SB40,751,76
5. A participant in the program of prescription drug assistance for elderly
7persons under s. 49.688.
SB40,751,88
6. A woman who receives services that are reimbursed under s. 255.06.
SB40, s. 1616
9Section
1616. 49.475 (1) (f) of the statutes is created to read:
SB40,751,1210
49.475
(1) (f) "Third party" means an entity that by statute, rule, or contract
11is responsible for payment of a claim for a health care item or service. "Third party"
12includes all of the following:
SB40,751,1313
1. An insurer.
SB40,751,15142. An employee benefit plan described in
29 USC 1003 (a) that is not exempt
15under
29 USC 1003 (b) and is not a multiple employer welfare arrangement.
SB40,751,16163. A service benefit plan, as specified in
42 USC 1396a (25) (I).
SB40,751,1717
4. A pharmacy benefits manager.
SB40, s. 1617
18Section
1617. 49.475 (2) of the statutes is repealed and recreated to read:
SB40,751,2019
49.475
(2) Requirements of 3rd parties. As a condition of doing business in this
20state, a 3rd party shall do all of the following:
SB40,751,2321
(a) Upon the department's request and in the manner prescribed by the
22department, provide information to the department necessary for the department to
23ascertain all of the following with respect to a recipient:
SB40,751,2524
1. Whether the recipient is being or has been provided coverage or a benefit or
25service by a 3rd party.
SB40,752,3
12. If subd. 1. applies, the nature and period of time of any coverage, benefit, or
2service provided, including the name, address, and identifying number of any
3applicable coverage plan.
SB40,752,74
(b) Accept assignment to the department of a right of a recipient to receive
53rd-party payment for an item or service for which payment under medical
6assistance has been made and accept the department's right to recover any
73rd-party payment made for which assignment has not been accepted.
SB40,752,108
(c) Respond to an inquiry by the department concerning a claim for payment
9of a health care item or service if the department submits the inquiry less than 36
10months after the date on which the health care item or service was provided.
SB40,752,1411
(d) If all of the following apply, agree not to deny a claim submitted by the
12department under par. (b) solely because of the claim's submission date, the type or
13format of the claim form, or failure by a recipient to present proper documentation
14at the time of delivery of the service, benefit, or item that is the basis of the claim:
SB40,752,1615
1. The department submits the claim less than 36 months after the date on
16which the health care item or service was provided.
SB40,752,1917
2. Action by the department to enforce the department's rights under this
18section with respect to the claim is commenced less than 72 months after the
19department submits the claim.
SB40, s. 1618
20Section
1618. 49.475 (3) (intro.) of the statutes is amended to read:
SB40,752,2321
49.475
(3) Written agreement. (intro.) Upon requesting
an insurer a 3rd party 22to provide the information under sub. (2)
(a), the department
and the 3rd party shall
23enter into a written agreement
with the insurer that satisfies all of the following:
SB40, s. 1619
24Section
1619. 49.475 (3) (a) of the statutes is amended to read:
SB40,753,2
149.475
(3) (a) Identifies
in detail the detailed format of the information to be
2disclosed provided to the department.
SB40, s. 1620
3Section
1620. 49.475 (3) (c) of the statutes is amended to read:
SB40,753,54
49.475
(3) (c) Specifies how the
insurer's 3rd party's reimbursable costs under
5sub. (5) will be determined and specifies the manner of payment.
SB40, s. 1621
6Section
1621. 49.475 (4) (a) of the statutes is amended to read:
SB40,753,107
49.475
(4) (a)
An insurer A 3rd party shall provide the information requested
8under sub. (2)
(a) within 180 days after receiving the department's request if it is the
9first time that the department has requested the
insurer 3rd party to disclose
10information under this section.
SB40, s. 1622
11Section
1622. 49.475 (4) (b) of the statutes is amended to read:
SB40,753,1512
49.475
(4) (b)
An insurer A 3rd party shall provide the information requested
13under sub. (2)
(a) within 30 days after receiving the department's request if the
14department has previously requested the
insurer 3rd party to disclose information
15under this section.
SB40, s. 1623
16Section
1623. 49.475 (4) (d) of the statutes is created to read:
SB40,753,1817
49.475
(4) (d) If a 3rd party other than an insurer fails to comply with par. (a)
18or (b), the department may so notify the attorney general.
SB40, s. 1624
19Section
1624. 49.475 (5) of the statutes is amended to read:
SB40,753,2520
49.475
(5) From the appropriations under s. 20.435 (4) (bm) and (pa), the
21department shall reimburse
an insurer A 3rd party that provides information under
22this section sub. (2) (a) for the
insurer's 3rd party's reasonable costs incurred in
23providing the requested information, including its reasonable costs, if any, to develop
24and operate automated systems specifically for the disclosure of
the information
25under this section.
SB40, s. 1625
1Section
1625. 49.475 (6) of the statutes is created to read:
SB40,754,112
49.475
(6) Sharing information. The department of health and family services
3shall provide to the department of workforce development, for purposes of the
4medical support liability program under s. 49.22, any information that the
5department of health and family services receives under this section. The
6department of workforce development may allow a county child support agency
7under s. 59.53 (5) or a tribal child support agency access to the information, subject
8to the use and disclosure restrictions under s. 49.83, and shall consult with the
9department of health and family services regarding procedures and methods to
10adequately safeguard the confidentiality of the information provided under this
11subsection.
SB40, s. 1626
12Section
1626. 49.475 (6) of the statutes, as created by 2007 Wisconsin Act ....
13(this act), is amended to read:
SB40,754,2314
49.475
(6) Sharing information. The department of health and family services
15shall provide to the department of
workforce development children and families, for
16purposes of the medical support liability program under s. 49.22, any information
17that the department of health and family services receives under this section. The
18department of
workforce development children and families may allow a county child
19support agency under s. 59.53 (5) or a tribal child support agency access to the
20information, subject to the use and disclosure restrictions under s. 49.83, and shall
21consult with the department of health and family services regarding procedures and
22methods to adequately safeguard the confidentiality of the information provided
23under this subsection.
SB40, s. 1627
24Section
1627. 49.48 (1m) of the statutes is amended to read:
SB40,755,7
149.48
(1m) If an individual who applies for or to renew a certification under
2sub. (1) does not have a social security number, the individual, as a condition of
3obtaining the certification, shall submit a statement made or subscribed under oath
4or affirmation to the department that the applicant does not have a social security
5number. The form of the statement shall be prescribed by the department of
6workforce development children and families. A certification issued or renewed in
7reliance upon a false statement submitted under this subsection is invalid.
SB40, s. 1628
8Section
1628. 49.48 (2) of the statutes is amended to read:
SB40,755,129
49.48
(2) The department
of health and family services may not disclose any
10information received under sub. (1) to any person except to the department of
11workforce development children and families for the purpose of making
12certifications required under s. 49.857.
SB40, s. 1629
13Section
1629. 49.48 (3) of the statutes is amended to read:
SB40,755,2514
49.48
(3) The department
of health and family services shall deny an
15application for the issuance or renewal of a certification specified in sub. (1), shall
16suspend a certification specified in sub. (1) or may, under a memorandum of
17understanding under s. 49.857 (2), restrict a certification specified in sub. (1) if the
18department of
workforce development children and families certifies under s. 49.857
19that the applicant for or holder of the certificate is delinquent in the payment of
20court-ordered payments of child or family support, maintenance, birth expenses,
21medical expenses or other expenses related to the support of a child or former spouse
22or fails to comply, after appropriate notice, with a subpoena or warrant issued by the
23department of
workforce development children and families or a county child
24support agency under s. 59.53 (5) and related to paternity or child support
25proceedings.
SB40, s. 1630
1Section
1630. 49.49 (3m) (a) (intro.) of the statutes is amended to read:
SB40,756,52
49.49
(3m) (a) (intro.) No provider may knowingly impose upon a recipient
3charges in addition to payments received for services under ss. 49.45 to
49.47 49.471 4or knowingly impose direct charges upon a recipient in lieu of obtaining payment
5under ss. 49.45 to
49.47 49.471 except under the following conditions:
SB40, s. 1631
6Section
1631. 49.49 (3m) (a) 1. of the statutes is amended to read:
SB40,756,87
49.49
(3m) (a) 1. Benefits or services are not provided under s. 49.46 (2)
or
849.471 (11) and the recipient is advised of this fact prior to receiving the service.
SB40, s. 1632
9Section
1632. 49.49 (3m) (a) 2. of the statutes is amended to read:
SB40,756,2010
49.49
(3m) (a) 2. If an applicant is determined to be eligible retroactively under
11s. 49.46 (1) (b)
or 49.47 (4) (d) and a provider bills the applicant directly for services
12and benefits rendered during the retroactive period, the provider shall, upon
13notification of the applicant's retroactive eligibility, submit claims for
14reimbursement payment under s. 49.45 for covered services or benefits rendered
to
15the recipient during the retroactive period. Upon receipt of payment
under s. 49.45,
16the provider shall reimburse the
applicant recipient or other person who has made
17prior payment to the provider
. No provider may be required to reimburse the
18applicant or other person in excess of the amount reimbursed under s. 49.45 for
19services provided to the recipient during the retroactive eligibility period, by the
20amount of the prior payment made.
