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) or
(w), 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) or
(w), 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;
2001 a. 16.
49.472 Cross-reference
Cross Reference: See also chs.
HFS 103 and
107 and s.
HFS 103.087, Wis. adm. code.
49.473
49.473
Medical assistance; women diagnosed with breast or cervical cancer. 49.473(2)
(2) A woman is eligible for medical assistance as provided under
sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:
49.473(2)(c)
(c) The woman is not eligible for health care coverage that qualifies as creditable coverage in
42 USC 300gg (c).
49.473(2)(d)
(d) The woman has been screened for breast or cervical cancer under a breast and cervical cancer early detection program that is authorized under a grant received under
42 USC 300k.
49.473(2)(e)
(e) The woman requires treatment for breast or cervical cancer.
49.473(3)
(3) Prior to applying to the department or a county department for medical assistance, a woman is eligible for medical assistance as provided under
sub. (5) beginning on the date on which a qualified entity determines, on the basis of preliminary information, that the woman meets the requirements specified in
sub. (2) and ending on one of the following dates:
49.473(3)(a)
(a) If the woman applies to the department or a county department for medical assistance within the time limit required under
sub. (4), the day on which the department or county department determines whether the woman meets the requirements under
sub. (2).
49.473(3)(b)
(b) If the woman does not apply to the department or county department for medical assistance within the time limit required under
sub. (4), the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(4)
(4) A woman who a qualified entity determines under
sub. (3) is eligible for medical assistance shall apply to the department or county department no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(5)
(5) The department shall audit and pay, from the appropriation accounts under
s. 20.435 (4) (b) and
(o), allowable charges to a provider who is certified under
s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under
sub. (2) for all benefits and services specified under
s. 49.46 (2).
49.473(6)
(6) A qualified entity that determines under
sub. (3) that a woman is eligible for medical assistance as provided under
sub. (5) shall do all of the following:
49.473(6)(a)
(a) Notify the department of the determination no later than 5 days after the date on which the determination is made.
49.473(6)(b)
(b) Inform the woman at the of time the determination that she is required to apply to the department or a county department for medical assistance no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(7)
(7) The department shall provide qualified entities with application forms for medical assistance and information on how to assist women in completing the form.
49.473 History
History: 2001 a. 16,
104.
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.
49.48(3)
(3) The department of health and family services shall deny an application for the issuance or renewal of a certification specified in
sub. (1), shall suspend a certification specified in
sub. (1) or may, under a memorandum of understanding under
s. 49.857 (2), restrict a certification specified in
sub. (1) if the department of workforce development certifies under
s. 49.857 that the applicant for or holder of the certificate is delinquent in the payment of court-ordered payments of child or family support, maintenance, birth expenses, medical expenses or other expenses related to the support of a child or former spouse or fails to comply, after appropriate notice, with a subpoena or warrant issued by the department of workforce development or a county child support agency under
s. 59.53 (5) and related to paternity or child support proceedings.
49.48 History
History: 1997 a. 191;
1999 a. 9.
49.49
49.49
Medical assistance offenses. 49.49(1)(a)(a)
Prohibited conduct. No person, in connection with a medical assistance program, may:
49.49(1)(a)1.
1. Knowingly and willfully make or cause to be made any false statement or representation of a material fact in any application for any benefit or payment.
49.49(1)(a)2.
2. Knowingly and willfully make or cause to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment.
49.49(1)(a)3.
3. Having knowledge of the occurrence of any event affecting the initial or continued right to any such benefit or payment or the initial or continued right to any such benefit or payment of any other individual in whose behalf he or she has applied for or is receiving such benefit or payment, conceal or fail to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized.
