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)(am)14.
14. Is a woman who is aged 45 to 64 and who is not a resident of a nursing home or otherwise receiving case management services under this paragraph.
49.45(25)(b)
(b) A county, city, village, town or, in a county having a population of 500,000 or more, the department 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, town or, in a county having a population of 500,000 or more, the department 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 (5) (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)(c)
(c) Except as provided in
pars. (b),
(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(30e)
(30e) Community-based psychosocial service programs. 49.45(30e)(a)(a)
When services are reimbursable. Services under
s. 49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
49.45(30e)(a)1.
1. Reimbursement for the services under
s. 49.46 (2) (b) 6. Lm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
49.45(30e)(a)2.
2. The county in which the individual resides elects to make the services under
s. 49.46 (2) (b) 6. Lm. available in the county through the medical assistance program.
49.45(30e)(a)3.
3. The individual's psychosocial health needs require more than outpatient counseling, but less than the services provided by a community support program under
s. 51.421.
49.45(30e)(a)4.
4. The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under
par. (b) 3.
49.45(30e)(b)
(b)
Rules. The department shall promulgate rules regarding all of the following:
49.45(30e)(b)3.
3. Requirements for certification of community-based psychosocial service programs.
49.45(30e)(c)
(c)
Provider reimbursement. A county that elects to make the services under
s. 49.46 (2) (b) 6. Lm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider 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(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 employees who administer the medical assistance program.
49.45(35)
(35) Training for nonprofit organizations. The department shall provide training to employees 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), a charter school, as defined in
s. 115.001 (1), the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin School for the Deaf. 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) and
(c). If the amendment to the state plan is approved, school districts, cooperative educational service agencies and the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin School for the Deaf claim reimbursement under
pars. (b) and
(c).
Paragraphs (b) and
(c) do not apply unless the amendment to the state plan is approved and in effect. The department shall submit to the federal department of health and human services an amendment to the state plan if necessary to permit the application of
pars. (b) and
(c) to the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin School for the Deaf.
49.45(39)(b)1.1. `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, as specified in
subd. 2., for allowable administrative costs. If the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin School for the Deaf elects to provide school medical services and meets all requirements under
par. (c), the department shall reimburse the department of public instruction for 60% of the federal share of allowable charges for the school medical services that the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin School for the Deaf provides and, as specified in
subd. 2., for allowable administrative costs. A school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin School for the Deaf may submit, and the department shall allow, claims for common carrier transportation costs as a school medical service unless the department receives notice from the federal health care financing administration that, under a change in federal policy, the claims are not allowed. If the department receives the notice, a school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin School for the Deaf may submit, and the department shall allow, unreimbursed claims for common carrier transportation costs incurred before the date of the change in federal policy. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. All other expenses for the school medical services provided by a school district or a cooperative educational service agency 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, the Wisconsin Center for the Blind and Visually Impaired, the Wisconsin School for the Deaf 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)(b)2.
2. `Payment for school medical services administrative costs.' The department shall reimburse a school district or a cooperative educational service agency specified under
subd. 1. and shall reimburse the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin School for the Deaf for 90% of the federal share of allowable administrative costs, using time studies, beginning in fiscal year 1999-2000. A school district or a cooperative education service agency may submit, and the department of health and family services shall allow, claims for administrative costs incurred during the period that is up to 24 months before the date of the claim, if allowable under federal law.
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 workforce 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)(a) In this subsection, "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, if the county is certified as a medical assistance provider.
49.45(41)(b)
(b) If a county elects to become certified as a provider of mental health crisis intervention services, the county may provide mental health crisis intervention services under this subsection in the county to medical assistance recipients through the medical assistance program. A county 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 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(45)
(45) In-home and community mental health and alcohol and other drug abuse services. 49.45(45)(a)(a) Services under
s. 49.46 (2) (b) 6. fm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
49.45(45)(a)1.
1. Reimbursement for the services under
s. 49.46 (2) (b) 6. fm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
49.45(45)(a)2.
2. The county, city, town or village in which the individual resides elects to make the services under
s. 49.46 (2) (b) 6. fm. available in the county, city, town or village through the medical assistance program.
49.45(45)(b)
(b) A county, city, town or village that elects to make the services under
s. 49.46 (2) (b) 6. fm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider 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(46)
(46) Alcohol and other drug abuse residential treatment services. 49.45(46)(a)(a) If a county, city, town or village elects to become certified as a provider of alcohol and other drug abuse residential treatment services or to contract with a certified provider to provide the services, the county, city, town or village may provide directly or under contract alcohol and other drug abuse residential treatment services in facilities with fewer than 16 beds under this subsection in the county, city, town or village to medical assistance recipients through the medical assistance program. A county, city, town or village that elects to provide or to contract for 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, city, town or village 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(46)(b)
(b) This subsection does not apply after July 1, 2003.
49.45(47)(a)(a) In this subsection, "adult day care center" means an entity that provides services for part of a day in a group setting to adults who need an enriched health-supportive or social experience and who may need assistance with activities of daily living, supervision or protection.
49.45(47)(b)
(b) No person may receive reimbursement under
s. 46.27 (11) for the provision of services to clients in an adult day care center unless the adult day care center is certified by the department under
sub. (2) (a) 11. as a provider of medical assistance.
49.45(47)(c)
(c) The biennial fee for the certification required under
par. (b) of an adult day care center is $89, plus a biennial fee of $17.80 per client, based on the number of clients that the adult day care center is certified to serve. Fees collected under this paragraph shall be credited to the appropriation account under
s. 20.435 (6) (jm).
49.45(47)(d)
(d) The department, by rule, may increase any fee specified in
par. (c).
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;
1997 a. 3,
13,
27,
114,
175,
191,
237,
252,
293;
1999 a. 9,
63,
103,
180,
185.
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 Wis. 2d 207,
522 N.W.2d 22 (Ct. App. 1994).
