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(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)(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:
49.45(37)(a)
(a) The adequacy, safety and comprehensiveness of plans of care developed for individuals and of the services provided to them.
49.45(37)(b)
(b) Opportunities for individuals to exercise choice and be involved in the provision of services.
49.45(37)(c)
(c) Overall conformance to required state and federal quality assurance standards.
49.45(37)(d)
(d) Factors in addition to those in
pars. (a) to
(c) that are required by the federal health care financing administration, if any.
49.45(38)
(38) Home or community-based services for disabled workers. The department shall request a waiver from the secretary of the federal department of health and human services to authorize federal financial participation for medical assistance coverage of persons described in
ss. 49.46 (1) (a) 14. and
49.47 (4) (as).
49.45(39)(a)1.
1. "School" means a public school described under
s. 115.01 (1) or a charter school, as defined in
s. 115.001 (1). It includes school-operated early childhood programs for developmentally delayed and disabled 4-year-old and 5-year-old children.
49.45(39)(a)2.
2. "School medical services" means health care services that are provided in a school to children who are eligible for medical assistance that are appropriate to a school setting, as provided in the amendment to the state medical assistance plan under
par. (am).
49.45(39)(am)
(am)
Plan amendment. No later than September 30, 1995, the department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of
pars. (b) to
(c). If the amendment to the state plan is approved, school districts and cooperative educational service agencies claim reimbursement under
pars. (b) to
(c).
Paragraphs (b) to
(c) do not apply unless the amendment to the state plan is approved and in effect.
49.45(39)(b)
(b)
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 and for allowable administrative costs. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. All other expenses for the school medical services 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 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.
49.45(39)(c)
(c)
Certification and reporting requirements. The department shall promulgate rules establishing specific certification and reporting requirements with respect to school medical services under this subsection.
49.45(40)
(40) Periodic record matches. The department shall cooperate with the department of industry, labor and job development in matching records of medical assistance recipients under
s. 49.32 (7).
49.45(41)
(41) Mental health crisis intervention services. 49.45(41)(a)1.
1. "Mental health crisis intervention services" means services that are provided by a mental health crisis intervention program operated by, or under contract with, a county or municipality, if the county or municipality is certified as a medical assistance provider.
49.45(41)(b)
(b) If a county or municipality elects to become certified as a provider of mental health crisis intervention services, the county or municipality may provide mental health crisis intervention services under this subsection in the county or municipality to medical assistance recipients through the medical assistance program. A county or municipality that elects to provide the services shall pay the amount of the allowable charges for the services under the medical assistance program that is not provided by the federal government. The department shall reimburse the county or municipality 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(42)
(42) Personal care services. Personal care services under
s. 49.46 (2) (b) 6. j. provided to an individual are reimbursable under medical assistance only if all of the following conditions are met:
49.45(42)(a)
(a) The provider of the personal care services receives prior authorization from the department for all personal care services that are provided to the individual in excess of 50 hours in a calendar year.
49.45(42)(b)
(b) The individual is not eligible to receive home health aide services under medicare, as defined in
sub. (3) (L) 1. b.
49.45(43)
(43) Case management services for high-cost recipients. The department may establish a program to provide case management services for medical assistance recipients with high-cost chronic health conditions or high-cost catastrophic health conditions. If the department establishes a program to provide these case management services, the department shall provide reimbursement for providers of these case management services under the medical assistance program.
49.45(44)
(44) Prenatal, postpartum and young child care coordination. Providers in Milwaukee County that are certified to provide care coordination services under
s. 49.46 (2) (b) 12. may be certified to provide to medical assistance recipients prenatal and postpartum care coordination services and care coordination services for children who have not attained the age of 7. The department shall provide reimbursement for these care coordination services only if at least one of the following conditions is met:
49.45(44)(a)
(a) The recipient is a resident of Milwaukee County and has received services under
s. 49.46 (2) (b) 12. and is pregnant or has given birth within 8 weeks after the individual ceased to receive services under
s. 49.46 (2) (b) 12.
49.45(44)(b)
(b) The recipient is a resident of Milwaukee County, is pregnant and has received a risk assessment approved by the department.
49.45(44)(c)
(c) The recipient is a resident of Milwaukee County, has given birth within the 8 weeks immediately preceding the request for services under
s. 49.46 (2) (b) 12m. and has received a risk assessment approved by the department.
49.45 History
History: 1971 c. 40 s.
93;
1971 c. 42,
125;
1971 c. 213 s.
5;
1971 c. 215,
217,
307;
1973 c. 62,
90,
147;
1973 c. 333 ss.
106g,
106h,
106j,
201w;
1975 c. 39;
1975 c. 223 s.
28;
1975 c. 224 ss.
54h,
56 to
59m;
1975 c. 383 s.
4;
1975 c. 411;
1977 c. 29,
418;
1979 c. 34 ss.
837f to
838,
2102 (20) (a);
1979 c. 102,
177,
221,
355;
1981 c. 20 ss.
839 to
854,
2202 (20) (r);
1981 c. 93,
317;
1983 a. 27 ss.
1046 to
1062m,
2200 (42);
1983 a. 245,
447,
527;
1985 a. 29 ss.
1026m to
1031d,
3200 (23), (56),
3202 (27);
1985 a. 120,
176,
269;
1985 a. 332 ss.
91,
251 (5),
253;
1985 a. 340;
1987 a. 27 ss.
989r to
1000s,
2247,
3202 (24);
1987 a. 186,
307,
339,
399;
1987 a. 403 s.
256;
1987 a. 413;
1989 a. 6;
1989 a. 31 ss.
1402 to
1452g,
2909g,
2909i;
1989 a. 107,
173,
310,
336,
351,
359;
1991 a. 22,
39,
80,
250,
269,
315,
316;
1993 a. 16 ss.
1362g to
1403,
3883;
1993 a. 27,
107,
112,
183,
212,
246,
269,
335,
356,
437,
446,
469;
1995 a. 20;
1995 a. 27 ss.
2947 to
3002r,
7299,
9126 (19),
9130 (4),
9145 (1);
1995 a. 191,
216,
225,
289,
303,
398,
417,
457.
49.45 Annotation
Wisconsin has no medical assistance plan independent of Medicaid. Non-residence under federal Medicaid regulations is determinative of medical assistance eligibility. Pope v. DHSS, 187 W (2d) 207, 522 NW (2d) 22 (Ct. App. 1994).
49.45 Annotation
A contract between the trustees of a nursing home and a medical clinic for exclusive medical services under the medical assistance act for residents of such home violates public policy of this state. 59 Atty. Gen. 68.
49.45 Annotation
Medical Assistance & Divestment. Canellos. Wis. Law. Aug. 1991.
49.453
49.453
Divestment of assets. 49.453(1)(am)
(am) "Covered individual" means an individual who is an institutionalized individual or a noninstitutionalized individual.
49.453(1)(c)
(c) "Expected value of the benefit" means the amount that an irrevocable annuity will pay to the annuitant during his or her expected lifetime as determined under
sub. (4) (c).
49.453(1)(f)
(f) "Look-back date" means for a covered individual, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under
s. 49.454 (2) (c) or
(3) (b) the date that is 60 months before:
49.453(1)(f)1.
1. For a covered individual who is an institutionalized individual, the first date on which the covered individual is both an institutionalized individual and has applied for medical assistance.
49.453(1)(f)2.
2. For a covered individual who is a noninstitutionalized individual, the date on which the covered individual applies for medical assistance or, if later, the date on which the covered individual, his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transferred assets for less than fair market value.
49.453(1)(g)
(g) "Reasonable compensation" means the prevailing local market rate of compensation for the service or care provided.
49.453(1)(h)
(h) "Relative" means an individual who is related to another by blood, marriage or adoption.
49.453(2)
(2) Ineligibility for medical assistance for certain services. 49.453(2)(a)(a)
Institutionalized individuals. Except as provided in
sub. (8), if an institutionalized individual or his or her spouse, or another person acting on behalf of the institutionalized individual or his or her spouse, transfers assets for less than fair market value on or after the institutionalized individual's look-back date, the institutionalized individual is ineligible for medical assistance for the following services for the period specified under
sub. (3):
49.453(2)(a)2.
