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) (13)Financial reports.
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)4. 4. Emergency services.
49.45(18)(b)5. 5. Family planning services.
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)(b)11. 11. Personal care services.
49.45(18)(b)12. 12. Case management 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(21)(d) (d) This subsection supersedes any provision of chs. 180, 181 and 185.
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) (25)Case management services.
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)1. 1. Are severe in degree;
49.45(25)(a)2. 2. Are expected to persist for at least one year;
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)1. 1. Has a developmental disability, as defined under s. 51.01 (5) (a).
49.45(25)(am)2. 2. Has a chronic mental illness, as defined under s. 51.01 (3g).
49.45(25)(am)3. 3. Has Alzheimer's disease, as defined under s. 46.87 (1) (a).
49.45(25)(am)4. 4. Is an alcoholic, as defined under s. 51.01 (1).
49.45(25)(am)5. 5. Is drug dependent, as defined under s. 51.01 (8).
49.45(25)(am)6. 6. Is physically disabled, as defined by the department.
49.45(25)(am)7. 7. Is a severely emotionally disturbed child.
49.45(25)(am)8. 8. Is age 65 or over.
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)(am)10. 10. Has HIV infection, as defined in s. 252.01 (2).
49.45(25)(am)11. 11. Is a child who is eligible for early intervention services under s. 51.44.
49.45(25)(am)12. 12. Is infected with tuberculosis.
49.45(25)(am)13. 13. Is a child with asthma.
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.
49.45(25)(bm)2. 2. A service coordination agency has determined under s. 46.56 (8) (d) that the person is a child with emotional and behavioral disabilities that meet the requirements under s. 46.56 (1) (c) 1. to 4.
49.45(25)(c) (c) Except as provided in pars. (be) and (bg), the department shall reimburse a provider of case management services under this subsection only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
49.45(25)(d) (d) This subsection does not apply to case management services provided under sub. (15) or s. 49.46 (2) (a) 2. or through a community support program under s. 49.46 (2) (b) 6. L.
49.45(26) (26)Managed care system. The department shall study alternatives for a system to manage the usage of alcohol and other drug abuse services, including day treatment services, provided under the medical assistance program. On or before September 1, 1988, the department shall submit a plan for a medical assistance alcohol and other drug abuse managed care system to the joint committee on finance. If the cochairpersons of the committee do not notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan within 14 working days after the date of the department's submittal, the department may implement the plan. 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 plan, the department may not implement the plan until it is approved by the committee, as submitted or as modified. If a waiver from the secretary of the federal department of health and human services is necessary to implement the proposed plan, the department of health and family services may request the waiver, but it may not implement the waiver until it is authorized to implement the plan, as provided in this subsection.
49.45(27) (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).
49.45(29) (29)Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46 and 49.47.
49.45(30) (30)Services provided by community support programs.
49.45(30)(a)(a) A county shall provide the portion of the cost of services under s. 49.46 (2) (b) 6. L. that is not provided by the federal government.
49.45(30)(b) (b) The department shall reimburse a provider of services under s. 49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.
49.45(30m) (30m)Certain services for developmentally disabled. A county shall provide the portion of the services under s. 51.06 (1) (d) to individuals who are eligible for medical assistance that is not provided by the federal government.
49.45(31) (31)Eligibility for long-term care insurance beneficiaries. The department shall seek federal approval of, and federal financial participation in, a pilot project under which a person who is the beneficiary of a long-term care insurance policy that satisfies criteria established by the department may become eligible for medical assistance while exceeding the usual medical assistance resource limits.
49.45(32) (32)Community care for the elderly. The department may request a waiver under 42 USC 1315 to permit the establishment of a community care for the elderly demonstration project to provide medical care, case management services, adult day care and other support services that promote independence and enhance the quality of life of frail elderly persons. If the waiver is approved, the department may establish the community care for the elderly demonstration project and pay a fixed per person fee for the services.
49.45(34) (34)Medical assistance manual. The department shall prepare a medical assistance manual that is clear, comprehensive and consistent with this subchapter and 42 USC 1396a to 1396u and shall, no later than July 1, 1992, provide the manual to counties for use by county employes who administer the medical assistance program. 
49.45(35) (35)Training for nonprofit organizations. The department shall provide training to employes and volunteers of private nonprofit organizations concerning medical assistance eligibility under s. 49.47 of persons whose incomes exceed the levels under s. 49.47 (4) (am) and (c) 1. before consideration, under s. 49.47 (4) (c) 2., of the level of those persons' medical expenses.
49.45(35m) (35m)Computer system redesign. The department shall ensure that any redesign or replacement of the computer network that is used by counties on May 12, 1992, to determine eligibility for medical assistance includes the capability of determining eligibility for medical assistance under s. 49.47 (4) (c) 2.
49.45(36) (36)Homeless beneficiaries. A county department under s. 46.215, 46.22 or 46.23 may not place the word "homeless" on the medical assistance identification card of any person who is determined to be eligible for medical assistance benefits and who is homeless.
49.45(37) (37)Plans of care. The department may seek a waiver of the requirement under 42 USC 1396n (c) (1) that the department review and approve every written plan of care developed for each individual who receives, under 42 USC 1396n (c) (1), home or community-based services under ss. 49.46 (2) (b) 8. and 49.47 (6) (a) 1. The waiver of the requirement, if granted, shall apply to those county departments or private nonprofit agencies that administer the services and that the department finds and certifies have implemented effective quality assurance systems for service plan development and implementation. If the federal health care financing administration approves the department's request for waiver of the requirement, the department shall, in evaluating a quality assurance system for certification, consider all of the following:
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This is an archival version of the Wis. Stats. database for 1995. See Are the Statutes on this Website Official?