49.45(8)(a)4.
4. "Patient care visit" means a personal contact with a patient in a patient's home that is made by a registered nurse, licensed practical nurse, home health aide, physical therapist, occupational therapist or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under
s. 49.46 or
49.47. "Patient care visit" does not include time spent by a nurse, therapist or home health aide on case management, care coordination, travel, record keeping or supervision that is related to the patient care visit.
49.45(8)(a)7.
7. "Speech-language pathologist" means an individual engaged in the practice of speech-language pathology, as regulated under
ch. 459.
49.45(8)(b)
(b) Reimbursement under
s. 20.435 (1) (b) and
(o) 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).
49.45(8)(c)
(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.
49.45(8e)
(8e) Monthly limits on home health, personal care and private-duty nursing services reimbursement. 49.45(8e)(a)(a) Except as provided in
par. (b), reimbursement under
s. 20.435 (1) (b) and
(o) for home health, personal care and private-duty nursing services provided to a medical assistance recipient in a month may not exceed 120% of the average monthly cost of nursing home care, as determined by the department.
49.45(8e)(b)
(b) This subsection does not apply to any of the following:
49.45(8e)(b)3.
3. Any individual, if the department determines that the cost of providing the individual with nursing home care would exceed the cost of providing the individual with home health, personal care and private-duty nursing services.
49.45(8e)(b)4.
4. Any individual, if the department determines that nursing home care is not available for that individual.
49.45(8m)
(8m) Rates for respiratory care services. Notwithstanding the limits under
subs. (8) and
(8e), the rates under
sub. (8) and rates charged by providers under
s. 49.46 (2) (a) 4. d. that are not home health agencies, for reimbursement for respiratory care services for ventilator-dependent individuals under
ss. 49.46 (2) (b) 6. m. and
49.47 (6) (a) 1., shall be as follows:
49.45(8m)(a)
(a) For visits subsequent to an initial visit and for extended visits by a licensed registered nurse, $30 per hour.
49.45(8m)(b)
(b) For visits subsequent to an initial visit and for extended visits by a licensed practical nurse, $20 per hour.
49.45(8r)
(8r) Payment for certain obstetric and gynecological care. The rate of payment for obstetric and gynecological care provided in primary care health professional shortage areas, as defined in
s. 560.184 (1) (c), or provided to recipients of medical assistance who reside in primary care health professional shortage areas, that is equal to 125% of the rates paid under this section to primary care physicians in primary care health professional shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.
49.45(8v)
(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. 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.
49.45(9)
(9) Free choice. Any person eligible for medical assistance under
ss. 49.46,
49.468 and
49.47 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.
49.45(9m)
(9m) Referrals. The department may, consistent with
sub. (9), specify services for which reimbursement will be made only if the services are provided in accordance with a referral, in writing, which specifies the services to be rendered and the duration of such services. The referral form shall describe the referred services as required by the department.
49.45(9s)
(9s) Disclosure. Any person who is an employe of, or an owner, partner, member, stockholder or investor in, any legal entity providing services which are reimbursed under this section, shall notify the department, on forms provided by the department for that purpose, if such person is an employe of, or an owner, partner, member, stockholder or investor in, any other legal entity providing services which are reimbursed under this section.
49.45(10)
(10) Rule-making powers. The department is authorized to promulgate such rules as are consistent with its duties in administering medical assistance.
49.45(11)
(11) Penalty. Any person who receives or assists another in receiving assistance under this section, to which the recipient is not entitled, shall be subject to the penalties under
s. 49.95.
49.45(12)
(12) Machine-readable medical assistance cards. 49.45(12)(a)(a) The department shall assist the commissioner of insurance to conduct the study of health insurance identification cards under
s. 601.57 (1).
49.45(12)(b)
(b) If the commissioner of insurance promulgates rules under
s. 601.57 (2) establishing a health insurance identification card system and its computerized support system, the department shall develop a plan to coordinate a system of machine-readable identification cards for medical assistance recipients with the systems established by the commissioner and shall submit the plan to the governor, and to the legislature under
s. 13.172 (2), before issuing a request for proposals under
par. (c).
49.45(12)(c)
(c) The department shall request proposals for a system of machine-readable identification cards for medical assistance recipients and a computerized support system for the cards that will accept and respond to electronically conveyed requests from health care providers for information related to medical assistance recipients, such as eligibility, coverages and authorizations. The request for proposals shall specify that the systems are to be operating by January 1, 1997.
49.45(13)(a)(a) The department may require service providers to prepare and submit cost reports or financial reports for purposes of rate certification under Title XIX, cost verification, fee schedule determination or research and study purposes. These financial reports may include independently audited financial statements which shall include balance sheets and statements of revenues and expenses. The department may withhold reimbursement or may decrease or not increase reimbursement rates if a provider does not submit the reports required under this paragraph or if the costs on which the reimbursement rates are based cannot be verified from the provider's cost or financial reports or records from which the reports are derived.
49.45(13)(b)
(b) The department may require any provider who fails to submit a cost report or financial report under
par. (a) within the period specified by the department to forfeit not less than $10 nor more than $100 for each day the provider fails to submit the report.
49.45(15)
(15) Community care organization project guarantee. Upon termination of the community care organization demonstration projects in Barron, La Crosse and Milwaukee counties, any client who was receiving services through any of those projects may continue to receive the full range of community care organization services. The cost of the services shall continue to be paid by medical assistance.
49.45(16)
(16) Certification. On or after January 1, 1984, the department may only continue to certify as a medical assistance provider a community-based residential facility that is so certified on December 31, 1983. On or after January 1, 1984, no community-based residential facility may be certified for more beds than the number for which it was certified on December 31, 1983.
49.45(18)
(18) Recipient cost sharing. Except as provided in
pars. (a) to
(d), any person eligible for medical assistance under
s. 49.46,
49.468 or
49.47 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 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 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. Liability under this subsection is limited by the following provisions:
49.45(18)(a)
(a) No person is liable under this subsection for services provided through prepayment contracts.
49.45(18)(b)
(b) The following services are not subject to recipient cost sharing under this subsection:
49.45(18)(b)1.
1. Any service provided to a person receiving care as an inpatient in a skilled nursing home or intermediate care facility certified under
42 USC 1396 to
1396k.
49.45(18)(b)2.
2. Any service provided to a person who is less than 18 years old.
49.45(18)(b)3.
3. Any service provided under
s. 49.46 (2) to a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy.
49.45(18)(b)6.
6. Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under
s. 46.215 or
46.22, or by specialized medical vehicle.
49.45(18)(b)7.
7. Home health services or, if a home health agency is unavailable, nursing services.
49.45(18)(c)
(c) The department may limit any medical assistance recipient's liability under this subsection for services it designates.
49.45(18)(d)
(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 $5 per month for prescription drugs received.
49.45(19)
(19) Establishing paternity and assigning support rights. 49.45(19)(a)(a) As a condition of eligibility for medical assistance, a person shall:
49.45(19)(a)1.
1. Fully cooperate in efforts directed at establishing the paternity of a nonmarital child and obtaining support payments or any other payments or property to which the person and the dependent child or children may have rights. This cooperation shall be in accordance with federal law and regulations applying to paternity establishment and collection of support payments.
49.45(19)(a)2.
2. Notwithstanding other provisions of the statutes, be deemed to have assigned to the state, by applying for or receiving medical assistance, any rights to medical support or other payment of medical expenses from any other person, including rights to unpaid amounts accrued at the time of application for medical assistance as well as any rights to support accruing during the time for which medical assistance is paid.
49.45(19)(b)
(b) If a person charged with the care and custody of a dependent child or children does not comply with the requirements of this subsection, the person is ineligible for medical assistance. In this case, medical assistance payments shall continue to be made on behalf of the eligible child or children.
49.45(19)(bm)
(bm) The county department under
s. 46.215 or
46.22 shall notify applicants of the requirements of this subsection at the time of application.
49.45(19)(c)
(c) If the mother of a child was enrolled in a health maintenance organization or other prepaid health care plan under medical assistance at the time of the child's birth, birth expenses that may be recovered by the state under this subsection are the birth expenses incurred by the health maintenance organization or other prepaid health care plan.
49.45(20)
(20) Exemption from continuation requirements. An insurer, as defined in
s. 632.897 (1) (d), with which the department contracts under
sub. (2) (b) 2. for the provision of health care to medical assistance recipients is exempt from the continuation of group coverage requirements of
s. 632.897 with regard to those recipients, their spouses and dependents.
49.45(21)
(21) Transfer of business, liability for repayments. 49.45(21)(a)(a) If any provider liable for repayment of improper or erroneous payments or overpayments under
ss. 49.43 to
49.497 sells or otherwise transfers ownership of his or her business or all or substantially all of the assets of the business, the transferor and transferee are each liable for the repayment. Prior to final transfer, the transferee is responsible for contacting the department and ascertaining if the transferor is liable under this paragraph.
