49.45(21)(ag)4.
4. The right to contact and offer services to patients, clients, or residents served by the provider.
49.45(21)(ag)5.
5. An agreement that the provider will not compete with the person at all or with respect to a patient, client, resident, service, geographical area, or other part of the provider's business.
49.45(21)(ag)6.
6. The right to perform services that are substantially similar to services performed by the provider at the same location as those performed by the provider.
49.45(21)(ag)7.
7. The right to use any distinctive name or symbol by which the provider is known in connection with services to be provided by the person.
49.45(21)(ar)
(ar) Before a person may take over the operation of a provider that is liable for repayment of improper or erroneous payments or overpayments under
ss. 49.43 to
49.497, full repayment shall be made. Upon request, the department shall notify the provider or the person that intends to take over the operation of the provider as to whether the provider is liable.
49.45(21)(b)
(b) If, notwithstanding the prohibition under
par. (ar), a person takes over the operation of a provider and the applicable amount under
par. (ar) has not been repaid, the department may, in addition to withholding certification as authorized under
sub. (2) (b) 8., proceed against the provider or the person. Within 30 days after the certified provider receives notice from the department, the amount shall be repaid in full. If the amount is not repaid in full, the department may bring an action to compel payment, may proceed under
sub. (2) (a) 12., or may do both.
49.45(21)(c)
(c) The department may enforce this subsection within 4 years following a transfer.
49.45(21)(e)
(e) The department shall promulgate rules to implement this subsection.
49.45(22)
(22) Medical assistance services provided by health maintenance organizations. If the department contracts with health maintenance organizations for the provision of medical assistance it shall give special consideration to health maintenance organizations that provide or that contract to provide comprehensive, specialized health care services to pregnant teenagers. If the department contracts with health maintenance organizations for the provision of medical assistance, the department shall determine which medical assistance recipients who have attained the age of 2 but have not attained the age of 6 and who are at risk for lead poisoning have not received lead screening from those health maintenance organizations. The department shall report annually to the appropriate standing committees of the legislature under
s. 13.172 (3) on the percentage of medical assistance recipients under the age of 2 who received a lead screening test in that year provided by a health maintenance organization compared with the percentage that the department set as a goal for that year.
49.45(24)
(24) Primary care provider pilot. The department may request a waiver from the secretary of the federal department of health and human services under
42 USC 1396n (b) (1) to permit the establishment of a primary care provider pilot project. If the waiver is granted, the department may establish a primary care provider pilot project under which primary care providers act as case managers for medical assistance beneficiaries. If the department establishes a primary care provider pilot project, it shall reimburse a case manager for the allowable charges for case management services provided to a beneficiary participating in the pilot project.
49.45(24g)
(24g) Managed care for dental services pilot. 49.45(24g)(a)(a) The department shall, in consultation with the Wisconsin Dental Association, develop a pilot project for the provision of dental services under a managed care system. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to implement the pilot project developed under this subsection. If the waiver is granted and in effect, and if the department of health and family services determines that the costs of providing dental services under
s. 49.46 (2) (b) 1. under the pilot project will not exceed the costs of providing those dental services in the absence of the pilot project, the department shall implement the pilot project in Ashland, Douglas, Bayfield and Iron counties. Only those dental services covered under
s. 49.46 (2) (b) 1. may be covered under the pilot project.
49.45(24g)(b)
(b) In developing the pilot project under this subsection, the department shall provide that recipients who are subject to the pilot project are required to select a dental provider from among those dentists participating in the pilot project. The department shall also provide that, if a recipient does not make a selection, a dental provider will be assigned to the recipient.
49.45(24g)(c)
(c) If the department is able to implement the pilot project under this subsection, the department shall contract with a person to do all of the following:
49.45(24g)(c)1.
1. Accept a capitation payment from the department for each recipient who is subject to the pilot project.
49.45(24g)(c)2.
2. Enroll dentists to be participating providers under the pilot project.
49.45(24g)(c)3.
3. Coordinate with county departments to provide outreach and education to recipients and persons who are eligible to be recipients.
49.45(24g)(c)4.
4. Pay all allowable charges on a fee-for-service basis to participating dentists on behalf of recipients in the pilot counties for dental services received by those recipients.
49.45(24m)
(24m) Home health care and personal care pilot program. From the appropriations under
s. 20.435 (4) (b),
(o), and
(w), in order to test the feasibility of instituting a system of reimbursement for providers of home health care and personal care services for medical assistance recipients that is based on competitive bidding, the department shall:
49.45(24m)(a)
(a) By September 1, 1990, select a county in this state and solicit bids from providers of home health care and personal care services in that county for the provision, on a contractual basis, of home health and personal care services authorized under
ss. 49.46 (2) (a) 4. d. and
(b) 6. j. and
49.47 (6) (a) 1.
49.45(24m)(b)
(b) Award contracts for the provision of home health care and personal care services from the bids received under
par. (a) only if the department determines that the contracts would result in a lower cost alternative to fee-for-service reimbursement.
49.45(24r)
(24r) Family planning demonstration project. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide family planning services, as defined in
s. 253.07 (1) (b), under medical assistance to any woman between the ages of 15 and 44 whose family income does not exceed 185% of the poverty line for a family the size of the woman's family. If the waiver is granted and in effect, the department shall implement the waiver no later than July 1, 1998, or on the effective date of the waiver, whichever is later.
49.45(25)(a)(a) In this subsection, "severely emotionally disturbed child" means an individual under 21 years of age who has emotional and behavioral problems that:
49.45(25)(a)3.
3. Substantially interfere with the individual's functioning in his or her family, school or community and with his or her ability to cope with the ordinary demands of life; and
49.45(25)(a)4.
4. Cause the individual to need services from 2 or more agencies or organizations that provide social services or services or treatment for mental health, juvenile justice, child welfare, special education or health.
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 (1m) (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 Educational Services Program for the Deaf and Hard of Hearing. 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 Educational Services Program for the Deaf and Hard of Hearing 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 Educational Services Program for the Deaf and Hard of Hearing.
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 Educational Services Program for the Deaf and Hard of Hearing 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 Educational Services Program for the Deaf and Hard of Hearing 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 Educational Services Program for the Deaf and Hard of Hearing 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 Educational Services Program for the Deaf and Hard of Hearing 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 Educational Services Program for the Deaf and Hard of Hearing, 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.