49.45(53)
(53) Payments for certain services. Beginning on January 1, 2003, the department may, from the appropriation account under
s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under
s. 49.46 (2) (a) 4. d. and
(b) 6. j. and
m.
49.45 History
History: 1971 c. 40 s.
93;
1971 c. 42,
125;
1971 c. 213 s.
5;
1971 c. 215,
217,
307;
1973 c. 62,
90,
147;
1973 c. 333 ss.
106g,
106h,
106j,
201w;
1975 c. 39;
1975 c. 223 s.
28;
1975 c. 224 ss.
54h,
56 to
59m;
1975 c. 383 s.
4;
1975 c. 411;
1977 c. 29,
418;
1979 c. 34 ss.
837f to
838,
2102 (20) (a);
1979 c. 102,
177,
221,
355;
1981 c. 20 ss.
839 to
854,
2202 (20) (r);
1981 c. 93,
317;
1983 a. 27 ss.
1046 to
1062m,
2200 (42);
1983 a. 245,
447,
527;
1985 a. 29 ss.
1026m to
1031d,
3200 (23), (56),
3202 (27);
1985 a. 120,
176,
269;
1985 a. 332 ss.
91,
251 (5),
253;
1985 a. 340;
1987 a. 27 ss.
989r to
1000s,
2247,
3202 (24);
1987 a. 186,
307,
339,
399;
1987 a. 403 s.
256;
1987 a. 413;
1989 a. 6;
1989 a. 31 ss.
1402 to
1452g,
2909g,
2909i;
1989 a. 107,
173,
310,
336,
351,
359;
1991 a. 22,
39,
80,
250,
269,
315,
316;
1993 a. 16 ss.
1362g to
1403,
3883;
1993 a. 27,
107,
112,
183,
212,
246,
269,
335,
356,
437,
446,
469;
1995 a. 20;
1995 a. 27 ss.
2947 to
3002r,
7299,
9126 (19),
9130 (4),
9145 (1);
1995 a. 191,
216,
225,
289,
303,
398,
417,
457;
1997 a. 3,
13,
27,
114,
175,
191,
237,
252,
293;
1999 a. 9,
63,
103,
180,
185;
2001 a. 13,
16,
35,
38,
57,
67,
104,
109;
2003 a. 33,
318,
321.
49.45 Annotation
Wisconsin has no medical assistance plan independent of Medicaid. Non-residence under federal Medicaid regulations is determinative of medical assistance eligibility. Pope v. DHSS,
187 Wis. 2d 207,
522 N.W.2d 22 (Ct. App. 1994).
49.45 Annotation
Section 49.89, not sub. (19) (a) 2., specifically addresses assignment of actions and subrogation of rights by a public assistance recipient who is injured and has a tort claim against a 3rd party. Ellsworth v. Schelbrock, 2000 WI 63,
235 Wis. 2d 678,
611 N.W.2d 764.
49.45 Annotation
Sub. (7) (a) requires that a health care facility resident who is a recipient of certain funds apply those funds toward the cost of care in the health care facility. The agent who received funds from the Social Security Administration on behalf of the resident has an obligation to pay the funds to the health care facility and is subject to an action for conversion. Methodist Manor of Waukesha, Inc. v. Martin, 2002 WI App 130,
255 Wis. 2d 707,
647 N.W.2d 409.
49.45 Annotation
Medical assistance eligibility is not a default position that the department must rebut, but a privilege for which the applicant must prove eligibility. An initial determination of eligibility does not preclude a later redetermination of that status. The state has an ongoing duty to ensure that a MA recipient is eligible and the recipient bears the ongoing burden of proving eligibility. Estate of Gonwa v. DHFS, 2003 WI App 152,
265 Wis. 2d 913,
668 N.W.2d 122,
02-2901.
49.45 Annotation
A contract between the trustees of a nursing home and a medical clinic for exclusive medical services under the medical assistance act for residents of such home violates public policy of this state. 59 Atty. Gen. 68.
49.45 Annotation
Medical Assistance & Divestment. Canellos. Wis. Law. Aug. 1991.
49.453
49.453
Divestment of assets. 49.453(1)(am)
(am) "Covered individual" means an individual who is an institutionalized individual or a noninstitutionalized individual.