49.45(21)(b)
(b) If a transfer occurs and the applicable amount under
par. (a) has not been repaid, the department may proceed against either the transferor or the transferee. Within 30 days after receiving notice from the department, the transferor or the transferee shall pay the amount in full. Upon failure to comply, the department may bring an action to compel payment. If a transferor fails to pay within 90 days after receiving notice from the department, the department may proceed under
sub. (2) (a) 12.
49.45(21)(c)
(c) The department may enforce this subsection within 4 years following a transfer.
49.45(22)
(22) Medical assistance services provided by health maintenance organizations. If the department contracts with health maintenance organizations for the provision of medical assistance it shall give special consideration to health maintenance organizations that provide or that contract to provide comprehensive, specialized health care services to pregnant teenagers.
49.45(24)
(24) Primary care provider pilot. The department may request a waiver from the secretary of the federal department of health and human services under
42 USC 1396n (b) (1) to permit the establishment of a primary care provider pilot project. If the waiver is granted, the department may establish a primary care provider pilot project under which primary care providers act as case managers for medical assistance beneficiaries. If the department establishes a primary care provider pilot project, it shall reimburse a case manager for the allowable charges for case management services provided to a beneficiary participating in the pilot project.
49.45(24m)
(24m) Home health care and personal care pilot program. From the appropriations under
s. 20.435 (1) (b) and
(o), 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:
49.45(24m)(a)
(a) By September 1, 1990, select a county in this state and solicit bids from providers of home health care and personal care services in that county for the provision, on a contractual basis, of home health and personal care services authorized under
ss. 49.46 (2) (a) 4. d. and
(b) 6. j. and
49.47 (6) (a) 1.
49.45(24m)(b)
(b) Award contracts for the provision of home health care and personal care services from the bids received under
par. (a) only if the department determines that the contracts would result in a lower cost alternative to fee-for-service reimbursement.
49.45(25)(a)(a) In this subsection, "severely emotionally disturbed child" means an individual under 21 years of age who has emotional and behavioral problems that:
49.45(25)(a)3.
3. Substantially interfere with the individual's functioning in his or her family, school or community and with his or her ability to cope with the ordinary demands of life; and
49.45(25)(a)4.
4. Cause the individual to need services from 2 or more agencies or organizations that provide social services or services or treatment for mental health, juvenile justice, child welfare, special education or health.
49.45(25)(am)
(am) Except as provided under
pars. (be) and
(bg) and
sub. (24), case management services under
s. 49.46 (2) (b) 9. and
(bm) are reimbursable under medical assistance only if provided to a medical assistance beneficiary who receives case management services from or through a certified case management provider in a county, city, village or town that elects, under
par. (b), to make the services available and who meets at least one of the following conditions:
49.45(25)(am)9.
9. Is a member of a family that has a child who is at risk of serious physical, mental or emotional dysfunction, as defined by the department.
49.45(25)(b)
(b) A county, city, village or town may elect to make case management services under this subsection available in the county, city, village or town to one or more of the categories of beneficiaries under
par. (am) through the medical assistance program. A county, city, village or town that elects to make the services available shall reimburse a case management provider for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government.
49.45(25)(be)
(be) A private nonprofit agency that is a certified case management provider may elect to provide case management services to medical assistance beneficiaries who have HIV infection, as defined in
s. 252.01 (2). The amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government shall be paid from the appropriation under
s. 20.435 (1) (am).
49.45(25)(bg)
(bg) An independent living center, as defined in
s. 46.96 (1) (ah), that is a certified case management provider may elect to provide case management services to one or more of the categories of medical assistance beneficiaries specified under
par. (am). The amount of allowable charges for the services under the medical assistance program that is not provided by the federal government shall be paid from nonfederal, public funds received by the independent living center from a county, city, village or town or from funds distributed as a grant under
s. 46.96.
49.45(25)(bm)
(bm) Case management services under this subsection may not be provided to a person under
par. (am) 7. unless any of the following is true:
49.45(25)(bm)1.
1. A team of mental health experts appointed by the case management provider determines that the person is a severely emotionally disturbed child. The team shall consist of at least 3 members. The case management provider shall appoint at least one member of the team who is a licensed psychologist or a physician specializing in psychiatry. The case management provider shall appoint at least 2 members of the team who are members of the professions of school psychologist, school social worker, registered nurse, social worker, child care worker, occupational therapist or teacher of emotionally disturbed children. The case management provider shall appoint as a member of the team at least one person who personally participated in a psychological evaluation of the child.
