49.45(6m)(ar)1.a.
a. The department shall establish standards for payment of allowable direct care costs under
par. (am) 1. bm., 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. For facilities in Douglas, Pierce, and St. Croix counties, the department shall perform the adjustment by use of the wage index that is used by the federal department of health and human services for hospital reimbursement under
42 USC 1395 to
1395ggg.
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.
49.45(6m)(ar)2.
2. For support service costs, the department shall establish one or more standards for the payment of support service costs that take into account support service costs for a sample of all facilities within the state.
49.45(6m)(ar)4.
4. For net property taxes or municipal services, payment shall be made for the amount of the previous calendar year's tax or the amount of municipal service costs for a period specified by the department, subject to a maximum limit as determined by the department.
49.45(6m)(ar)6.
6. Capital payment shall be based on a replacement value for a facility. The replacement value shall be determined by a commercial estimator contracted for by the department and paid for by the facility. The replacement value shall be subject to limitations determined by the department.
49.45(6m)(av)
(av) The department shall calculate a payment rate for a facility by applying the criteria set forth under
pars. (ag) 1. to
5. and
7.,
(am) 1. bm.,
4.,
5m. and
6., and
(ar) 1.,
4., and
6. to information from cost reports submitted by the facility, as affected by any adjustment for ancillary services and materials under
par. (b).
49.45(6m)(b)
(b) The charges for ancillary materials and services that would be incurred by a prudent buyer may be included as an adjustment to the rate determined by
par. (av) when so determined by the department. The department may not authorize any adjustments to the rate established under
par. (av) to pay for a cost overrun that the department fails to approve under
s. 150.11 (3). Ancillary materials and services for which payment may be made include, if provided, oxygen, medical transportation and laboratory and X-ray services. Payment for these services and materials shall not exceed medical assistance limitations for reimbursement of the services and materials. For services in a facility for which the department may make payment to a service provider other than a facility, the department may make payment to the facility but not in excess of the estimated amount of payment available if a separate service provider provided the service. The department may promulgate rules setting forth conditions of and limitations to this paragraph.
49.45(6m)(bg)
(bg) The department shall determine payment levels for the provision of skilled, intermediate, limited, personal or residential care or care for the mentally retarded in the state centers for the developmentally disabled, in the Wisconsin Veterans Home at King and in the nursing care facility operated by the department of veterans affairs under
s. 45.385 separately from the payment principles, applicable costs and methods established under this subsection.
49.45(6m)(bm)
(bm) Except as provided in
par. (bo), the department may establish payment methods for a facility for which any of the following apply:
49.45(6m)(bm)2.
2. The total of licensed beds for the facility has significantly increased or decreased prior to calculation of its rate under the payment system.
49.45(6m)(bm)3.
3. The facility has undergone a change in certification or licensure level.
49.45(6m)(bm)5.
5. The facility has received approval or disapproval for provision of service to residents requiring supplemental skilled care due to complex medical conditions.
49.45(6m)(bm)6.
6. The facility has received approval or been disapproved for provision of service to residents who have any of the following:
49.45(6m)(bm)6.c.
c. An HIV infection, as defined in
s. 252.01 (2), and illness or injury associated with the development of acquired immunodeficiency syndrome.
49.45(6m)(bo)
(bo) The department may establish payment methods for capital payment for a newly constructed facility that first provided services after June 30, 1984.
49.45(6m)(bp)
(bp) Notwithstanding
pars. (am) 6. and
(ar) 6., the department may establish payment methods based on actual costs for capital payment for a facility to which, after December 31, 1982, any of the following applies:
49.45(6m)(bp)3.
3. The facility incurred annual remodeling costs of more than $600,000.
49.45(6m)(bp)4.
4. The facility incurred remodeling costs necessary to meet physical plant requirements under
42 USC 1396a (a) (13) (A).
49.45(6m)(br)
(br) If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds under applicable federal acts or programs for the reduction of operation deficits under
sub. (6u), all of the following apply:
49.45(6m)(br)1.
1. Notwithstanding
s. 20.410 (3) (cd),
20.435 (4) (bt) or
(7) (b) or
20.445 (3) (dz), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under
s. 20.435 (4) (bt) or
(7) (b), or the department shall direct the department of workforce development to reduce allocations of funds to counties or Wisconsin works agencies in the amount of the disallowance from the appropriation account under
s. 20.445 (3) (dz) or direct the department of corrections to reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under
s. 20.410 (3) (cd), in accordance with
s. 16.544 to the extent applicable.
49.45(6m)(br)2.
2. If a city, village or town owns and operates a facility that has received funds to reduce an operating deficit, the city, village or town shall reimburse the county in which the city, village or town is located in the amount of funds so received.
49.45(6m)(c)
(c) As a condition of payment under this section a facility shall:
49.45(6m)(c)1.
1. Meet the staffing standard requirements for direct care costs including the supplement, if any, made under
par. (ar) 1. c. and maintain such records as prescribed by the department to document that such level of care was actually provided.
49.45(6m)(c)2.
2. Provide at the time of a patient's admission to a home, for the development and implementation of a rehabilitation plan including the development of an alternate care plan for the patient.
49.45(6m)(c)3.
3. Provide, upon request, cost information relating to the overall financial operation of the facility, including, but not limited to wages and hours worked, costs of food, housekeeping, maintenance and administration.
49.45(6m)(c)6.
6. Provide, upon request, such information as the department considers necessary to determine allowable interest expenses under
par. (am) 5m.
49.45(6m)(d)2.
2. Terminate payment to a facility for a patient, unless a utilization review team established pursuant to federal regulations upon review of the patient's needs and the implementation of a rehabilitation plan for that patient determines that the patient's need for care and services can only be provided in a facility and determines the appropriate level of care.
49.45(6m)(d)3.
3. Establish, maintain, and periodically update a patient needs evaluation system to be used in determining the need and level of care at a facility, which shall include the social and rehabilitative needs of the patient, provide levels of care to correspond to the actual staff time required to provide such care, and define the contents of the services to be provided.
49.45(6m)(d)4.
4. Periodically audit all nursing homes and intermediate care facilities receiving funds under this paragraph, and recover payments made where the home is not meeting the conditions under which the payment was made as specified in
par. (c) 1. and
2. Erroneous information provided under
par. (c) 3. shall constitute grounds for recovery.
49.45(6m)(d)5.
5. Beginning October 1, 1989, deny payment to a facility for a patient who is admitted to the facility after the department has provided newspaper notice and notice under
s. 50.03 (2m) (b) that the facility violates
42 USC 1396 to
1396s and before the date, if any, that the department determines that the facility is in substantial compliance with
42 USC 1396 to
1396s.
49.45(6m)(e)
(e) The department shall establish an appeals mechanism within the department to review petitions from facilities providing skilled, intermediate, limited, personal or residential care or providing care for the mentally retarded for modifications to any payment under this subsection. The department may, upon the presentation of facts, modify a payment if demonstrated substantial inequities exist for the period appealed. Upon review of the department's decision the secretary may grant the modifications, which may exceed maximum payment levels allowed under this subsection but may not exceed federal maximum reimbursement levels. The department shall develop specific criteria and standards for granting payment modifications, and shall take into account the following, without limitation because of enumeration, in reviewing petitions for modification:
49.45(6m)(e)1.
1. The efficiency and effectiveness of the facility if compared with facilities providing similar services and if valid cost variations are considered.
49.45(6m)(e)3.
3. The need for additional revenue to correct licensure and certification deficiencies.
49.45(6m)(e)4.
4. The relationship between total revenue and total costs for all patients.
49.45(6m)(e)5.
5. The existence and effectiveness of specialized programs for the chronically mentally ill or developmentally disabled.
49.45(6m)(e)7.
7. Demonstrated experience in providing high quality patient care.
49.45(6m)(g)
(g) Payment under this section to a facility may not include the cost of care reimbursable for persons eligible for medicare benefits under
42 USC 1395 to
1395zz. Medical assistance recipients are not liable for these costs. The department may require that a facility recover these costs from the appropriate agencies. The department may, by rule, require medicare certification under
42 USC 1395 to
1395zz, in whole or in part, of skilled nursing facilities. Any intermediate care facility or skilled nursing facility is subject to a fine of not less than $10 nor more than $100 for each day it refuses to recover costs or refuses to obtain the required certification.
49.45(6m)(h)
(h) The department may require by rule that all claims for payment of services provided facility residents under this subchapter be submitted or countersigned by the respective facility administrator. The department may specify those categories of services for which payment will be made only if the services are rendered or authorized in writing by a primary health care provider designated by the recipient for the particular category of services.
49.45(6m)(i)1.1. On or after October 1, 1981, medical assistance payment for inpatient nursing care may only be provided for persons receiving skilled, intermediate, or limited levels of nursing care as these levels are defined under
s. HFS 132.13, Wis. Adm. Code.
49.45(6m)(i)2.
2. Payment for personal or residential care is available for a person in a facility certified under
42 USC 1396 to
1396p only if the person entered a facility before the date specified in
subd. 1. and has continuously resided in a facility since the date specified in
subd. 1. If the person has a primary diagnosis of developmental disabilities or chronic mental illness, payment for personal or residential care is available only if the person entered a facility on or before November 1, 1983.
49.45(6m)(j)
(j) The department may develop a separate rate of payment, under this subsection, for persons requiring intense skilled nursing care, as defined by the department.
49.45(6m)(k)
(k) Notwithstanding
pars. (ag) to
(b),
(bp) and
(br), the department may participate in a demonstration project on case mix nursing home reimbursement authorized under
42 USC 1315 (a) and may modify the payment system under this section, on an experimental basis, as necessary for participation in the demonstration project.
49.45(6m)(L)
(L) For purposes of
ss. 46.27 (11) (c) 7. and
46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under
s. 46.27 (11) (c) 7. or
46.277 (5) (e).
49.45(6t)
(6t) County department and local health department operating deficit reduction. 49.45(6t)(a)(a) From the appropriation under
s. 20.435 (4) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a county department under
s. 46.215,
46.22,
46.23, or
51.42 or by a local health department, as defined in
s. 250.01 (4), for services provided under
s. 49.46 (2) (a) 4. d. and
(b) 6. f.,
fm.,
j.,
k.,
L., and
Lm.,
9., and
15., for case management services under
s. 49.46 (2) (b) 12. and for mental health day treatment services for minors provided under the authorization under
42 USC 1396d (r) (5), the department shall allocate moneys in each fiscal year to these county departments, or local health departments as determined by the department, and shall perform all of the following:
49.45(6t)(a)1.
1. For the reduction of operating deficits incurred by the county departments or local health departments, estimate the availability of federal medicaid funds that may be matched to county, city, town, or village funds that are expended for costs in excess of reimbursement for services provided under
s. 49.46 (2) (a) 4. d. and
(b) 6. f.,
fm.,
j.,
k.,
L., and
Lm.,
9., and
15., for case management services under
s. 49.46 (2) (b) 12. and for mental health day treatment services for minors provided under the authorization under
42 USC 1396d (r) (5).
49.45(6t)(a)2.
2. Based on the amount estimated to be available under
subd. 1., develop a method, which need not be promulgated as rules under
ch. 227, to distribute this allocation to the individual county departments under
s. 46.215,
46.22,
46.23 or
51.42 or to local health departments that have incurred operating deficits that shall include all of the following:
49.45(6t)(a)2.b.
b. Agreement, by the county in which is located a county department that has an operating deficit, or by the county, city, town or village that has established a local health department that has an operating deficit, to provide funds to match federal medicaid funds.
49.45(6t)(a)2.c.
c. Consideration of the size of a county department's or local health department's operating deficit.
49.45(6t)(a)3.
3. Except as provided in
subd. 4., distribute the allocation under the distribution method that is developed.
49.45(6t)(a)4.
4. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under
s. 20.435 (4) (o) that result in a lesser allocation amount than that allocated under this subsection or disallows use of the allocation of federal medicaid funds under
subd. 3., reduce allocations under this subsection and distribute on a prorated basis, as determined by the department.
Effective date note
NOTE: Par. (a) is renumbered sub. (6t) eff. 1-1-06 by
2003 Wis. Act 318.
49.45(6tu)
(6tu) Distributions to county departments and local health departments. From the appropriation under
s. 20.435 (4) (w), the department may in each fiscal year distribute moneys to county departments under
s. 46.215,
46.22,
46.23, or
51.42 or to local health departments, as defined in
s. 250.01 (4), under a plan developed by the department.
49.45(6u)
(6u) Supplemental payments to certain facilities and care management organizations. 49.45(6u)(ag)1.
1. "Care management organization" means a care management organization, as defined in
s. 46.2805 (1), that contracts under
s. 46.284 (4) (d) for provision of services with a facility that is established under
s. 49.70 (2) or that is owned and operated by a city, village, or town.
49.45(6u)(am)
(am) Notwithstanding
sub. (6m), from the appropriations under
s. 20.435 (4) (o),
(w), and
(wm), for reduction of operating deficits, as defined under the methodology used by the department in December 2000, incurred by a facility that is established under
s. 49.70 (1) or that is owned and operated by a city, village, or town, and as payment to care management organizations, the department may not distribute to these facilities and to care management organizations more than $37,100,000 in each fiscal year, as determined by the department. The total amount that a county certifies under this subsection may not exceed 100% of otherwise-unreimbursed care. In distributing funds under this subsection, the department shall perform all of the following:
49.45(6u)(am)1.
1. Estimate the availability of federal medical assistance funds that may be matched to county funds or funds of a city, village or town for the reduction of operating deficits incurred by the facility.
49.45(6u)(am)2.
2. Based on the amount estimated available under
subd. 1., develop a method to distribute this allocation to the individual facilities that have incurred operating deficits that shall include:
49.45(6u)(am)2.b.
b. Agreement by the county in which is located the facility established under
s. 49.70 (1) and agreement by the city, village, or town that owns and operates the facility that the applicable county, city, village, or town shall provide funds to match federal medical assistance matching funds under this paragraph.
49.45(6u)(am)2.bm.
bm. Identification by the county in which is located the facility established under
s. 49.70 (1) of all county funds expended in each calendar year to operate the facility, and certification by the county to the department of this amount.
49.45(6u)(am)3.
3. Distribute the allocation under the distribution method that is developed, unless a county has failed to comply with
subd. 2. bm.
49.45(6u)(am)4.
4. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under
s. 20.435 (4) (o) and
(w) that result in a lesser allocation amount than that allocated under this paragraph, allocate not more than the lesser amount so approved by the federal department of health and human services.
49.45(6u)(am)5.
5. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under
s. 20.435 (4) (o) and
(w) that result in a lesser allocation amount than that allocated under this paragraph, submit a revision of the method developed under
subd. 2. for approval by the joint committee on finance in that state fiscal year.
49.45(6u)(am)6.
6. If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds distributed under
subd. 3., apply the requirements under
sub. (6m) (br).
49.45(6u)(am)7.
7. If a facility that is otherwise eligible for an allocation of funds under this section is found by the federal health care financing administration or the department to be an institution for mental diseases, as defined under
42 CFR 435.1009, cease distributing to that facility funds under this section after the date on which the finding is made.