49.453(1)(c)
(c) "Expected value of the benefit" means the amount that an irrevocable annuity will pay to the annuitant during his or her expected lifetime as determined under
sub. (4) (c).
49.453(1)(f)
(f) "Look-back date" means for a covered individual, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under
s. 49.454 (2) (c) or
(3) (b) the date that is 60 months before:
49.453(1)(f)1.
1. For a covered individual who is an institutionalized individual, the first date on which the covered individual is both an institutionalized individual and has applied for medical assistance.
49.453(1)(f)2.
2. For a covered individual who is a noninstitutionalized individual, the date on which the covered individual applies for medical assistance or, if later, the date on which the covered individual, his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transferred assets for less than fair market value.
49.453(1)(g)
(g) "Reasonable compensation" means the prevailing local market rate of compensation for the service or care provided.
49.453(1)(h)
(h) "Relative" means an individual who is related to another by blood, marriage or adoption.
49.453(2)
(2) Ineligibility for medical assistance for certain services. 49.453(2)(a)(a)
Institutionalized individuals. Except as provided in
sub. (8), if an institutionalized individual or his or her spouse, or another person acting on behalf of the institutionalized individual or his or her spouse, transfers assets for less than fair market value on or after the institutionalized individual's look-back date, the institutionalized individual is ineligible for medical assistance for the following services for the period specified under
sub. (3):
49.453(2)(a)2.
2. For a level of care in a medical institution equivalent to that of a nursing facility.
49.453(2)(b)
(b)
Noninstitutionalized individuals. Except as provided in
sub. (8), if a noninstitutionalized individual or his or her spouse, or another person acting on behalf of the noninstitutionalized individual or his or her spouse, transfers assets for less than fair market value on or after the noninstitutionalized individual's look-back date, the noninstitutionalized individual is ineligible for medical assistance for the following services for the period specified under
sub. (3):
49.453(2)(b)2.
2. Other long-term care services specified by the department by rule.
49.453(3)(a)(a) The period of ineligibility under this subsection begins on the first day of the first month beginning on or after the look-back date during or after which assets have been transferred for less than fair market value and that does not occur in any other periods of ineligibility under this subsection.
49.453(3)(b)
(b) The department shall determine the number of months of ineligibility as follows:
49.453(3)(b)1.
1. The department shall determine the total, cumulative uncompensated value of all assets transferred by the covered individual or his or her spouse on or after the look-back date.
49.453(3)(b)2.
2. The department shall determine the average monthly cost to a private patient of nursing facility services in the state at the time that the covered individual applied for medical assistance.
49.453(3)(b)3.
3. The number of months of ineligibility equals the number determined by dividing the amount determined under
subd. 1. by the amount determined under
subd. 2.
49.453(3)(c)
(c) If the spouse of an individual makes a transfer of assets that results in a period of ineligibility under this section and otherwise becomes eligible for medical assistance, the department shall apportion the period of ineligibility between the individual and the spouse. The department shall promulgate rules establishing a reasonable methodology for apportioning a period of ineligibility under this paragraph.
49.453(4)
(4) Irrevocable annuities, promissory notes and similar transfers. 49.453(4)(a)(a) For the purposes of
sub. (2), whenever a covered individual or his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transfers assets to an irrevocable annuity, or transfers assets by promissory note or similar instrument, in an amount that exceeds the expected value of the benefit, the covered individual or his or her spouse transfers assets for less than fair market value. A transfer to an annuity, or a transfer by promissory note or similar instrument, is not in excess of the expected value only if all of the following are true:
49.453(4)(a)1.
1. The periodic payments back to the transferor include principal and interest that, at the time that the transfer is made, is at least at one of the following:
49.453(4)(a)1.a.
a. For an annuity, promissory note or similar instrument that is not specified under
subd. 1. b. or
par. (am), the applicable federal rate required under section
1274 (d) of the Internal Revenue Code, as defined in
s. 71.01 (6).
49.453(4)(a)1.b.
b. For an annuity with a guaranteed life payment, the appropriate average of the applicable federal rates based on the expected length of the annuity minus 1.5%.
49.453(4)(a)2.
