49.47(6)(c)
(c) Benefits shall not include any payment with respect to:
49.47(6)(c)1.
1. Care or services in any private or public institution, unless the institution has been approved by a standard-setting authority responsible by law for establishing and maintaining standards for such institution.
49.47(6)(c)2.
2. That part of any service otherwise authorized under this section which is payable through 3rd party liability or any federal, state, county, municipal or private benefit systems, to which the beneficiary may otherwise be entitled.
49.47(6)(c)3.
3. Care or services for an individual who is an inmate of a public institution, except as a patient in a medical institution or a resident in an intermediate care facility.
49.47(6)(c)4.
4. Services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this subdivision, the department shall define "convalescent leave" and "conditional release" by rule.
49.47(6)(d)
(d) No payment under this subsection may include care for services rendered earlier than 3 months preceding the month of application.
49.47(7)
(7) Reduction of benefits. If the funds appropriated become or are estimated to be insufficient to make full payment of benefits provided under this section, all charges for service so authorized shall be prorated on the basis of funds available or by limiting the benefits provided.
49.47(8)
(8) Enrollment fee. As long as an enrollment fee or premium is required for persons receiving benefits under Title XIX of the social security act, the department shall charge the minimum enrollment fee or premium required under federal law. The fee or premium so charged shall be related to the beneficiary's income, in accordance with guidelines established by the secretary of the U.S. department of health and human services.
49.47(9m)
(9m) Eligibility for long-term care insurance beneficiaries. 49.47(9m)(b)
(b) A person who meets the eligibility requirements for medical assistance under
sub. (4) except that the person has liquid assets in excess of the limits under
sub. (4) (b) is eligible for medical assistance under this section if all of the following conditions are satisfied:
49.47(9m)(b)2.
2. The person is the beneficiary of a long-term care insurance policy that is certified to meet the standards set by the department by rule.
49.47(9m)(b)3.
3. The long-term care insurance policy paid for institutional or community-based long-term care services, or both, up to the limits specified in the long-term care insurance policy.
49.47(9m)(b)4.
4. The person required the services paid for under the long-term care insurance policy because of a severe limitation in activities of daily living or because of medical necessity, as defined by the department by rule.
49.47(9m)(b)5.
5. The amount of liquid assets retained by the person does not exceed the amount paid under the policy or the actual charges, whichever is lower, for the following services provided to the beneficiary that are reimbursed under the medical assistance program:
49.47(9m)(c)
(c) A person who seeks benefits under this subsection shall apply to an office of the department designated by the department.
49.47(9m)(d)
(d) Paragraphs (b) and
(c) do not apply unless the federal department of health and human services approves a waiver of federal medical assistance eligibility limits that authorizes federal financial participation in providing medical assistance benefits to persons eligible under
par. (b). If a waiver is approved, the department shall implement
pars. (b) and
(c) no later than 3 months after the date on which it is notified of that approval.
49.47 History
History: 1971 c. 125;
1971 c. 213 s.
5;
1971 c. 215;
1973 c. 90,
147,
333;
1977 c. 29 ss.
593,
1656 (18);
1977 c. 105 s.
59;
1977 c. 273,
418;
1979 c. 34;
1981 c. 20,
93;
1981 c. 314 s.
144;
1983 a. 27,
245;
1985 a. 29;
1987 a. 27,
307,
399,
413;
1989 a. 9;
1989 a. 31 ss.
1462k to
1466d,
2909c to
2909i;
1989 a. 173,
336,
351;
1991 a. 39,
178,
269,
316;
1993 a. 16,
269,
277,
437;
1995 a. 27 ss.
3026 to
3028,
9126 (19);
1995 a. 225,
289,
295;
1997 a. 27;
1999 a. 9.
49.47 Annotation
Section 49.46 (1) (b) and sub. (6) (d) limit retroactive medical assistance payments to services received not more than three months prior to the date the application was submitted. St. Paul Ramsey Medical Center v. DHSS,
186 Wis. 2d 37,
519 N.W.2d 706 (Ct. App. 1994).
49.47 Annotation
Regulation which "deemed" resources of one spouse to be "available" to the other was valid. Schweiker v. Gray Panthers, 453 US 34 (1981).
49.472
49.472
Medical assistance purchase plan. 49.472(1)(am)
(am) "Family" means an individual, the individual's spouse and any dependent child, as defined in
s. 49.141 (1) (c), of the individual.
49.472(1)(b)
(b) "Health insurance" means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.
49.472(1)(c)
(c) "Independence account" means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which an individual began receiving medical assistance under this section.
49.472(1)(d)
(d) "Medical assistance purchase plan" means medical assistance, eligibility for which is determined under this section.
49.472(2)
(2) Waivers and amendments. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.
49.472(3)
(3) Eligibility. Except as provided in
sub. (6) (a), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:
49.472(3)(a)
(a) The individual's family's net income is less than 250% of the poverty line for a family the size of the individual's family. In calculating the net income, the department shall apply all of the exclusions specified under
42 USC 1382a (b).
49.472(3)(b)
(b) The individual's assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under
42 USC 1382b (a) or assets accumulated in an independence account. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.
49.472(3)(c)
(c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under
42 USC 1396d (q) (2) (B) and (D).
49.472(3)(e)
(e) The individual is legally able to work in all employment settings without a permit under
s. 103.70.
49.472(3)(f)
(f) The individual maintains premium payments calculated by the department in accordance with
sub. (4), unless the individual is exempted from premium payments under
sub. (4) (b) or
(5).
49.472(3)(g)
(g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals.
49.472(3)(h)
(h) The individual meets all other requirements established by the department by rule.
49.472(4)(a)(a) Except as provided in
par. (b) and
sub. (5), an individual who is eligible for medical assistance under
sub. (3) and receives medical assistance shall pay a monthly premium to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:
49.472(4)(a)1.
1. The premium for any individual may not exceed the sum of the following:
49.472(4)(a)1.a.
a. Three and one-half percent of the individual's earned income after the disregards specified in
subd. 2m.
49.472(4)(a)1.b.
b. One hundred percent of the individual's unearned income after the deductions specified in
subd. 2.
49.472(4)(a)2.
2. In determining an individual's unearned income under
subd. 1., the department shall disregard all of the following:
49.472(4)(a)2.a.
a. A maintenance allowance established by the department by rule. The maintenance allowance may not be less than the sum of $20, the federal supplemental security income payment level determined under
42 USC 1382 (b) and the state supplemental payment determined under
s. 49.77 (2m).
49.472(4)(a)2.b.
b. Medical and remedial expenses and impairment-related work expenses.
49.472(4)(a)2m.
2m. If the disregards under
subd. 2. exceed the unearned income against which they are applied, the department shall disregard the remainder in calculating the individual's earned income.
49.472(4)(a)3.
3. The department may reduce the premium by 25% for an individual who is covered by private health insurance.
49.472(4)(b)
(b) The department may waive monthly premiums that are calculated to be below $10 per month. The department may not assess a monthly premium for any individual whose income level, after adding the individual's earned income and unearned income, is below 150% of the poverty line.
49.472(5)
(5) Community options participants. From the appropriation under
s. 20.435 (7) (bd), the department may pay all or a portion of the monthly premium calculated under
sub. (4) (a) for an individual who is a participant in the community options program under
s. 46.27 (11).
49.472(6)(a)(a) Notwithstanding
sub. (4) (a) 3., from the appropriation under
s. 20.435 (4) (b), the department shall, on the part of an individual who is eligible for medical assistance under
sub. (3), pay premiums for or purchase individual coverage offered by the individual's employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.
49.472(6)(b)
(b) If federal financial participation is available, from the appropriation under
s. 20.435 (4) (b), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under
sub. (3).
49.472(7)
(7) Department duties. The department shall do all of the following:
49.472(7)(a)
(a) Determine eligibility, or contract with a county department, as defined in 49.45 (6c) (a) 3., or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with
sub. (3).
49.472(7)(b)
(b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.
49.472 History
History: 1999 a. 9,
185.
49.475
49.475
Information about medical assistance beneficiaries. 49.475(2)
(2) Disclosure to department. An insurer that issues or delivers a disability insurance policy that provides coverage to a resident of this state shall provide to the department, upon the department's request, information contained in the insurer's records regarding all of the following:
49.475(2)(a)
(a) Information that the department needs to identify beneficiaries of medical assistance who satisfy any of the following:
49.475(2)(a)1.
1. Are eligible for benefits under a disability insurance policy.
49.475(2)(a)2.
2. Would be eligible for benefits under a disability insurance policy if the beneficiary were enrolled as a dependent of a person insured under the disability insurance policy.
49.475(2)(b)
(b) Information required for submittal of claims under the insurer's disability insurance policy.
49.475(2)(c)
(c) The types of benefits provided by the disability insurance policy.
49.475(3)
(3) Written agreement. Upon requesting an insurer to provide the information under
sub. (2), the department shall enter into a written agreement with the insurer that satisfies all of the following:
49.475(3)(a)
(a) Identifies in detail the information to be disclosed.
49.475(3)(b)
(b) Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.
49.475(3)(c)
(c) Specifies how the insurer's reimbursable costs under
sub. (5) will be determined and specifies the manner of payment.
49.475(4)
(4) Deadline for response; enforcement. 49.475(4)(a)(a) An insurer shall provide the information requested under
sub. (2) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer to disclose information under this section.
49.475(4)(b)
(b) An insurer shall provide the information requested under
sub. (2) within 30 days after receiving the department's request if the department has previously requested the insurer to disclose information under this section.
49.475(4)(c)
(c) If an insurer fails to comply with
par. (a) or
(b), the department may notify the commissioner of insurance, and the commissioner of insurance may initiate enforcement proceedings against the insurer under
s. 601.41 (4) (a).
49.475(5)
(5) Reimbursement of costs. From the appropriations under
s. 20.435 (4) (bm) and
(pa), the department shall reimburse an insurer that provides information under this section for the insurer's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of information under this section.
49.475 History
History: 1991 a. 39;
1999 a. 9.
49.48
49.48
Denial, nonrenewal and suspension of certification of service providers based on certain delinquency in payment. 49.48(1)(1) Except as provided in
sub. (1m), the department shall require each applicant to provide the department with the applicant's social security number, if the applicant is an individual, as a condition of issuing or renewing a certification under
s. 49.45 (2) (a) 11. as an eligible provider of services.
49.48(1m)
(1m) If an individual who applies for or to renew a certification under
sub. (1) does not have a social security number, the individual, as a condition of obtaining the certification, shall submit a statement made or subscribed under oath or affirmation to the department that the applicant does not have a social security number. The form of the statement shall be prescribed by the department of workforce development. A certification issued or renewed in reliance upon a false statement submitted under this subsection is invalid.
49.48(2)
(2) The department of health and family services may not disclose any information received under
sub. (1) to any person except to the department of workforce development for the purpose of making certifications required under
s. 49.857.
