect, the department shall implement the amended waiver no later than July 1, 1998 January 1, 2008, or on the federally approved effective date of the amended waiver, whichever is later.

SB1, s. 1550 Section 1550. 49.45 (29) of the statutes is amended to read:

SB1,706,3 49.45 (29) Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46 and, 49.47, and 49.471.

SB1, s. 1551c Section 1551c. 49.45 (31) of the statutes is repealed and recreated to read:

SB1,706,13 49.45 (31) Long-Term Care Partnership Program. (a) The department shall submit to the federal department of health and human services, not later than 3 months after the effective date of this paragraph .... [revisor inserts date], an amendment to the state medical assistance plan that establishes in this state a Long-Term Care Partnership Program, as described in this subsection, and shall implement the program if the amendment to the state plan is approved. Under the program, the department shall exclude an amount equal to the amount of benefits that an individual receives under a qualifying long-term care insurance policy, as described in par. (b), when determining any of the following:

SB1,706,15 1. The individual's resources for purposes of determining the individual's eligibility for medical assistance.

SB1,706,17 2. The amount to be recovered from the individual's estate if the individual receives medical assistance.

SB1,706,20 (b) To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:

SB1,706,23 1. The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.

SB1,706,25 2. The policy meets the definition of a qualified long-term care insurance policy under 26 USC 7702B (b).

SB1,707,4 3. The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in 42 USC 1396p (b) (5).

SB1,707,6 4. The policy includes the applicable inflation protection specified in 42 USC 1396p (b) (1) (C) (iii) (IV).

SB1,707,8 5. The commissioner of insurance certifies to the department that the policy meets the criteria under subds. 2. to 4.

SB1,707,14 (c) 1. The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.

SB1,707,20 2. The training program approved under this paragraph shall include initial training that is not less than 8 hours long and ongoing training sessions that are not less than 4 hours long per session. Individuals who sell long-term care insurance policies shall be required to attend an ongoing training session every 24 months after the initial training. The commissioner may approve the initial and ongoing training sessions for continuing education requirements under s. 628.04 (3).

SB1,707,24 3. The training under this paragraph shall cover at a minimum long-term care insurance, long-term care services, qualified partnerships, and the relationship between qualified partnerships and other public and private coverage of long-term care costs.

SB1,708,6 (d) An insurer that issues a long-term care insurance policy described in par. (b) shall be required to submit reports to the secretary of the federal department of health and human services, in accordance with regulations developed by the secretary, that include notice of when benefits are paid under the policy, the amount of the benefits, notice of the termination of the policy, and any other information required by the secretary.

SB1, s. 1552 Section 1552. 49.45 (35) of the statutes is repealed.

SB1, s. 1553 Section 1553. 49.45 (40) of the statutes is amended to read:

SB1,708,12 49.45 (40) Periodic record matches. If the department contracts with the department of workforce development children and families under s. 49.197 (5), the department shall cooperate with the department of workforce development children and families in matching records of medical assistance recipients under s. 49.32 (7).

SB1, s. 1554 Section 1554. 49.45 (42m) (a) of the statutes is amended to read:

SB1,708,20 49.45 (42m) (a) If, in authorizing the provision of physical or occupational therapy services under s. 49.46 (2) (b) 6. b. or 49.471 (11) (i), the department authorizes a reduced duration of services from the duration that the provider specifies in the authorization request, the department shall substantiate the reduction that the department made in the duration of the services if the provider of the services requests any additional authorizations for the provision of physical or occupational therapy services to the same individual.

SB1, s. 1554m Section 1554m. 49.45 (44m) of the statutes is created to read:

SB1,709,4 49.45 (44m) Extension of parent eligibility when child dies. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to extend the eligibility of a parent, for up to 90 days, under the Medical Assistance program under this subchapter or the Badger Care health care program under s. 49.665 if the parent's child dies while both the parent and the child are covered under the Medical Assistance program or the Badger Care health care program and the parent would lose eligibility solely due to the death of the child. The department shall implement any waiver that is granted.

SB1, s. 1555 Section 1555. 49.45 (48) of the statutes is amended to read:

SB1,709,10 49.45 (48) Payment of medicare part B outpatient hospital services coinsurances. The department shall include in the state plan for medical assistance a methodology for payment of the medicare part B outpatient hospital services coinsurance amounts that are authorized under ss. 49.46 (2) (c) 2., 4., and 5m., 49.468 (1) (b), and 49.47 (6) (a) 6. b., d., and f., and 49.471 (6) (j) 1.

SB1, s. 1556 Section 1556. 49.45 (49m) (c) 1. of the statutes is amended to read:

SB1,709,15 49.45 (49m) (c) 1. A list of the prescription drugs that are included as a benefit under s. ss. 49.46 (2) (b) 6. h. and 49.471 (11) (a) that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.

SB1, s. 1557 Section 1557. 49.45 (52) of the statutes is amended to read:

SB1,710,2 49.45 (52) Payment adjustments. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payment adjustments to county departments under s. 46.215, 46.22, 46.23, or 51.42, or 51.437 or to local health departments, as defined in s. 250.01 (4), as appropriate, for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16. Payment adjustments under this subsection shall include the state share of the payments. The total of any payment adjustments under this subsection and Medical Assistance payments made from appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w), and (xd) may not exceed applicable limitations on payments under 42 USC 1396a (a) (30) (A).

SB1, s. 1558 Section 1558. 49.45 (53) of the statutes is amended to read:

SB1,710,7 49.45 (53) Payments for certain services. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under s. ss. 49.46 (2) (a) 4. d. and (b) 6. j. and m. and 49.471 (11) (f).

SB1, s. 1559e Section 1559e. 49.45 (55) of the statutes is created to read:

SB1,710,18 49.45 (55) Health Opportunity Accounts Demonstration Program. The department shall request from the federal Centers for Medicare and Medicaid Services approval to participate in a demonstration program under 42 USC 1396u-8, under which Badger Care recipients may voluntarily enroll to contribute to health opportunity accounts and receive certain alternative benefits under medical assistance. If the Centers for Medicare and Medicaid Services approve the department's request, the department shall submit a proposed plan for implementation of the demonstration program to the joint committee on finance. The department may not implement the plan until it is approved by the committee, as submitted or as modified.

SB1, s. 1559g Section 1559g. 49.45 (56) of the statutes is created to read:

SB1,711,2 49.45 (56) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57), the department shall develop and implement, for Medical Assistance recipients, 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:

SB1,711,5 (a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.

SB1,711,7 (b) Educating health care providers on health care process improvement by developing best practice models.

SB1,711,10 (c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.

SB1,711,12 (d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.

SB1,711,14 (e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.

SB1, s. 1559h Section 1559h. 49.45 (57) of the statutes is created to read:

SB1,711,20 49.45 (57) Physical health risk assessment. The department shall encourage each individual who is determined on or after the effective date of this subsection .... [revisor inserts date], to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.

SB1, s. 1559n Section 1559n. 49.45 (58) of the statutes is created to read:

SB1,712,11 49.45 (58) Health maintenance organization payments to hospitals. (a) The department shall establish a schedule of amounts that each health maintenance organization that contracts with the department to provide medical assistance services or services under s. 49.665 for a capitated payment rate shall pay monthly to each hospital that serves recipients of medical assistance services or recipients of services under s. 49.665. The amounts shall be based on any increase in the capitated rate that the department pays a health maintenance organization, which increase is intended to cover inpatient and outpatient hospital services and which is associated with the assessment imposed on hospitals under s. 50.375. The department shall use the information that it uses to calculate the capitated rates that the department pays health maintenance organizations and encounter data that is provided by the health maintenance organizations to calculate the amounts in the schedule. The department shall disclose publicly the methodology it uses to calculate the amounts in the schedule. The department shall recalculate the amounts in the schedule at least once every 12 months.

SB1,712,15 (b) The department shall require, as a term of contracts with health maintenance organizations to provide medical assistance services or services under s. 49.665 for a capitated payment rate, that the health maintenance organization do all of the following:

SB1,712,16 1. Monthly pay hospitals the applicable amounts in the schedule under par. (a).

SB1,712,24 2. Every 6 months, and for each hospital to which the health maintenance organization made payments under par. (a), reconcile the amount that the health maintenance organization paid the hospital under par. (a) for the previous 6 months with the amount that the hospital charged the health maintenance organization for providing inpatient and outpatient services during the same 6 months to recipients of medical assistance or recipients of services under s. 49.665, and, if the amount of the charges exceeds the amount of the payments, pay the hospital the difference within 90 days.

SB1,713,7 (bm) If the total payments that a health maintenance organization makes to a hospital under par. (a), for a 6-month period that is subject to a reconciliation under par. (b), exceed the amount that the hospital charges the health maintenance organization for providing inpatient and outpatient services to recipients of medical assistance or recipients of services under s. 49.665 for that 6-month period, the hospital shall pay the health maintenance organization the difference within 90 days after the end of the 6-month period.

SB1,713,15 (c) If the department determines that a health maintenance organization has not complied with a condition under par. (b), the department shall require the health maintenance organization to comply with the condition within 15 days after the department's determination. The department may terminate a contract with a health maintenance organization to provide medical assistance services or services under s. 49.665 for a capitated payment rate for failure to comply with a condition under par. (b). The department may audit health maintenance organizations to determine whether they have complied with the conditions under par. (b).

SB1,713,24 (d) If a health maintenance organization and hospital cannot resolve the amount that a health maintenance organization owes a hospital under par. (b) 2. or that a hospital owes a health maintenance organization under par. (bm), and either the health maintenance organization or the hospital, within 6 months after the end of the time period to which the disputed amount relates, requests that the department determine the amount owed, the department shall determine the amount within 90 days after the request is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under ch. 227 on the department's determination.

SB1,713,25 (e) Paragraphs (a), (b), (bm), and (c) do not apply after December 31, 2010.

SB1, s. 1560 Section 1560. 49.453 (1) (a) of the statutes is amended to read:

SB1,714,2 49.453 (1) (a) "Assets" has the meaning given in 42 USC 1396p (e) (h) (1).

SB1, s. 1561 Section 1561. 49.453 (1) (ar) of the statutes is created to read:

SB1,714,5 49.453 (1) (ar) "Community spouse" means the spouse of either the institutionalized person or the noninstitutionalized person.

SB1, s. 1562 Section 1562. 49.453 (1) (d) of the statutes is amended to read:

SB1,714,7 49.453 (1) (d) "Income" has the meaning given in 42 USC 1396p (e) (h) (2).

SB1, s. 1563 Section 1563. 49.453 (1) (e) of the statutes is amended to read:

SB1,714,10 49.453 (1) (e) "Institutionalized individual" has the meaning given in 42 USC 1396p (e) (h) (3).

SB1, s. 1564 Section 1564. 49.453 (1) (f) (intro.) of the statutes is amended to read:

SB1,714,13 49.453 (1) (f) (intro.) "Look-back date" means for a covered individual, either of the following:

SB1,714,17 1m. For transfers made before February 8, 2006, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under s. 49.454 (2) (c) or (3) (b) the date that is 60 months before:

SB1, s. 1565 Section 1565. 49.453 (1) (f) 1. of the statutes is renumbered 49.453 (1) (f) 1m. a.

SB1, s. 1566 Section 1566. 49.453 (1) (f) 2. of the statutes is renumbered 49.453 (1) (f) 1m. b.

SB1, s. 1567 Section 1567. 49.453 (1) (f) 2m. of the statutes is created to read:

SB1,714,24 49.453 (1) (f) 2m. For all transfers made on or after February 8, 2006, the date that is 60 months before the dates specified in subd. 1m. a. and b.

SB1, s. 1568 Section 1568. 49.453 (1) (fm) of the statutes is amended to read:

SB1,715,2 49.453 (1) (fm) "Noninstitutionalized individual" has the meaning given in 42 USC 1396p (e) (h) (4).

SB1, s. 1569 Section 1569. 49.453 (1) (i) of the statutes is amended to read:

SB1,715,4 49.453 (1) (i) "Resources" has the meaning given in 42 USC 1396p (e) (h) (5).

SB1, s. 1570 Section 1570. 49.453 (3) (a) of the statutes is renumbered 49.453 (3) (a) (intro.) and amended to read:

SB1,715,8 49.453 (3) (a) (intro.) The period of ineligibility under this subsection begins on either of the following:

SB1,715,12 1. In the case of a transfer of assets made before February 8, 2006, the first day of the first month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value and that does not occur in any other periods of ineligibility under this subsection.

SB1, s. 1571 Section 1571. 49.453 (3) (a) 2. of the statutes is created to read:

SB1,715,21 49.453 (3) (a) 2. In the case of a transfer of assets made on or after February 8, 2006, the first day of a month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance and would otherwise be receiving institutional level care described in sub. (2) (a) 1. to 3. based on an approved application for the care but for the application of the penalty period, whichever is later, and that does not occur during any other period of ineligibility under this subsection.

SB1, s. 1572 Section 1572. 49.453 (3) (b) (intro.) of the statutes is amended to read: