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.
49.45(6v)(b)
(b) The department shall, each year, submit to the joint committee on finance a report for the previous fiscal year, except for the 1997-98 fiscal year, that provides information on the utilization of beds by recipients of medical assistance in facilities and a discussion and detailed projection of the likely balances, expenditures, encumbrances and carry over of currently appropriated amounts in the appropriation accounts under
s. 20.435 (4) (b),
(gp), and
(o).
49.45(6v)(c)
(c) If the report specified in
par. (b) indicates that utilization of beds by recipients of medical assistance in facilities is less than estimates for that utilization reflected in the intentions of the joint committee on finance, legislature and governor, as expressed by them in the budget determinations, the department shall include a proposal to transfer moneys from the appropriation under
s. 20.435 (4) (b) to the appropriation under
s. 20.435 (7) (bd) for the purpose of increasing funding for the community options program under
s. 46.27. The amount proposed for transfer may not reduce the balance in the appropriation account under
s. 20.435 (4) (b) below an amount necessary to ensure that that appropriation account will end the current fiscal year or the current fiscal biennium with a positive balance. The secretary shall transfer the amount identified under the proposal.
49.45(6w)
(6w) Hospital operating deficit reduction. 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 hospital, as defined under
s. 50.33 (2) (a) and
(b), that is operated by the state, established under
s. 49.71 or owned and operated by a city or village, the department shall allocate up to $3,300,000 in each fiscal year to these hospitals, as determined by the department, and shall perform all of the following:
49.45(6w)(a)
(a) For the reduction of operating deficits incurred by the hospital, estimate the availability of federal medicaid funds that may be matched to any of the following:
49.45(6w)(a)1.
1. State general purpose revenues, for a hospital operated by the state.
49.45(6w)(a)3.
3. Funds of a city or village, for a hospital owned and operated by a city or village.
49.45(6w)(b)
(b) Based on the amount estimated available under
par. (a), develop a method to distribute this allocation to the individual hospitals that have incurred operating deficits that shall include:
49.45(6w)(b)1.
1. Development of criteria for determining operating deficits.
49.45(6w)(b)2.
2. With respect to funds to match federal medicaid matching funds under this section, any of the following, as applicable:
49.45(6w)(b)2.a.
a. Provision by the state of matching funds from general purpose revenues for a hospital operated by the state.
49.45(6w)(b)2.b.
b. Agreement to provide matching funds by the county in which is located a hospital established under
s. 49.71.
49.45(6w)(b)2.c.
c. Agreement to provide matching funds by the city or village that owns and operates a hospital.
49.45(6w)(b)3.
3. Consideration of the size of a hospital's operating deficit.
49.45(6w)(c)
(c) Except as provided in
par. (d), distribute the allocation under the distribution method that is developed.
49.45(6w)(d)
(d) 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
par. (c), reduce allocations under this subsection and distribute on a prorated basis, as determined by the department.
49.45(6x)
(6x) Funding for essential access city hospital. 49.45(6x)(a)(a) Notwithstanding
sub. (3) (e), from the appropriation accounts under
s. 20.435 (4) (b),
(gp),
(o), and
(w), the department shall distribute not more than $4,748,000 in each fiscal year, to provide funds to an essential access city hospital, except that the department may not allocate funds to an essential access city hospital to the extent that the allocation would exceed any limitation under
42 USC 1396b (i) (3).
49.45(6x)(b)
(b) The department shall develop procedures for solicitation and review of requests for funds and a method to distribute the funds under
par. (a) to an individual hospital that shall include establishment of criteria for the designation as an essential access city hospital.
49.45(6x)(c)
(c) Except as provided in
par. (d), the department shall distribute the funds under
par. (a) under the distribution method that is developed under
par. (b).
49.45(6x)(d)
(d) If the federal department of health and human services approves for state expenditure in any state fiscal year amounts under
s. 20.435 (4) (o) that result in a lesser distribution amount than that distributed under this subsection or disallows use of federal medicaid funds under
par. (a), the department of health and family services shall reduce the distributions under this subsection.
49.45(6x)(e)
(e) The department need not promulgate as rules under
ch. 227 the procedures, method of distribution and criteria required for distribution under this subsection.
49.45(6y)
(6y) Supplemental funding for certain hospitals. 49.45(6y)(a)(a) Notwithstanding
sub. (3) (e), from the appropriation accounts under
s. 20.435 (4) (b),
(gp),
(o), and
(w), the department shall distribute funding in each fiscal year to provide supplemental payment to hospitals that enter into a contract under
s. 49.02 (2) to provide health care services funded by a relief block grant, as determined by the department, for hospital services that are not in excess of the hospitals' customary charges for the services, as limited under
42 USC 1396b (i) (3). If no relief block grant is awarded under this chapter or if the allocation of funds to such hospitals would exceed any limitation under
42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into a contract under
s. 49.02 (2).
49.45(6y)(am)
(am) Notwithstanding
sub. (3) (e), from the appropriation accounts under
s. 20.435 (4) (b),
(h),
(gp),
(o), and
(w), the department shall distribute funding in each fiscal year to provide supplemental payments to hospitals that enter into contracts under
s. 49.02 (2) with a county having a population of 500,000 or more to provide health care services funded by a relief block grant, as determined by the department, for hospital services that are not in excess of the hospitals' customary charges for the services, as limited under
42 USC 1396b (i) (3).
49.45(6y)(b)
(b) The department need not promulgate as rules under
ch. 227 the procedures, methods of distribution and criteria required for distribution under
pars. (a) and
(am).
49.45(6z)
(6z) Supplemental funding for certain hospitals serving low-income patients. 49.45(6z)(a)(a) Notwithstanding
sub. (3) (e), from the appropriation accounts under
s. 20.435 (4) (b),
(gp),
(o), and
(w), the department shall distribute funding in each fiscal year to supplement payment for services to hospitals that enter into a contract under
s. 49.02 (2) to provide health care services funded by a relief block grant under this chapter, if the department determines that the hospitals serve a disproportionate number of low-income patients with special needs. If no medical relief block grant under this chapter is awarded or if the allocation of funds to such hospitals would exceed any limitation under
42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into a contract under
s. 49.02 (2). The department may not distribute funds under this subsection to the extent that the distribution would do any of the following:
49.45(6z)(b)
(b) The department need not promulgate as rules under
ch. 227 the procedures, methods of distribution and criteria required for distribution under
par. (a).
49.45(7)(a)(a) A recipient who is a patient in a public medical institution or an accommodated person and has a monthly income exceeding the payment rates established under
42 USC 1382 (e) may retain $45 unearned income or the amount of any pension paid under
38 USC 5503 (d), whichever is greater, per month for personal needs. Except as provided in
s. 49.455 (4) (a), the recipient shall apply income in excess of $45 or the amount of any pension paid under
38 USC 5503 (d), whichever is greater, less any amount deducted under rules promulgated by the department, toward the cost of care in the facility.
49.45(7)(b)
(b) Where a facility participating in the medical assistance program has been delegated in writing by a resident within that facility to manage and control the personal funds of the resident including but not limited to those funds identified in
par. (a) the facility shall establish for the resident a personal fund account. All deposits and withdrawals of funds shall be documented by the facility to indicate the amount and date of deposit and amount, date and purpose of withdrawal. Such documentation shall be maintained in the resident's records.
49.45(7)(c)
(c) Upon the removal of a resident from the facility as a result of death or permanent transfer, the facility shall transfer the balance of the resident's trust account to the personal representative of the resident's estate, the legal guardian of the resident or if appropriate to the resident personally. A copy of the trust account records shall be transferred with the funds. No facility or any of its employees or representatives may benefit from the distribution of a deceased resident's personal funds unless they are specifically named in the resident's will or constitute an heir at law.
49.45(7)(d)1.1. The department shall accept from any person a verified complaint concerning any violation of this subsection. The department shall forward to the accused within 10 days a copy of such complaint. The department, upon such investigation as it deems necessary, may dismiss the complaint or may find probable cause to believe that a violation of this subsection has occurred.
49.45(7)(d)2.
2. If the department finds probable cause to believe that a violation of this subsection has occurred, it may assess a forfeiture of not less than $25 nor more than $500 for each occurrence, and in addition may order that any amount illegally charged against a resident's account be restored. The department shall immediately inform the complainant and respondent of any such decision and the amount of forfeiture or repayment, if any. If the department is not notified in writing that a party wishes to contest a decision within 15 working days after the parties are informed of such decision, the department's determination shall be deemed final and may not be appealed to a court.
49.45(7)(d)3.
3. The department shall inform the nursing home administrators examining board of all decisions made under this paragraph.
49.45(7)(d)4.
4. The department's determination of serious misconduct under this subsection shall be cause for terminating the facility's participation in the state-funded portion of the medical assistance program under this subchapter.
49.45(7)(e)
(e) Nursing homes shall adopt a uniform accounting system prescribed by the department for purposes of managing residents personal fund accounts.
49.45(8)
(8) Per-visit limits on home health services reimbursement. 49.45(8)(a)4.
4. "Patient care visit" means a personal contact with a patient in a patient's home that is made by a registered nurse, licensed practical nurse, home health aide, physical therapist, occupational therapist or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under
s. 49.46 or
49.47. "Patient care visit" does not include time spent by a nurse, therapist or home health aide on case management, care coordination, travel, record keeping or supervision that is related to the patient care visit.
49.45(8)(a)7.
7. "Speech-language pathologist" means an individual engaged in the practice of speech-language pathology, as regulated under
ch. 459.
49.45(8)(b)
(b) Reimbursement under
s. 20.435 (4) (b),
(gp),
(o), and
(w) for home health services provided by a certified home health agency or independent nurse shall be made at the home health agency's or nurse's usual and customary fee per patient care visit, subject to a maximum allowable fee per patient care visit that is established under
par. (c).
49.45(8)(c)
(c) The department shall establish a maximum statewide allowable fee per patient care visit, for each type of visit with respect to provider, that may be no greater than the cost per patient care visit, as determined by the department from cost reports of home health agencies, adjusted for costs related to case management, care coordination, travel, record keeping and supervision.
49.45(8m)
(8m) Rates for respiratory care services. Notwithstanding the limit under
sub. (8), the rates under
sub. (8) and rates charged by providers under
s. 49.46 (2) (a) 4. d. that are not home health agencies, for reimbursement for respiratory care services for ventilator-dependent individuals under
ss. 49.46 (2) (b) 6. m. and
49.47 (6) (a) 1., shall be as follows:
49.45(8m)(a)
(a) For visits subsequent to an initial visit and for extended visits by a licensed registered nurse, $31.21 per hour.
49.45(8m)(b)
(b) For visits subsequent to an initial visit and for extended visits by a licensed practical nurse, $20.81 per hour.
49.45(8r)
(8r) Payment for certain obstetric and gynecological care. The rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in
s. 560.183 (1) (cm), or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125% of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.
49.45(8v)
(8v) Incentive-based pharmacy payment system. The department shall establish a system of payment to pharmacies for legend and over-the-counter drugs provided to recipients of medical assistance that has financial incentives for pharmacists who perform services that result in savings to the medical assistance program. Under this system, the department shall establish a schedule of fees that is designed to ensure that any incentive payments made are equal to or less than the documented savings. The department may discontinue the system established under this subsection if the department determines, after performance of a study, that payments to pharmacists under the system exceed the documented savings under the system.
49.45(9)
(9) Free choice. Any person eligible for medical assistance under
ss. 49.46,
49.468 and
49.47 may use the physician, chiropractor, dentist, pharmacist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist or dentist may be required to practice exclusively in the medical assistance program.
49.45(9m)
(9m) Referrals. The department may, consistent with
sub. (9), specify services for which reimbursement will be made only if the services are provided in accordance with a referral, in writing, which specifies the services to be rendered and the duration of such services. The referral form shall describe the referred services as required by the department.
49.45(9s)
(9s) Disclosure. Any person who is an employee of, or an owner, partner, member, stockholder or investor in, any legal entity providing services which are reimbursed under this section, shall notify the department, on forms provided by the department for that purpose, if such person is an employee of, or an owner, partner, member, stockholder or investor in, any other legal entity providing services which are reimbursed under this section.
49.45(10)
(10) Rule-making powers and duties. The department is authorized to promulgate such rules as are consistent with its duties in administering medical assistance. The department shall promulgate a rule defining the term "part-time intermittent care" for the purpose of
s. 49.46.
49.45(11)
(11) Penalty. Any person who receives or assists another in receiving assistance under this section, to which the recipient is not entitled, shall be subject to the penalties under
s. 49.95.
49.45(12)
(12) Machine-readable medical assistance cards. 49.45(12)(a)(a) The department shall assist the commissioner of insurance to conduct the study of health insurance identification cards under
s. 601.57 (1).
49.45(12)(b)
(b) If the commissioner of insurance promulgates rules under
s. 601.57 (2) establishing a health insurance identification card system and its computerized support system, the department shall develop a plan to coordinate a system of machine-readable identification cards for medical assistance recipients with the systems established by the commissioner and shall submit the plan to the governor, and to the legislature under
s. 13.172 (2), before issuing a request for proposals under
par. (c).
49.45(12)(c)
(c) The department shall request proposals for a system of machine-readable identification cards for medical assistance recipients and a computerized support system for the cards that will accept and respond to electronically conveyed requests from health care providers for information related to medical assistance recipients, such as eligibility, coverages and authorizations. The request for proposals shall specify that the systems are to be operating by January 1, 1997.
49.45(13)(a)(a) The department may require service providers to prepare and submit cost reports or financial reports for purposes of rate certification under Title XIX, cost verification, fee schedule determination or research and study purposes. These financial reports may include independently audited financial statements which shall include balance sheets and statements of revenues and expenses. The department may withhold reimbursement or may decrease or not increase reimbursement rates if a provider does not submit the reports required under this paragraph or if the costs on which the reimbursement rates are based cannot be verified from the provider's cost or financial reports or records from which the reports are derived.
49.45(13)(b)
(b) The department may require any provider who fails to submit a cost report or financial report under
par. (a) within the period specified by the department to forfeit not less than $10 nor more than $100 for each day the provider fails to submit the report.
49.45(15)
(15) Community care organization project guarantee. Upon termination of the community care organization demonstration projects in Barron, La Crosse and Milwaukee counties, any client who was receiving services through any of those projects may continue to receive the full range of community care organization services. The cost of the services shall continue to be paid by medical assistance.
49.45(16)
(16) Certification. On or after January 1, 1984, the department may only continue to certify as a medical assistance provider a community-based residential facility that is so certified on December 31, 1983. On or after January 1, 1984, no community-based residential facility may be certified for more beds than the number for which it was certified on December 31, 1983.
49.45(18)(ac)(ac) Except as provided in
pars. (am) to
(d), and subject to
par. (ag), any person eligible for medical assistance under
s. 49.46,
49.468, or
49.47 shall pay up to the maximum amounts allowable under
42 CFR 447.53 to
447.58 for purchases of services provided under
s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.
49.45(18)(ag)
(ag) Except as provided in
pars. (am),
(b), and
(c), and subject to
par. (d), a recipient specified in
par. (ac) shall pay all of the following:
49.45(18)(am)
(am) No person is liable under this subsection for services provided through prepayment contracts.
49.45(18)(b)
(b) The following services are not subject to recipient cost sharing under this subsection:
49.45(18)(b)1.
1. Any service provided to a person receiving care as an inpatient in a skilled nursing home or intermediate care facility certified under
42 USC 1396 to
1396k.
49.45(18)(b)2.
2. Any service provided to a person who is less than 18 years old.
49.45(18)(b)3.
3. Any service provided under
s. 49.46 (2) to a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy.
49.45(18)(b)6.
6. Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under
s. 46.215 or
46.22.
49.45(18)(b)7.
7. Home health services or, if a home health agency is unavailable, nursing services.
