JR1 AB11: Bill Text

AB11,45,14 5. Improving the health status of individuals who receive benefits under a Medical Assistance program.

AB11,45,16 6. Aligning Medical Assistance program benefit recipient and service provider incentives with health care outcomes.

AB11,45,17 7. Supporting responsibility and choice of medical assistance recipients.

AB11,45,21 (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 promulgate rules that do any of the following related to Medical Assistance programs:

AB11,45,23 1. Require cost sharing from program benefit recipients up to the maximum allowed by federal law or a waiver of federal law.

AB11,45,25 2. Authorize 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.

AB11,46,2 3. Modify existing benefits or establish various benefit packages and offer different packages to different groups of recipients.

AB11,46,3 4. Revise provider reimbursement models for particular services.

AB11,46,4 5. Mandate that program benefit recipients enroll in managed care.

AB11,46,5 6. Restrict or eliminate presumptive eligibility.

AB11,46,7 7. To the extent permitted by federal law, impose restrictions on providing benefits to individuals who are not citizens of the United States.

AB11,46,8 8. Set standards for establishing and verifying eligibility requirements.

AB11,46,10 9. Develop standards and methodologies to assure accurate eligibility determinations and redetermine continuing eligibility.

AB11,46,12 10. Reduce 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.

AB11,46,24 (d) Before promulgating a rule under par. (c), the department shall submit to the joint committee on finance the proposed rule and any plan that the department develops as a result of the study under par. (b). 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 rule or plan, the proposed rule may be promulgated and any plan may be implemented as proposed by the department. 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 rule or plan, the proposed rule may be promulgated, and the plan may be implemented only upon approval of the committee.

AB11,47,6 (e) 1. 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 rule promulgated 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 put the rule into effect or implement the action described in the rule.

AB11,47,16 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).

AB11,47,24 (f) Using the procedure under s. 227.24, the department may promulgate a rule under par. (c) as an emergency rule. Notwithstanding s. 227.24 (1) (a) and (3), the department is not required to provide evidence that promulgating a rule under par. (c) as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under par. (c). Notwithstanding s. 227.24 (1) (c) and (2), an emergency rule promulgated under this paragraph remains in effect until whichever of the following occurs first:

AB11,47,25 1. The effective date of the repeal of the emergency rule.

AB11,48,2 2. The date on which the permanent rule promulgated under par. (c) takes effect.

AB11, s. 113 Section 113. 49.45 (3) (n) of the statutes is created to read:

AB11,48,5 49.45 (3) (n) This subsection does not apply if the department promulgates a rule under sub. (2m) (c) 4., to the extent that the rule conflicts with this subsection.

AB11, s. 114 Section 114. 49.45 (6m) (n) of the statutes is created to read:

AB11,48,8 49.45 (6m) (n) This subsection does not apply if the department promulgates a rule under sub. (2m) (c) 4., to the extent that the rule conflicts with this subsection.

AB11, s. 115 Section 115. 49.45 (8) (b) of the statutes is amended to read:

AB11,48,15 49.45 (8) (b) Reimbursement Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), reimbursement under s. 20.435 (4) (b), (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).

AB11, s. 116 Section 116. 49.45 (8) (c) of the statutes is amended to read:

AB11,48,22 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 rule promulgated under sub. (2m) (c).

AB11, s. 117 Section 117. 49.45 (8r) of the statutes is amended to read:

AB11,49,6 49.45 (8r) Payment for certain obstetric and gynecological care. The Unless otherwise provided by the department by rule promulgated 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.

AB11, s. 118 Section 118. 49.45 (8v) of the statutes is amended to read:

AB11,49,18 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 rule promulgated 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.

AB11, s. 119 Section 119. 49.45 (18) (ac) of the statutes is amended to read:

AB11,50,7 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 Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), 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.

AB11, s. 120 Section 120. 49.45 (18) (ag) (intro.) of the statutes is amended to read:

AB11,50,11 49.45 (18) (ag) (intro.) Except as provided in pars. (am), (b), and (c), and subject to par. (d), a recipient specified in par. (ac) shall pay all of the following, unless otherwise provided by the department by rule promulgated under sub. (2m) (c):

AB11, s. 121 Section 121. 49.45 (18) (b) (intro.) of the statutes is amended to read:

AB11,50,15 49.45 (18) (b) (intro.) The Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), the following services are not subject to recipient cost sharing under this subsection:

AB11, s. 122 Section 122. 49.45 (18) (d) of the statutes is amended to read:

AB11,50,21 49.45 (18) (d) No person who designates a pharmacy or pharmacist as his or her sole provider of prescription drugs and who so uses that pharmacy or pharmacist is liable under this subsection for more than $12 per month for prescription drugs received, unless otherwise provided by the department by rule promulgated under sub. (2m) (c).