2. For a level of care in a medical institution equivalent to that of a nursing facility.
49.453(2)(b)
(b)
Noninstitutionalized individuals. Except as provided in
sub. (8), if a noninstitutionalized individual or his or her spouse, or another person acting on behalf of the noninstitutionalized individual or his or her spouse, transfers assets for less than fair market value on or after the noninstitutionalized individual's look-back date, the noninstitutionalized individual is ineligible for medical assistance for the following services for the period specified under
sub. (3):
49.453(2)(b)2.
2. Other long-term care services specified by the department by rule.
49.453(3)(a)(a) The period of ineligibility under this subsection begins on the first day of the first month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value and that does not occur in any other periods of ineligibility under this subsection.
49.453(3)(b)
(b) The department shall determine the number of months of ineligibility as follows:
49.453(3)(b)1.
1. The department shall determine the total, cumulative uncompensated value of all assets transferred by the covered individual or his or her spouse on or after the look-back date.
49.453(3)(b)2.
2. The department shall determine the average monthly cost to a private patient of nursing facility services in the state at the time that the covered individual applied for medical assistance.
49.453(3)(b)3.
3. The number of months of ineligibility equals the number determined by dividing the amount determined under
subd. 1. by the amount determined under
subd. 2.
49.453(3)(c)
(c) If the spouse of an individual makes a transfer of assets that results in a period of ineligibility under this section and otherwise becomes eligible for medical assistance, the department shall apportion the period of ineligibility between the individual and the spouse. The department shall promulgate rules establishing a reasonable methodology for apportioning a period of ineligibility under this paragraph.
49.453(4)(a)(a) For the purposes of
sub. (2), whenever a covered individual or his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transfers assets to an irrevocable annuity in an amount that exceeds the expected value of the benefit, the covered individual or his or her spouse transfers assets for less than fair market value.
49.453(4)(b)
(b) The amount of assets that is transferred for less than fair market value under
par. (a) is the amount by which the transferred amount exceeds the expected value of the benefit.
49.453(4)(c)
(c) The department shall promulgate rules specifying the method to be used in calculating the expected value of the benefit, based on
26 CFR 1.72-
1 to
1.72-
18, and specifying the criteria for adjusting the expected value of the benefit based on a medical condition diagnosed by a physician before the assets were transferred to the annuity.
49.453(5)
(5) Care or personal services. For the purposes of
sub. (2), whenever a covered individual or his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transfers assets to a relative as payment for care or personal services that the relative provides to the covered individual, the covered individual or his or her spouse transfers assets for less than fair market value unless the care or services directly benefit the covered individual, the amount of the payment does not exceed reasonable compensation for the care or services that the relative performs and, if the amount of the payment exceeds 10% of the community spouse resource allowance limit specified in
s. 49.455 (6) (b) 1., the agreement to pay the relative is specified in a notarized written agreement that exists at the time that the relative performs the care or services.
49.453(6)
(6) Common ownership. For purposes of
sub. (2), if a covered individual holds an asset in common with another person in a joint tenancy, tenancy in common, or similar arrangement, the asset, or the affected portion of the asset, is considered to be transferred by the covered individual when an action is taken, either by the covered individual or by any other person, that reduces or eliminates the covered individual's ownership or control of the asset.
49.453(7)
(7) Certain authorizations. For the purposes of
sub. (2), if a covered individual or his or her spouse authorizes another person to transfer, encumber, lease, consume or otherwise act with respect to an asset as though the asset belonged to that other person; if that other person exercises the authority in a way that causes the asset to be unavailable for the support and maintenance of the covered individual or his or her spouse; and if the covered individual does not receive fair market value for the asset, then the covered individual or his or her spouse transfers assets for less than fair market value at the time that the other person exercises the authority.
49.453(8)
(8) Inapplicability. Subsections (2) and
(3) do not apply to transfers of assets if the assets are exempt under
42 USC 1396p (c) (2) or if the department determines that application of this section would work an undue hardship. The department shall promulgate rules concerning the transfer of assets exempt under
42 USC 1396p (c) (2).
49.453 History
History: 1993 a. 437 ss.
74 to
92.
49.454
49.454
Treatment of trust amounts. 49.454(1)(a)(a) Except as provided in
sub. (4), this section applies to an individual with respect to a trust if assets of the individual or the individual's spouse were used to form all or part of the corpus of the trust and if any of the following persons established the trust other than by will:
