49.45(5)(b)1.b.
b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.
49.45(5)(b)1.c.
c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department.
49.45(5)(b)2.
2. If a recipient requests a hearing within the timely notice period specified in
42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. The department shall promptly notify the county department or, if a Wisconsin works agency is responsible for making the medical assistance determination, the Wisconsin works agency of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced or discontinued if:
49.45(5)(b)2.a.
a. The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient's behalf.
49.45(5)(b)2.b.
b. The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.
49.45(5)(b)3.
3. The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.
49.45(5m)
(5m) Supplemental funding for rural hospitals. 49.45(5m)(am)
(am) Notwithstanding
sub. (3) (e), from the appropriations under
s. 20.435 (4) (b) and
(o) the department shall distribute not more than $2,256,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, and to provide supplemental funds to critical access hospitals, except that the department may not distribute funds to a rural hospital or to a critical access hospital to the extent that the distribution would exceed any limitation under
42 USC 1396b (i) (3).
49.45(5m)(b)
(b) The supplemental funding for rural hospitals under
par. (am) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation to that utilization in other rural hospitals.
49.45(5r)
(5r) Supplemental payments for hospitals. From the appropriations under
s. 20.435 (4) (b) and
(o), the department shall distribute not more than $2,451,000, beginning on July 1, 2000, as a supplemental payment to a hospital for which medical assistance revenues were at least 8% of the hospital's total revenues in the most recent fiscal year prior to the year of payment. The department shall calculate a qualifying hospital's supplemental payment amount by multiplying the total amount by the percentage obtained by dividing the hospital's total medical assistance revenues in the most recent prior fiscal year by the total amount of medical assistance revenues for all qualifying hospitals for that period.
49.45(6b)
(6b) Centers for the developmentally disabled. From the appropriation under
s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Reimbursement to the centers for the developmentally disabled shall be reduced following each placement made under
s. 46.275 that involves a relocation from a center for the developmentally disabled, by $184 per day, beginning in fiscal year 1999-2000, and by $190 per day, beginning in fiscal year 2000-01.
49.45(6c)
(6c) Preadmission screening and resident review. 49.45(6c)(a)1.
1. "Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. "Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.
49.45(6c)(a)2.
2. "Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under
ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.
49.45(6c)(a)4.
4. "Developmental disability" means any of the following:
49.45(6c)(a)4.a.
a. Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.
49.45(6c)(a)6.
6. "Facility care" means services provided in a facility that are in conformity with
42 USC 1396r and that are payable under
sub. (6m).
49.45(6c)(b)
(b)
Preadmission screening. Except as provided in
par. (e), beginning on August 9, 1989, every individual who applies for admission to a facility or to an institution for mental diseases shall be screened to determine if the individual has developmental disability or mental illness. Beginning on August 9, 1989, the department or an entity to which the department has delegated authority shall screen every individual who has been identified as having a developmental disability or mental illness to determine if the individual needs facility care. If the individual is determined to need facility care, the department or an entity to which the department has delegated authority shall also assess the individual to determine if he or she requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(c)
(c)
Resident review. Except as provided in
par. (e), the department or an entity to which the department has delegated authority shall review every resident of a facility or institution for mental diseases who has a developmental disability or mental illness and who has experienced a significant change in his or her physical or mental condition to determine if any of the following applies:
49.45(6c)(c)2.
2. The resident requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(d)1.1. No payment may be made under
sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under
s. 49.46 or
49.47, who has developmental disability or mental illness and for whom under
par. (b) or
(c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under
par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.
49.45(6c)(d)2.
2. Payment may be made under
sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under
s. 49.46 or
49.47 and who has developmental disability or mental illness and is determined under
par. (b) or
(c) to need facility care, regardless of whether it is determined under
par. (b) or
(c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)1.1. Payment under
sub. (6m) may be made to a facility and no screening under
par. (b) or review under
par. (c) is required for an individual who is medically diagnosed as having developmental disability or mental illness, and who is not a danger to himself or herself or to others, if, immediately after release from a hospital, the individual enters the facility, as part of a medically prescribed period of recovery, for a period not to exceed 30 days and the admission is approved by the department or an entity to which the department has delegated authority.
49.45(6c)(e)2.
2. Payment under
sub. (6m) may be made to a facility or institution for mental diseases for an individual who is 65 years of age or older, is medically diagnosed as having developmental disability or mental illness, is not a danger to himself or herself or to others and is competent to make an independent decision, if, following screening under
par. (b) or review under
par. (c), all of the following apply:
49.45(6c)(e)2.a.
a. It is determined that the individual needs facility care and requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)2.b.
b. The individual chooses not to participate in active treatment.
49.45(6c)(f)
(f)
Hearing. An individual for whom admission to a facility or institution for mental diseases is denied under
par. (b) or for whom a determination under
par. (c) results in prohibition of payment to a facility or institution for mental diseases under
par. (d) and relocation from the facility to a facility or institution for mental diseases may request a hearing from the department.
49.45(6c)(g)
(g)
Rule making. The department shall promulgate all of the following rules:
49.45(6c)(g)1.
1. Establishing criteria and procedures for a determination by the department under
par. (d) that a resident be relocated from a facility after March 31, 1990, and before December 31, 1993.
49.45(6h)
(6h) Liability for disallowances. If the department or the federal health care financing administration finds a skilled nursing facility or intermediate care facility in this state that provides care to medical assistance recipients for which the facility receives reimbursement under
sub. (6m) to be an institution for mental diseases, the facility shall be liable for any retroactive federal medicaid disallowances for services provided after the date of the finding.
49.45(6j)
(6j) Limitation on certain facility coverage. The department shall determine, under a method devised by the department, the average population during the period from January 1, 1987, to June 30, 1988, of persons in each skilled nursing facility or an intermediate care facility who are mentally ill and are aged 21 to 64, except persons under 22 years of age who were receiving medical assistance services in the facility prior to reaching age 21 and continuously thereafter. Beginning July 1, 1988, the payment under
sub. (6m) for services provided by a facility to persons who are mentally ill and are within the age limitations specified in this subsection may not exceed the payment for the average population of these persons in that facility, as determined by the department.
49.45(6m)(a)2.
2. "Cost center" means a group of similar facility expenses.
49.45(6m)(a)3.
3. "Facility" means a nursing home 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(6m)(a)4.
4. "Net property tax" means property tax from which the Wisconsin state property tax credit has been deducted.
49.45(6m)(ag)
(ag) Payment for care provided in a facility under this subsection made under
s. 20.435 (4) (b),
(pa) or
(o) shall, except as provided in
pars. (bg),
(bm) and
(br), be determined according to a prospective payment system updated annually by the department. The payment system shall implement standards that are necessary and proper for providing patient care and that meet quality and safety standards established under
subch. II of ch. 50 and
ch. 150. The payment system shall reflect all of the following:
49.45(6m)(ag)1.
1. A prudent buyer approach to payment for services, under which a reasonable price recognizing selected factors that influence costs is paid for service that is of acceptable quality.
49.45(6m)(ag)2.
2. Standards established by the department that shall be based upon allowable costs incurred by facilities in the state as available from information submitted under
par. (c) 3. and compiled by the department.
49.45(6m)(ag)3m.
3m. For state fiscal year 1999-2000, rates that shall be set by the department based on information from cost reports for the 1998 fiscal year of the facility and for state fiscal year 2000-01, rates that shall be set by the department based on information from cost reports for the 1999 fiscal year of the facility.
49.45(6m)(ag)6.
6. Standards for capital payment that will be based upon replacement value of a facility as determined by a commercial estimator with which the department contracts and criteria and limitations as determined by the department.
49.45(6m)(ag)7.
7. Assurance of an acceptable quality of care for all medical assistance recipients provided nursing home care.
49.45(6m)(am)
(am) In determining payments for a facility under the payment system in
par. (ag), the department shall consider all of the following cost centers:
49.45(6m)(am)1.
1. Allowable direct care costs, including, if provided, any of the following:
49.45(6m)(am)1.d.
d. Services of facility medical personnel that are not separately billable under medical assistance requirements.
49.45(6m)(am)1.e.
e. Nonbillable services of a registered nurse, licensed practical nurse, nursing assistant, ward clerk, activity person, recreation person, social worker, volunteer coordinator, teacher for residents aged 22 and older, vocational counselor for residents aged 22 and older, religious person, therapy aide, therapy assistant and counselor on resident living.
49.45(6m)(am)2.
2. Allowable support service costs, including the following allowable facility expenses:
49.45(6m)(am)2.a.
a. Dietary service for the provision of meals to facility residents.
49.45(6m)(am)2.b.
b. Environmental service for the provision of maintenance, housekeeping, laundry and security service.