AB11, s. 123 Section 123. 49.45 (23) (a) of the statutes is amended to read:

AB11,51,6 49.45 (23) (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. If the department promulgates a rule under sub. (2m) (c) 10., this paragraph does not apply to the extent that it conflicts with the rule.

AB11, s. 124 Section 124. 49.45 (23) (b) of the statutes is amended to read:

AB11,51,17 49.45 (23) (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. Cost Unless otherwise provided by the department by rule promulgated under sub. (2m) (c), cost sharing may include an annual enrollment fee, which may not exceed $75 per year. 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.

AB11, s. 125 Section 125. 49.45 (24g) (c) of the statutes is amended to read:

AB11,52,3 49.45 (24g) (c) The department's proposal under par. (a) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or 2., and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than July 1, 2011. If the department promulgates a rule under sub. (2m) (c) 4., this paragraph does not apply to the extent that it conflicts with the rule.

AB11, s. 126 Section 126. 49.45 (24r) (a) of the statutes is amended to read:

AB11,52,11 49.45 (24r) (a) The department shall implement any waiver granted by the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide family planning, as defined in s. 253.07 (1) (a), under medical assistance to any woman between the ages of 15 and 44 whose family income does not exceed 200% of the poverty line for a family the size of the woman's family. If the department promulgates a rule under sub. (2m) (c) 10., this paragraph does not apply to the extent it conflicts with the rule.

AB11, s. 127 Section 127. 49.45 (24r) (b) of the statutes is amended to read:

AB11,52,19 49.45 (24r) (b) The department may request an amended waiver from the secretary to permit the department to conduct a demonstration project to provide family planning to any man between the ages of 15 and 44 whose family income does not exceed 200 percent of the poverty line for a family the size of the man's family. If the amended waiver is granted, the department may implement the waiver. If the department promulgates a rule under sub. (2m) (c) 10., this paragraph does not apply to the extent it conflicts with the rule.

AB11, s. 128 Section 128. 49.45 (25g) (c) of the statutes is amended to read:

AB11,53,7 49.45 (25g) (c) The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (b) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011. The increases in reimbursement rates and monthly per-patient care coordination fees that are not provided by the federal government shall be paid from the appropriation under. s. 20.435 (1) (am). If the department promulgates a rule under sub. (2m) (c) 4., this paragraph does not apply to the extent it conflicts with the rule.

AB11, s. 129 Section 129. 49.45 (27) of the statutes is amended to read:

AB11,53,13 49.45 (27) Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v), unless otherwise provided by the department by rule promulgated under sub. (2m) (c).

AB11, s. 130 Section 130. 49.45 (39) (b) 1. of the statutes is amended to read:

AB11,54,24 49.45 (39) (b) 1. `Payment for school medical services.' If a school district or a cooperative educational service agency elects to provide school medical services and meets all requirements under par. (c), the department shall reimburse the school district or the cooperative educational service agency for 60% of the federal share of allowable charges for the school medical services that it provides , unless otherwise provided by the department by rule promulgated under sub. (2m) (c), and, as specified in subd. 2., for allowable administrative costs. If the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing elects to provide school medical services and meets all requirements under par. (c), the department shall reimburse the department of public instruction for 60% of the federal share of allowable charges for the school medical services that the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing provides, unless otherwise provided by the department by rule promulgated under sub. (2m) (c), and, as specified in subd. 2., for allowable administrative costs. A school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, claims for common carrier transportation costs as a school medical service unless the department receives notice from the federal health care financing administration that, under a change in federal policy, the claims are not allowed. If the department receives the notice, a school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, unreimbursed claims for common carrier transportation costs incurred before the date of the change in federal policy. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. All other expenses for the school medical services provided by a school district or a cooperative educational service agency shall be paid for by the school district or the cooperative educational service agency with funds received from state or local taxes. The school district, the Wisconsin Center for the Blind and Visually Impaired, the Wisconsin Educational Services Program for the Deaf and Hard of Hearing, or the cooperative educational service agency shall comply with all requirements of the federal department of health and human services for receiving federal financial participation.

AB11, s. 131 Section 131. 49.46 (1) (n) of the statutes is created to read:

AB11,55,2 49.46 (1) (n) If the department promulgates a rule under s. 49.45 (2m) (c) 8., 9., or 10., this subsection does not apply to the extent that it conflicts with the rule.