2. The terms of the instrument provide for a payment schedule that includes equal periodic payments, except that payments may be unequal if the interest payments are tied to an interest rate and the inequality is caused exclusively by fluctuations in that rate.
49.453(4)(am)
(am) Paragraph (a) 1. does not apply to a variable annuity that is tied to a mutual fund that is registered with the federal securities and exchange commission.
49.453(4)(b)
(b) The amount of assets that is transferred for less than fair market value under
par. (a) is the amount by which the transferred amount exceeds the expected value of the benefit.
49.453(4)(c)
(c) The department shall promulgate rules specifying the method to be used in calculating the expected value of the benefit, based on
26 CFR 1.72-
1 to
1.72-
18, and specifying the criteria for adjusting the expected value of the benefit based on a medical condition diagnosed by a physician before the assets were transferred to the annuity, or transferred by promissory note or similar instrument. In calculating the amount of the divestment when a transfer to an annuity, or a transfer by promissory note or similar instrument, is made, payments made to the transferor in any year subsequent to the year in which the transfer was made shall be discounted to the year in which the transfer was made by the applicable federal rate specified under
par. (a) on the date of the transfer.
49.453(5)
(5) Care or personal services. For the purposes of
sub. (2), whenever a covered individual or his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transfers assets to a relative as payment for care or personal services that the relative provides to the covered individual, the covered individual or his or her spouse transfers assets for less than fair market value unless the care or services directly benefit the covered individual, the amount of the payment does not exceed reasonable compensation for the care or services that the relative performs and, if the amount of the payment exceeds 10% of the community spouse resource allowance limit specified in
s. 49.455 (6) (b) 1., the agreement to pay the relative is specified in a notarized written agreement that exists at the time that the relative performs the care or services.
49.453(6)
(6) Common ownership. For purposes of
sub. (2), if a covered individual holds an asset in common with another person in a joint tenancy, tenancy in common, or similar arrangement, the asset, or the affected portion of the asset, is considered to be transferred by the covered individual when an action is taken, either by the covered individual or by any other person, that reduces or eliminates the covered individual's ownership or control of the asset.
49.453(7)
(7) Certain authorizations. For the purposes of
sub. (2), if a covered individual or his or her spouse authorizes another person to transfer, encumber, lease, consume or otherwise act with respect to an asset as though the asset belonged to that other person; if that other person exercises the authority in a way that causes the asset to be unavailable for the support and maintenance of the covered individual or his or her spouse; and if the covered individual does not receive fair market value for the asset, then the covered individual or his or her spouse transfers assets for less than fair market value at the time that the other person exercises the authority.
49.453(8)
(8) Inapplicability. Subsections (2) and
(3) do not apply to transfers of assets if the assets are exempt under
42 USC 1396p (c) (2) or if the department determines that application of this section would work an undue hardship. The department shall promulgate rules concerning the transfer of assets exempt under
42 USC 1396p (c) (2).
49.453 History
History: 1993 a. 437 ss.
74 to
92;
1997 a. 35;
1999 a. 9,
185.
49.453 Annotation
A wife's failure to assert a claim against her deceased husband's estate for her statutorily granted share of the estate constituted an act of divestment. Tannler v. DHSS,
211 Wis. 2d 179,
564 N.W.2d 735 (1997).
49.453 Annotation
The grantor of an irrevocable trust that allowed the grantor to live in trust property for her life unless the grantor was found incompetent, in which case the trust could be terminated and the property distributed, did not divest an asset when she was found incompetent and the trustee distributed the residence pursuant to the trust document. Artac v. DHFS, 2000 WI App 88,
234 Wis. 2d 480,
610 N.W.2d 115.
49.453 Annotation
Although this section has specific requirements with which an annuity must comply, the initial question is whether the transfer of assets to the annuity was made for less than fair market value under sub. (2) (a). Buettner v. DHFS, 2003 WI App 90,
264 Wis. 2d 700,
663 N.W.2d 282,
01-0981.
49.454
49.454
Treatment of trust amounts. 49.454(1)(a)(a) Except as provided in
sub. (4), this section applies to an individual with respect to a trust if assets of the individual or the individual's spouse were used to form all or part of the corpus of the trust and if any of the following persons established the trust other than by will:
49.454(1)(a)3.
3. A person, including a court or administrative body with legal authority to act in place of or on behalf of the individual or the individual's spouse.
49.454(1)(a)4.
4. A person, including a court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse.
49.454(1)(b)
(b) If the corpus of a trust under
par. (a) includes assets of a person other than the individual or the individual's spouse, this section applies only with respect to the portion of the trust attributable to the assets of the individual or the individual's spouse.
49.454(2)
(2) Treatment of revocable trust amounts. For purposes of determining an individual's eligibility for, or amount of benefits under, medical assistance:
49.454(2)(a)
(a) The corpus of a revocable trust is considered a resource available to the individual.
49.454(2)(b)
(b) Payments from a revocable trust to or for the benefit of the individual are considered income of the individual.
49.454(2)(c)
(c) Other payments from a revocable trust are considered transfers of assets by the individual subject to
s. 49.453.
49.454(3)
(3) Treatment of irrevocable trust amounts. For purposes of determining an individual's eligibility for, or amount of benefits under, medical assistance:
49.454(3)(a)
(a) If there are circumstances under which payment from an irrevocable trust could be made to or for the benefit of the individual, the portion of the corpus from which, or the income on the corpus from which, payment to or for the benefit of the individual could be made is considered a resource available to the individual, and payments from that portion of the corpus or income:
49.454(3)(a)1.
1. To or for the benefit of the individual, are considered income of the individual.
49.454(3)(a)2.
2. For any other purpose, are considered transfers of assets by the individual subject to
s. 49.453.
49.454(3)(b)
(b) Any portion of an irrevocable trust from which, or any income on the corpus from which, no payment could under any circumstances be made to or for the benefit of the individual, is considered to be an asset transferred by the individual subject to
s. 49.453. The asset is considered to be transferred as of the date of the establishment of the trust, or, if later, the date on which payment to the individual was foreclosed. The value of the trust shall be determined for purposes of
s. 49.453 by including the amount of any payments made from that portion of the trust after that date.
49.454(4)
(4) Inapplicability. This section does not apply to any trust described in
42 USC 1396p (d) (4) or if the department determines, pursuant to procedures established by the department by rule, that the application of this section would work an undue hardship on an individual.
49.454 History
History: 1993 a. 437.
49.454 Annotation
Transfer of a disabled ward's property to a newly-established "Medicaid Payback Trust" was in the ward's best interest and authorized by ss. 49.454 (4) and 880.19 (5) (b). Marjorie A. G. v. Dodge County Department of Human Services, 2003 WI App 52,
261 Wis. 2d 679,
659 N.W.2d 438,
02-1121.
49.454 Annotation
Regardless of whether the asset held in an irrevocable trust is transferred as an annuity, it is nevertheless held in an irrevocable trust governed by s. 49.454, which specifically governs the treatment of trust amounts for purposes of MA eligibility. Estate of Gonwa v. DHFS, 2003 WI App 152,
265 Wis. 2d 913,
668 N.W.2d 122,
02-2901.
49.455
49.455
Protection of income and resources of couple for maintenance of community spouse. 49.455(1)(a)
(a) "Community spouse" means an individual who is married to an institutionalized spouse.
49.455(1)(b)
(b) "Consumer price index" means the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
49.455(1)(c)
(c) "Family member" means a minor or dependent child, dependent parent or dependent sibling of an institutionalized or community spouse who resides with the community spouse.
49.455(1)(d)
(d) "Institutionalized spouse" means either an individual who is in a medical institution or nursing facility and is married to an individual who is not in a medical institution or nursing facility or an individual who receives services under a waiver under
42 USC 1396n (c) or (d) and is married to an individual who is not in a medical institution or nursing facility and does not receive services under a waiver under
42 USC 1396n (c) or (d).
49.455(1)(e)
(e) "Resources" does not include items excluded under
42 USC 1382b (a) or (d) or items that would be excluded under
42 USC 1382b (a) (2) (A) but for the limitation on total value established under that provision.
49.455(2)
(2) Applicability. The department shall use the provisions of this section in determining the eligibility for medical assistance under
s. 49.46 or
49.47 and the required contribution toward care of an institutionalized spouse.