SB40, s. 1633
21Section
1633
. 49.49 (3m) (a) 2. of the statutes, as affected by 2007 Wisconsin
22Act .... (this act), is amended to read:
SB40,757,623
49.49
(3m) (a) 2. If an applicant is determined to be eligible retroactively under
24s. 49.46 (1) (b)
or, 49.47 (4) (d)
, or 49.471 and a provider bills the applicant directly
25for services and benefits rendered during the retroactive period, the provider shall,
1upon notification of the applicant's retroactive eligibility, submit claims for payment
2under s. 49.45 for covered services or benefits rendered to the recipient during the
3retroactive period. Upon receipt of payment under s. 49.45, the provider shall
4reimburse the recipient or other person who has made prior payment to the provider
5for services provided to the recipient during the retroactive eligibility period, by the
6amount of the prior payment made.
SB40, s. 1634
7Section
1634
. 49.49 (3m) (a) 3. of the statutes is amended to read:
SB40,757,118
49.49
(3m) (a) 3. Benefits or services for which recipient copayment,
9coinsurance
, or deductible is required under s. 49.45 (18), not to exceed maximum
10amounts allowable under
42 CFR 447.53 to
447.58, or for which recipient copayment
11or coinsurance is required under s. 49.471 (11).
SB40, s. 1635
12Section
1635. 49.497 (title) of the statutes is amended to read:
SB40,757,14
1349.497 (title)
Recovery of incorrect Medical Assistance or Badger Care
14payments and of unpaid employer penalties.
SB40, s. 1636
15Section
1636. 49.497 (1r) of the statutes is created to read:
SB40,758,216
49.497
(1r) (a) The department may recover any penalty assessment not paid
17under s. 49.471 (9) (c) from the employer against which the penalty was assessed.
18If, after notice that payment of a penalty is overdue, the employer who is liable fails
19to pay the penalty amount, or enter into or comply with an agreement for payment,
20the department may bring an action to enforce the liability or may issue an order to
21compel payment of the liability. Any person aggrieved by an order issued by the
22department under this paragraph may appeal the order as a contested case under
23ch. 227 by filing with the department a request for a hearing within 30 days after the
24date of the order. The only issue at the hearing shall be the determination by the
1department that the person has not paid the penalty or entered into, or complied
2with, an agreement for payment.
SB40,758,123
(b) If any employer named in an order to compel payment issued under par. (a)
4fails to pay the department any amount due under the terms of the order and no
5contested case to review the order is pending and the time for filing for a contested
6case review has expired, the department may present a certified copy of the order to
7the circuit court for any county. The sworn statement of the secretary shall be
8evidence of the failure to pay the penalty. The circuit court shall, without notice,
9render judgment in accordance with the order. A judgment rendered under this
10paragraph shall have the same effect and shall be entered in the judgment and lien
11docket and may be enforced in the same manner as if the judgment had been
12rendered in an action tried and determined by the circuit court.
SB40,758,1413
(c) The recovery procedure under this subsection is in addition to any other
14recovery procedure authorized by law.
SB40, s. 1637
15Section
1637. 49.497 (4) of the statutes is amended to read:
SB40,758,2016
49.497
(4) The department may appear for the state in any and all collection
17matters under this section, and may commence suit in the name of the department
18to recover an incorrect payment from the recipient to whom or on whose behalf it was
19made
or to recover an unpaid penalty from the employer against which the penalty
20was assessed.
SB40, s. 1638
21Section
1638. 49.665 (4) (ap) 2. of the statutes is repealed.
SB40, s. 1639
22Section
1639. 49.665 (4) (at) 1. a. of the statutes is amended to read:
SB40,759,323
49.665
(4) (at) 1. a. Except as provided in subd. 1. b., the department shall
24establish a lower maximum income level for the initial eligibility determination if
25funding under s. 20.435 (4)
(bc), (jz), (p),
and (x)
, and (xd) is insufficient to
1accommodate the projected enrollment levels for the health care program under this
2section. The adjustment may not be greater than necessary to ensure sufficient
3funding.
SB40, s. 1640
4Section
1640. 49.665 (4) (at) 1. cm. of the statutes is amended to read:
SB40,759,155
49.665
(4) (at) 1. cm. Notwithstanding s. 20.001 (3) (b), if, after reviewing the
6plan submitted under subd. 1. b., the joint committee on finance determines that the
7amounts appropriated under s. 20.435 (4)
(bc), (jz), (p),
and (x)
, and (xd) are
8insufficient to accommodate the projected enrollment levels, the committee may
9transfer appropriated moneys from the general purpose revenue appropriation
10account of any state agency, as defined in s. 20.001 (1), other than a sum sufficient
11appropriation account, to the appropriation account under s. 20.435 (4) (bc) to
12supplement the health care program under this section if the committee finds that
13the transfer will eliminate unnecessary duplication of functions, result in more
14efficient and effective methods for performing programs, or more effectively carry out
15legislative intent, and that legislative intent will not be changed by the transfer.