AB11, s. 132 Section 132. 49.46 (2) (a) (intro.) of the statutes is amended to read:

AB11,55,7 49.46 (2) (a) (intro.) Except as provided in par. (be) and unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits:

AB11, s. 133 Section 133. 49.46 (2) (b) (intro.) of the statutes is amended to read:

AB11,55,12 49.46 (2) (b) (intro.) Except as provided in pars. (be) and (dc) and unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services:

AB11, s. 134 Section 134. 49.465 (2) (intro.) of the statutes is amended to read:

AB11,55,20 49.465 (2) (intro.) A Unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), a pregnant woman is eligible for medical assistance benefits, as provided under sub. (3), during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman's family income does not exceed the highest level for eligibility for benefits under s. 49.46 (1) or 49.47 (4) (am) or (c) 1. and ending as follows:

AB11, s. 135 Section 135. 49.47 (4) (a) (intro.) of the statutes is amended to read:

AB11,55,25 49.47 (4) (a) (intro.) Any Unless otherwise provided by the department by rule under s. 49.45 (2m) (c), any individual who meets the limitations on income and resources under pars. (b) to (c) and who complies with pars. (cm) and (cr) shall be eligible for medical assistance under this section if such individual is:

AB11, s. 136 Section 136. 49.47 (5) (intro.) of the statutes is amended to read:

AB11,56,3 49.47 (5) Investigation by department. (intro.) The department may make additional investigation of eligibility at any of the following times:

AB11, s. 137 Section 137. 49.47 (5) (a) of the statutes is amended to read:

AB11,56,7 49.47 (5) (a) When there is reasonable ground for belief that an applicant may not be eligible or that the beneficiary may have received benefits to which the beneficiary is not entitled; or.

AB11, s. 138 Section 138. 49.47 (5) (c) of the statutes is created to read:

AB11,56,13 49.47 (5) (c) Any time determined by the department by rule promulgated under s. 49.45 (2m) (c) to determine eligibility or to reevaluate continuing eligibility, except that if federal law allows a reevaluation of eligibility more frequently than every 12 months and if there is no conflicting provision of state law, the department is not required to promulgate a rule to reevaluate eligibility under this section.

AB11, s. 139 Section 139. 49.47 (6) (a) (intro.) of the statutes is amended to read:

AB11,56,17 49.47 (6) (a) (intro.) The Unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), the department shall audit and pay charges to certified providers for medical assistance on behalf of the following:

AB11, s. 140 Section 140. 49.471 (13) of the statutes is created to read:

AB11,56,21 49.471 (13) Applicability. If the department promulgates a rule under s. 49.45 (2m) (c), subs. (4), (5), (6), (7), (8), (10), and (11) do not apply to the extent that those subsections conflict with the rule.

AB11, s. 141 Section 141. 49.472 (3) (intro.) of the statutes is amended to read:

AB11,57,2 49.472 (3) Eligibility. (intro.) Except as provided in sub. (6) (a) and unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:

AB11, s. 142 Section 142. 49.472 (4) (b) (intro.) of the statutes is amended to read:

AB11,57,8 49.472 (4) (b) (intro.) The department may waive monthly premiums that are calculated to be below $10 per month. The Unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), the department may not assess a monthly premium for any individual whose income level, after adding the individual's earned income and unearned income, is below 150% of the poverty line.

AB11, s. 143 Section 143. 49.473 (2) (intro.) of the statutes is amended to read:

AB11,57,14 49.473 (2) (intro.) A Unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c), a woman is eligible for medical assistance as provided under sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:

AB11, s. 144 Section 144. 49.473 (5) of the statutes is amended to read:

AB11,57,21 49.473 (5) The department shall audit and pay, from the appropriation accounts under s. 20.435 (4) (b) and (o), allowable charges to a provider who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under sub. (2) for all benefits and services specified under s. 49.46 (2), unless otherwise provided by the department by rule promulgated under s. 49.45 (2m) (c).

AB11, s. 145 Section 145. 49.825 (3) (b) 4. of the statutes is repealed.

AB11, s. 146 Section 146. 49.826 (3) (b) 4. of the statutes is repealed.

AB11, s. 147 Section 147. Chapter 52 of the statutes is repealed.

AB11, s. 148 Section 148. 59.875 of the statutes is created to read:

AB11,58,3 59.875 Payment of contributions in an employee retirement system of populous counties. (1) In this section, "county" means any county having a population of 500,000 or more.