49.45(6m)(am)3.
3. Allowable fuel and utility costs, including the facility expenses that the department determines are allowable for the provision of:
49.45(6m)(am)4.
4. Net property tax or allowable municipal service costs incurred by the owner of the facility for the facility.
49.45(6m)(am)5.
5. Allowable administrative and general costs, including costs related to the facility's overall management and administration and allowable expenses that are not recognized or reimbursed in other cost centers and including the costs of commercial estimators approved by the department under
par. (ar) 6.
49.45(6m)(am)5m.
5m. Allowable interest expense of the facility, less interest income of the facility and less interest income of affiliated entities, to the extent required under the approved state plan for services under
42 USC 1396.
49.45(6m)(am)6.
6. Capital payment necessary for the provision of service over time, including allowable facility expenses for suitable space, furnishings, property insurance and movable equipment for patient care.
49.45(6m)(ap)
(ap) If the bed occupancy of a nursing home is below the minimum patient day occupancy standards that are established by the department under
par. (ar) (intro.), the department may approve a request by the nursing home to delicense any of the nursing home's licensed beds. If the department approves the nursing home's request, all of the following apply:
49.45(6m)(ap)1.
1. The department shall delicense the number of beds in accordance with the nursing home's request.
49.45(6m)(ap)2.
2. The department may not include the number of beds of the nursing home that the department delicenses under this paragraph in determining the costs per patient day under the minimum patient day occupancy standards under
par. (ar).
49.45(6m)(ap)3.
3. The nursing home may not use or sell a bed that is delicensed under this paragraph.
49.45(6m)(ap)4.a.a. Every 12 months following the delicensure of a bed under this paragraph, for which a nursing home has not resumed licensure under
subd. 5., the department shall reduce the licensed bed capacity of the nursing home by 10% of all of the nursing home's beds that remain delicensed under this paragraph or by 25% of one bed, whichever is greater. The department shall reduce the statewide maximum number of licensed nursing home beds under
s. 150.31 (1) (intro.) by the number or portion of a number of beds by which the nursing home's licensed bed capacity is reduced under this subdivision.
49.45(6m)(ap)4.b.
b. Subdivision 4. a. does not apply with respect to the delicensure of beds between October 14, 1997, and the date that is 60 days after October 14, 1997, during the period of any contract entered into by a nursing home prior to January 1, 1997, if the contract requires the nursing home to maintain its current licensed bed capacity.
49.45(6m)(ap)5.
5. A nursing home retains the right to resume licensure of a bed of the nursing home that was delicensed under this paragraph unless the licensed bed capacity of the nursing home has been reduced by that bed under
subd. 4. The nursing home may not resume licensure of a fraction of a bed. The nursing home may resume licensure 18 months after the nursing home notifies the department in writing that the nursing home intends to resume the licensure. If a nursing home resumes licensure of a bed under this subdivision,
subd. 2. does not apply with respect to that bed.
49.45(6m)(ap)6.
6. If
subd. 4. b. applies and the nursing home later resumes licensure of a bed that was delicensed between October 14, 1997, and the date that is 60 days after October 14, 1997, the department shall calculate the costs per patient day using the methodology specified in the state plan that is in place at the time that the delicensed beds are resumed.
49.45(6m)(ar)
(ar) In determining payments for a facility under
par. (ag), the department may establish minimum patient day occupancy standards for determining costs per patient day and shall apply the following methods to calculate amounts payable for the rate year for the cost centers described under
par. (am):
49.45(6m)(ar)1.a.
a. The department shall establish standards for payment of allowable direct care costs, for facilities that do not primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state and separate standards for payment of allowable direct care costs, for facilities that primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state. The standards shall be adjusted by the department for regional labor cost variations.
49.45(6m)(ar)1.b.
b. The department shall establish the direct care component of the facility rate for each facility by comparing actual allowable direct care cost information of that facility adjusted for inflation to the standards established under
subd. 1. a.
49.45(6m)(ar)1.c.
c. If a facility has an approved program for provision of service to mentally retarded residents, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under
subd. 1. b. may be made to that facility according to a method developed by the department.
49.45(6m)(ar)1.cm.
cm. Funding distributed to facilities for the provision of active treatment to residents with a diagnosis of developmental disability shall be distributed in accordance with a method developed by the department which is consistent with a prudent buyer approach to payment for services.