SB40, s. 1641
16Section
1641. 49.665 (4) (at) 2. of the statutes is amended to read:
SB40,759,2117
49.665
(4) (at) 2. If, after the department has established a lower maximum
18income level under subd. 1., projections indicate that funding under s. 20.435 (4)
(bc), 19(jz), (p),
and (x)
, and (xd) is sufficient to raise the level, the department shall, by state
20plan amendment, raise the maximum income level for initial eligibility, but not to
21exceed 185% of the poverty line.
SB40, s. 1642
22Section
1642. 49.665 (5m) of the statutes is repealed and recreated to read:
SB40,759,2523
49.665
(5m) Information about Badger Care recipients. The department
24shall obtain and share information about Badger Care health care program
25recipients as provided in s. 49.475.
SB40, s. 1643
1Section
1643. 49.665 (6) of the statutes is repealed.
SB40, s. 1644
2Section
1644. 49.665 (7) (a) 1. of the statutes is amended to read:
SB40,760,63
49.665
(7) (a) 1. Notwithstanding sub. (4) (a) 3m.
and (ap) 2., the department
4shall mail information verification forms to the employers of the individuals required
5to provide the verifications under sub. (4) (a) 3m.
and (ap) 2. to obtain the information
6specified.
SB40, s. 1645
7Section
1645. 49.68 (3) (e) of the statutes is amended to read:
SB40,760,198
49.68
(3) (e)
State aids for services provided under this section shall be equal
9to the allowable charges under the federal Medicare program. In no case shall state
10rates for individual service elements exceed the federally defined allowable costs.
11The rate of charges for services not covered by public and private insurance shall not
12exceed the reasonable charges as established by medicare fee determination
13procedures. A person that provides to a patient a service for which aid is provided
14under this section shall accept the amount paid under this section for the service as
15payment in full and may not bill the patient for any amount by which the charge for
16the service exceeds the amount paid for the service under this section. The state may
17not pay for the cost of travel, lodging, or meals for persons who must travel to receive
18inpatient and outpatient dialysis treatment for kidney disease. This paragraph shall
19not apply to donor related costs as defined in par. (b).
SB40, s. 1646
20Section
1646. 49.686 (6) of the statutes is created to read:
SB40,761,221
49.686
(6) Health Insurance Risk-Sharing Plan pilot program. (a) Subject
22to par. (b), the department shall conduct a 3-year pilot program under which the
23department may pay premiums for coverage under the Health Insurance
24Risk-Sharing Plan under subch. II of ch. 149, and pay copayments under that plan
1for prescription drugs for which reimbursement may be provided under sub. (2), for
2individuals who satisfy all of the following:
SB40,761,33
1. The individuals are eligible for reimbursement under this section.
SB40,761,44
2. The individuals are currently taking antiretroviral drugs.
SB40,761,55
3. The individuals do not have health insurance coverage.
SB40,761,96
4. The individuals are not eligible for premium subsidies under s. 252.16 or
7252.17 because they are not on unpaid medical leave, are not unable to continue
8employment, and have not had to reduce their employment hours because of an
9illness or medical condition arising from or related to HIV.
SB40,761,1110
(b) The pilot program shall be limited to no more than 100 individuals at any
11given time.
SB40,761,1412
(c) The department may promulgate rules for the administration of the pilot
13program. Notwithstanding s. 227.24 (3), rules under this paragraph may be
14promulgated as emergency rules under s. 227.24 without a finding of emergency.
SB40, s. 1647
15Section
1647. 49.687 (title) of the statutes is amended to read:
SB40,761,17
1649.687 (title)
Disease aids; patient requirements; rebate agreements;
17cost containment general provisions.
SB40, s. 1648
18Section
1648. 49.687 (2r) of the statutes is created to read:
SB40,761,2319
49.687
(2r) A person that provides a patient with a service for which aid is
20provided under s. 49.68, 49.683, or 49.685 shall accept the amount paid under s.
2149.68, 49.683, or 49.685 for the service as payment in full and may not bill the patient
22for any amount by which the charge for the service exceeds the amount paid for the
23service under s. 49.68, 49.683, or 49.685.
SB40, s. 1649
24Section
1649. 49.687 (5) of the statutes is created to read: