The Department is proposing to modify the current rate structure used to reimburse home health agencies, personal care agencies and nurses in private practice to permit negotiated payments for unusual, high-cost cases. This change in reimbursement may be implemented by the Department effective October 1, 1995. The proposed change is:
The Department may negotiate an alternative payment for home health, personal care, private duty nursing and respiratory care services provided to a recipient if the Medical Assistance Program determines that the following requirements are met:
1. Home health, personal care, respiratory care and private duty nursing services are appropriate and cost-effective compared to other available services;
2. All applicable prior authorization requirements are met; and
3. The Department determines, on an individual basis, that the recipient's medical condition, environment or need for care is unusual, which may include one of the following situations:
A. The recipient is subject to the Medicaid average monthly home care payment limit under s. 49.45 (8e), Stats., as created by 1995 Wisconsin Act 27, and, without a negotiated payment, the total monthly Medicaid expenditures for home health, personal care and private duty nursing for the recipient are expected to exceed the Medicaid average monthly cost of nursing home care, as determined by the Department;
B. The total average Medicaid expenditures for home health, personal care, private duty nursing and respiratory care services for the recipient are expected to exceed the Medicaid average monthly cost of nursing home care, as determined by the Department, and, pursuant to s. 49.45 (8e), Stats., as created by 1995 Wisconsin Act 27, the recipient is exempt from Medicaid's home care payment limit under one of the following:
1) The recipient is under the age of 22;
2) The recipient is ventilator-dependent;
3) The Department grants the recipient an exemption based on its determination that the actual nursing home cost for the recipient will exceed the cost of care provided in the community, resulting in higher overall Medicaid costs;
4) The Department grants the recipient an exemption based on its determination that no nursing home bed is available for the recipient;
C. The recipient qualifies for high-cost case management services under s. 49.45 (43), Stats., as created by 1995 Wisconsin Act 27;
D. At the sole discretion of the Department, the services required cannot be reasonably provided by any other Wisconsin Medicaid-certified provider.
The estimated net effect of this change in the current rate structure on annual expenditures of the Wisconsin Medical Assistance Program is minimal.
Copies of the Proposed Changes
Copies of the proposed change will be sent to every county social services or human services department main office where they will be available for public review. For more information, interested people may write to:
State Plan Coordinator
Bureau of Health Care Financing
Division of Health
P.O. Box 309
Madison, WI 53701-0309
Written Comments
Written comments on the proposed change are welcome. Comments should be sent to the above address. Comments received on the change will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily at:
Bureau of Health Care Financing
State Office Building, Room 250
One West Wilson Street
Madison, Wisconsin
E x e c u t i v e O r d e r s
The following is a listing of recent Executive Orders issued by the Governor.
Executive Order 254. Relating to a Proclamation that the Flags of the United States and the State of Wisconsin be Flown at Half-Staff as a Mark of Respect for the Three United States Diplomats who Recently Died in Bosnia-Herzegovina.
Executive Order 255. Relating to a Special Session of the Legislature.
Executive Order 256. Relating to Proclamation of a State of Emergency.
Executive Order 257. Relating to a Proclamation that the Flags of the United States and the State of Wisconsin be Flown at Half-Staff as a Mark of Respect for the Honorable Donald J. Hanaway, Late Judge of the Circuit Court of Brown County.
Executive Order 258. Relating to Amending A Special Session of the Legislature.
Executive Order 259. Relating to a Proclamation that the Flags of the United State and the State of Wisconsin be Flown at Half-Staff as a Mark of Respect for The Honorable John Plewa, Late Senator of the Seventh Senate District of Wisconsin.
The State of Wisconsin
Department of Administration
Document Sales Unit
P.O. Box 7840
Dated Material. Please Do Not Delay!
