49.45(6m)(av)5.
5. If
subd. 4. does not apply, the facility's payment rate shall be the payment rate calculated under
subd. 1.
49.45(6m)(av)5m.
5m. Notwithstanding the limitations under
par. (ag) 8., the rate under
subd. 1.,
4. or
5. may be adjusted by the department to reflect payments for the provision of active treatment to facility residents with a diagnosis of developmental disability.
49.45(6m)(av)6.
6. The total payment rate for a facility as calculated under
subd. 1.,
4.,
5. or
5m. shall be the sum of the rate so calculated, plus capital payment calculated under
pars. (am) 6. and
(ar) 6. and payment for ancillary services and materials under
par. (b) and for nonprescription drugs under
par. (bc).
49.45(6m)(b)
(b) The charges for ancillary materials and services that would be incurred by a prudent buyer may be included as an adjustment to the rate determined by
par. (av) when so determined by the department. The department may not authorize any adjustments to the rate established under
par. (av) to pay for a cost overrun that the department fails to approve under
s. 150.11 (3). Ancillary materials and services for which payment may be made include, if provided, oxygen, medical transportation and laboratory and X-ray services. Payment for these services and materials shall not exceed medical assistance limitations for reimbursement of the services and materials. For services in a facility for which the department may make payment to a service provider other than a facility, the department may make payment to the facility but not in excess of the estimated amount of payment available if a separate service provider provided the service. The department may promulgate rules setting forth conditions of and limitations to this paragraph.
49.45(6m)(bc)
(bc) The department may include charges for nonprescription drugs approved by the department as an adjustment to the rate determined under
par. (av).
49.45(6m)(bg)
(bg) The department shall determine payment levels for the provision of skilled, intermediate, limited, personal or residential care or care for the mentally retarded in the state centers for the developmentally disabled and in the Wisconsin veterans home at King separately from the payment principles, applicable costs and methods established under this subsection.
49.45(6m)(bm)
(bm) Except as provided in
par. (bo), the department may establish payment methods for a facility for which any of the following apply:
49.45(6m)(bm)2.
2. The total of licensed beds for the facility has significantly increased or decreased prior to calculation of its rate under the payment system.
49.45(6m)(bm)3.
3. The facility has undergone a change in certification or licensure level.
49.45(6m)(bm)5.
5. The facility has received approval or disapproval for provision of service to residents requiring supplemental skilled care due to complex medical conditions.
49.45(6m)(bm)6.
6. The facility has received approval or been disapproved for provision of service to residents who have any of the following:
49.45(6m)(bm)6.c.
c. An HIV infection, as defined in
s. 252.01 (2), and illness or injury associated with the development of acquired immunodeficiency syndrome.
49.45(6m)(bo)
(bo) The department may establish payment methods for capital payment for a newly constructed facility that first provided services after June 30, 1984.
49.45(6m)(bp)
(bp) Notwithstanding
pars. (ag) 3m.,
(am) 6. and
(ar) 6., the department may establish payment methods based on actual costs for capital payment for a facility to which, after December 31, 1982, any of the following applies:
49.45(6m)(bp)3.
3. The facility incurred annual remodeling costs of more than $600,000.
49.45(6m)(bp)4.
4. The facility incurred remodeling costs necessary to meet physical plant requirements under
42 USC 1396a (a) (13) (A).
49.45(6m)(br)
(br) If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds under applicable federal acts or programs for the reduction of operation deficits under
sub. (6u), all of the following apply:
49.45(6m)(br)2.
2. If a city, village or town owns and operates a facility that has received funds to reduce an operating deficit, the city, village or town shall reimburse the county in which the city, village or town is located in the amount of funds so received.
49.45(6m)(c)
(c) As a condition of payment under this section a facility shall:
49.45(6m)(c)1.
1. Meet the staffing standard requirements for direct care costs including the supplement, if any, made under
par. (ar) 1. c. and maintain such records as prescribed by the department to document that such level of care was actually provided.
49.45(6m)(c)2.
2. Provide at the time of a patient's admission to a home, for the development and implementation of a rehabilitation plan including the development of an alternate care plan for the patient.
49.45(6m)(c)3.
3. Provide, upon request, cost information relating to the overall financial operation of the facility, including, but not limited to wages and hours worked, costs of food, housekeeping, maintenance and administration.
49.45(6m)(c)6.
6. Provide, upon request, such information as the department considers necessary to determine allowable interest expenses under
par. (am) 5m.
49.45(6m)(d)2.
2. Terminate payment to a facility for a patient, unless a utilization review team established pursuant to federal regulations upon review of the patient's needs and the implementation of a rehabilitation plan for that patient determines that the patient's need for care and services can only be provided in a facility and determines the appropriate level of care.
49.45(6m)(d)3.
3. Establish, maintain, and periodically update a patient needs evaluation system to be used in determining the need and level of care at a facility, which shall include the social and rehabilitative needs of the patient, provide levels of care to correspond to the actual staff time required to provide such care, and define the contents of the services to be provided.
49.45(6m)(d)4.
4. Periodically audit all nursing homes and intermediate care facilities receiving funds under this paragraph, and recover payments made where the home is not meeting the conditions under which the payment was made as specified in
par. (c) 1. and
2. Erroneous information provided under
par. (c) 3. shall constitute grounds for recovery.
49.45(6m)(d)5.
5. Beginning October 1, 1989, deny payment to a facility for a patient who is admitted to the facility after the department has provided newspaper notice and notice under
s. 50.03 (2m) (b) that the facility violates
42 USC 1396 to
1396s and before the date, if any, that the department determines that the facility is in substantial compliance with
42 USC 1396 to
1396s.
49.45(6m)(e)
(e) The department shall establish an appeals mechanism within the department to review petitions from facilities providing skilled, intermediate, limited, personal or residential care or providing care for the mentally retarded for modifications to any payment under this subsection. The department may, upon the presentation of facts, modify a payment if demonstrated substantial inequities exist for the period appealed. Upon review of the department's decision the secretary may grant the modifications, which may exceed maximum payment levels allowed under this subsection but may not exceed federal maximum reimbursement levels. The department shall develop specific criteria and standards for granting payment modifications, and shall take into account the following, without limitation because of enumeration, in reviewing petitions for modification:
49.45(6m)(e)1.
1. The efficiency and effectiveness of the facility if compared with facilities providing similar services and if valid cost variations are considered.
49.45(6m)(e)3.
3. The need for additional revenue to correct licensure and certification deficiencies.
49.45(6m)(e)4.
4. The relationship between total revenue and total costs for all patients.
49.45(6m)(e)5.
5. The existence and effectiveness of specialized programs for the chronically mentally ill or developmentally disabled.
49.45(6m)(e)7.
7. Demonstrated experience in providing high quality patient care.
49.45(6m)(g)
(g) Payment under this section to a facility may not include the cost of care reimbursable for persons eligible for medicare benefits under
42 USC 1395 to
1395zz. Medical assistance recipients are not liable for these costs. The department may require that a facility recover these costs from the appropriate agencies. The department may, by rule, require medicare certification under
42 USC 1395 to
1395zz, in whole or in part, of skilled nursing facilities. Any intermediate care facility or skilled nursing facility is subject to a fine of not less than $10 nor more than $100 for each day it refuses to recover costs or refuses to obtain the required certification.
49.45(6m)(h)
(h) The department may require by rule that all claims for payment of services provided facility residents under this subchapter be submitted or countersigned by the respective facility administrator. The department may specify those categories of services for which payment will be made only if the services are rendered or authorized in writing by a primary health care provider designated by the recipient for the particular category of services.
49.45(6m)(i)1.1. On or after October 1, 1981, medical assistance payment for inpatient nursing care may only be provided for persons receiving skilled, intermediate or limited levels of nursing care as these levels are defined under
s. HSS 132.13, Wis. adm. code.
49.45(6m)(i)2.
2. Payment for personal or residential care is available for a person in a facility certified under
42 USC 1396 to
1396p only if the person entered a facility before the date specified in
subd. 1. and has continuously resided in a facility since the date specified in
subd. 1. If the person has a primary diagnosis of developmental disabilities or chronic mental illness, payment for personal or residential care is available only if the person entered a facility on or before November 1, 1983.
49.45(6m)(j)
(j) The department may develop a separate rate of payment, under this subsection, for persons requiring intense skilled nursing care, as defined by the department.
49.45(6m)(k)
(k) Notwithstanding
pars. (ag) to
(b),
(bp) and
(br), the department may participate in a demonstration project on case mix nursing home reimbursement authorized under
42 USC 1315 (a) and may modify the payment system under this section, on an experimental basis, as necessary for participation in the demonstration project.
49.45(6m)(L)
(L) For purposes of
ss. 46.27 (11) (c) 7. and
46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under
s. 46.27 (11) (c) 7. or
46.277 (5) (e).
49.45(6r)(a)1g.
1g. "Facility" means a nursing home as defined in
s. 50.01 (3) or a community-based residential facility that is licensed under
s. 50.03 and that is certified by the department as a provider of medical assistance.
49.45(6r)(a)1m.
1m. "Provider" means a facility or an ambulatory surgery center, except that "provider" does not include a facility or ambulatory surgery center that is state-owned or state-operated, federally owned or federally operated or located outside the state.
49.45(6r)(a)1r.
1r. "Services" means services or items under this section that the provider directly provides and does not reimburse a 3rd party for providing.
49.45(6r)(a)2.
2. "State share" means that portion of the medical assistance payments made to a provider under this section for the provision of authorized services that is not reimbursed by federal funds, unless no federal financial participation is available for these services. If no federal financial participation is available for a service that is payable under this section, "state share" means that portion of the payments that would be the state share if federal financial participation were available.
49.45(6r)(b)
(b) For the privilege of doing business in this state, there is imposed on a provider an assessment at the rate of 6.98% in fiscal year 1991-92 and 13.10% in fiscal year 1992-93 that shall be deposited in the general fund. The assessment shall be made on the state share of payments made to a provider for services provided beginning on July 1, 1991, except that assessments imposed on ambulatory surgery centers shall be made for services provided beginning on January 1, 1992.
49.45(6r)(c)
(c) The department shall send an invoice to each provider on October 31, 1991, for the amount due for the 3 months preceding that month and shall, thereafter, send an invoice to each provider by the end of every month for the amount due, which shall be based on payments received for services to which the assessment is applicable for the month preceding the month during which the invoice is sent, except that, for an ambulatory surgery center, the department shall first send an invoice by February 29, 1992. Each provider shall pay the amount shown on the invoice on or before the last day of the month after the month in which the invoice is sent. The department may provide to a provider an alternative to payment by invoice under which a provider may elect to have the assessment amounts deducted from net payments made for services.
49.45(6r)(e)
(e) The department shall levy, enforce and collect the assessment under this subsection.
49.45(6r)(f)
(f) Sections 71.74 (1) to
(3),
(6),
(7) and
(9) to
(15),
71.75 (1),
(2),
(4),
(5) and
(6) to
(10),
71.76,
71.77,
71.78 (1) to
(8),
71.80 (1) (a) to
(d),
(3),
(3m),
(6),
(8) to
(12),
(14) and
(18),
71.87,
71.88,
71.89,
71.90,
71.91 and
71.93 as they apply to the taxes under
ch. 71 and to the department of revenue apply to the assessment under this subsection and to the department.
49.45(6r)(g)
(g) This subsection does not apply after September 30, 1992.
49.45(6s)
(6s) Supplemental payments to county homes. Notwithstanding
sub. (6m), the department shall, from the appropriation under
s. 20.435 (1) (o), distribute not more than $20,000,000 in fiscal year 1995-96 and not more than $20,000,000 in fiscal year 1996-97, to provide supplemental payments for care to recipients of medical assistance provided in county homes established under
s. 49.14 (1) [49.70 (1)], except that the department shall also distribute for this same purpose from the appropriation under
s. 20.435 (1) (o) any additional federal medical assistance funds that were not anticipated before enactment of the biennial budget act or other legislation affecting
s. 20.435 (1) (o), were not used to fund nursing home rate increases under
sub. (6m) (ag) 8. and are matched by county funds under
sub. (6u) (b) 2. and certified under
sub. (6u) (b) 2m. The total amount certified under
sub. (6u) (b) 2m. and under this subsection may not exceed 100% of otherwise-unreimbursed care.
49.45 Note
NOTE: The bracketed language indicates the correct cross-reference.
1995 Wis. Act 27 renumbered s. 49.14 (1) to be 49.70 (1). Corrective legislation is pending.
49.45(6t)
(6t) County department and local health department operating deficit reduction. From the appropriation under
s. 20.435 (1) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a county department under
s. 46.215,
46.22,
46.23 or
51.42 or by a local health department, as defined in
s. 250.01 (4), for services provided under
s. 49.46 (2) (a) 4. d. and
(b) 6. f.,
j.,
k. and
L.,
9. and
15., for case management services under
s. 49.46 (2) (b) 12. and for mental health day treatment services for minors provided under the authorization under
42 USC 1396d (r) (5), the department shall allocate up to $4,500,000 in each fiscal year to these county departments, or local health departments as determined by the department, and shall perform all of the following:
49.45(6t)(a)
(a) For the reduction of operating deficits incurred by the county departments or local health departments, estimate the availability of federal medicaid funds that may be matched to county, city, town or village funds that are expended for costs in excess of reimbursement for services provided under
s. 49.46 (2) (a) 4. d. and
(b) 6. f.,
j.,
k. and
L.,
9. and
15., for case management services under
s. 49.46 (2) (b) 12. and for mental health day treatment services for minors provided under the authorization under
42 USC 1396d (r) (5).
49.45(6t)(b)
(b) Based on the amount estimated to be available under
par. (a), develop a method, which need not be promulgated as rules under
ch. 227, to distribute this allocation to the individual county departments under
s. 46.215,
46.22,
46.23 or
51.42 or to local health departments that have incurred operating deficits that shall include all of the following:
49.45(6t)(b)1.
1. Development of criteria for determining operating deficits.
49.45(6t)(b)2.
2. Agreement, by the county in which is located a county department that has an operating deficit, or by the county, city, town or village that has established a local health department that has an operating deficit, to provide funds to match federal medicaid funds.
49.45(6t)(b)3.
3. Consideration of the size of a county department's or local health department's operating deficit.
49.45(6t)(c)
(c) Except as provided in
par. (d), distribute the allocation under the distribution method that is developed.
49.45(6t)(d)
(d) If the federal department of health and human services approves for state expenditure in a fiscal year amounts under
s. 20.435 (1) (o) that result in a lesser allocation amount than that allocated under this subsection or disallows use of the allocation of federal medicaid funds under
par. (c), reduce allocations under this subsection and distribute on a prorated basis, as determined by the department.
49.45(6u)
(6u) Facility operating deficit reduction. Except as provided in
par. (g), from the appropriation under
s. 20.435 (1) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a facility, as defined under
sub. (6m) (a) 2., that is established under
s. 49.70 (1) or that is owned and operated by a city, village or town, the department shall distribute to these facilities not more than $18,600,000 in each fiscal year, as determined by the department, and shall perform all of the following:
49.45(6u)(a)
(a) Estimate the availability of federal medical assistance funds that may be matched to county funds or funds of a city, village or town for the reduction of operating deficits incurred by the facility.
49.45(6u)(b)
(b) Based on the amount estimated available under
par. (a), develop a method to distribute this allocation to the individual facilities that have incurred operating deficits that shall include:
49.45(6u)(b)1.
1. Development of criteria for determining operating deficits.
49.45(6u)(b)2.
2. Agreement by the county in which is located the facility established under
s. 49.70 (1) and agreement by the city, village or town that owns and operates the facility that the applicable county, city, village or town shall provide funds to match federal medical assistance matching funds under this subsection.
49.45(6u)(b)2m.
2m. Identification by the county in which is located the facility established under
s. 49.70 (1) of all county funds expended in each calendar year to operate the facility, and certification by the county to the department of this amount.
49.45(6u)(b)3.
3. Consideration of the size of a facility's operating deficit.
49.45(6u)(c)
(c) Distribute the allocation under the distribution method that is developed, unless a county has failed to comply with
par. (b) 2m.
49.45(6u)(d)
(d) If the federal department of health and human services approves for state expenditure in a fiscal year amounts under
s. 20.435 (1) (o) that result in a lesser allocation amount than that allocated under this subsection, allocate not more than the lesser amount so approved by the federal department of health and human services.
49.45(6u)(e)
(e) If the federal department of health and human services approves for state expenditure in a fiscal year amounts under
s. 20.435 (1) (o) that result in a lesser allocation amount than that allocated under this subsection, submit a revision of the method developed under
par. (b) for approval by the joint committee on finance in that state fiscal year.
49.45(6u)(f)
(f) If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds distributed under
par. (c), the requirements under
sub. (6m) (br) shall apply.
49.45(6u)(g)
(g) If a facility that is otherwise eligible for an allocation of funds under this section is found by the federal health care financing administration or the department to be an institution for mental diseases, as defined under
42 CFR 435.1009, the department may not allocate to that facility funds under this section after the date on which the finding is made.
49.45(6w)
(6w) Hospital operating deficit reduction. From the appropriation under
s. 20.435 (1) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a hospital, as defined under
s. 50.33 (2) (a) and
(b), that is operated by the state, established under
s. 49.71 or owned and operated by a city or village, the department shall allocate up to $3,300,000 in each fiscal year to these hospitals, as determined by the department, and shall perform all of the following:
49.45(6w)(a)
(a) For the reduction of operating deficits incurred by the hospital, estimate the availability of federal medicaid funds that may be matched to any of the following:
