OTHER SUPPORT AND MEDICAL PROGRAMS
49.66
49.66
Definitions. In this subchapter:
49.66(1)
(1) "Department" means the department of health and family services.
49.66(2)
(2) "Secretary" means the secretary of health and family services.
49.66 History
History: 1995 a. 27 ss.
3179,
9126 (19).
49.665(1)(b)
(b) "Child" means a person who is under the age of 19.
49.665(1)(c)
(c) "Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80% of the cost, excluding any deductibles or copayments that may be required under the plan.
49.665(1)(d)
(d) "Family" means a unit that consists of at least one child and his or her parent or parents, all of whom reside in the same household. "Family" includes the spouse of an individual who is a parent if the spouse resides in the same household as the individual.
49.665(2)(a)(a) The department of health and family services shall request a waiver from the secretary of the federal department of health and human services to permit the department of health and family services to implement, beginning not later than July 1, 1998, or the effective date of the waiver, whichever is later, a health care program under this section. If a waiver that is consistent with all of the provisions of this section, excluding
sub. (4) (a) 3m., is granted and in effect, the department of health and family services shall implement the program under this section. The department of health and family services may not implement the program under this section unless a waiver that is consistent with all of the provisions of this section, excluding
sub. (4) (a) 3m., is granted and in effect.
49.665(2)(b)
(b) If the department of health and family services determines that it needs a waiver to require the verification specified in
sub. (4) (a) 3m., the department shall request a waiver from the secretary of the federal department of health and human services and may not implement the verification requirement under
sub. (4) (a) 3m. unless the waiver is granted. If a waiver is required and is granted, the department of health and family services may implement the verification requirement under
sub. (4) (a) 3m. as appropriate. If a waiver is not required, the department of health and family services may require the verification specified in
sub. (4) (a) 3m. for eligibility determinations and annual review eligibility determinations made by the department, beginning on January 1, 2004.
49.665(3)
(3) Administration. The department shall administer a program to provide the health services and benefits described in
s. 49.46 (2) to persons that meet the eligibility requirements specified in
sub. (4). The department shall promulgate rules setting forth the application procedures and appeal and grievance procedures. The department may promulgate rules limiting access to the program under this section to defined enrollment periods. The department may also promulgate rules establishing a method by which the department may purchase family coverage offered by the employer of a member of an eligible family or by a member of a child's household under circumstances in which the department determines that purchasing that coverage would not be more costly than providing the coverage under this section.
49.665(4)(a)(a) A family is eligible for health care coverage under this section if the family meets all of the following requirements:
49.665(4)(a)1.
1. The family's income does not exceed 185% of the poverty line, except as provided in
par. (at) and except that a family that is already receiving health care coverage under this section may have an income that does not exceed 200% of the poverty line. The department shall establish by rule the criteria to be used to determine income.
49.665(4)(a)2.
2. The family does not have access to employer-subsidized health care coverage.
49.665(4)(a)3.
3. The family has not had access to employer-subsidized health care coverage within the time period established by the department by rule, but not to exceed 18 months, immediately preceding application for health care coverage under this section. The department may establish exceptions to this time period restriction by rule.
49.665(4)(a)3m.
3m. Each member of the family who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings, of whether the employer provides health care coverage for which the family is eligible, and of the amount that the employer pays, if any, towards the cost of the health care coverage, excluding any deductibles or copayments required under the coverage.
49.665(4)(a)4.
4. The family meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements.
49.665(4)(am)
(am) A child who does not reside with his or her parent is eligible for health care coverage under this section if the child meets all of the following requirements:
49.665(4)(am)1.
1. The child's income does not exceed 185% of the poverty line, except as provided in
par. (at) and except that a child that is already receiving health care coverage under this section may have an income that does not exceed 200% of the poverty line. The department shall use the criteria established under
par. (a) 1. to determine income under this subdivision.
49.665(4)(am)2.
2. The child does not have access to employer-subsidized health care coverage.
49.665(4)(am)3.
3. The child has not had access to employer-subsidized health care coverage within the time period established by the department under
par. (a) 3. The department may establish exceptions to this subdivision.
49.665(4)(am)4.
4. The child meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements.
49.665(4)(at)1.a.a. Except as provided in
subd. 1. b., the department shall establish a lower maximum income level for the initial eligibility determination if funding under
s. 20.435 (4) (bc),
(jz),
(p), and
(x) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding.
49.665(4)(at)1.b.
b. The department may not lower the maximum income level for initial eligibility unless the department first submits to the joint committee on finance a plan for lowering the maximum income level. If, within 14 days after the date on which the plan is submitted to the joint committee on finance, the cochairpersons of the committee do not notify the secretary that the committee has scheduled a meeting for the purpose of reviewing the plan, the department shall implement the plan as proposed. If, within 14 days after the date on which the plan is submitted to the committee, the cochairpersons of the committee notify the secretary that the committee has scheduled a meeting to review the plan, the department may implement the plan only as approved by the committee.
49.665(4)(at)1.cm.
cm. Notwithstanding
s. 20.001 (3) (b), if, after reviewing the plan submitted under
subd. 1. b., the joint committee on finance determines that the amounts appropriated under
s. 20.435 (4) (bc),
(jz),
(p), and
(x) are insufficient to accommodate the projected enrollment levels, the committee may transfer appropriated moneys from the general purpose revenue appropriation account of any state agency, as defined in
s. 20.001 (1), other than a sum sufficient appropriation account, to the appropriation account under
s. 20.435 (4) (bc) to supplement the health care program under this section if the committee finds that the transfer will eliminate unnecessary duplication of functions, result in more efficient and effective methods for performing programs, or more effectively carry out legislative intent, and that legislative intent will not be changed by the transfer.
49.665(4)(at)2.
2. If, after the department has established a lower maximum income level under
subd. 1., projections indicate that funding under
s. 20.435 (4) (bc),
(jz),
(p), and
(x) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185% of the poverty line.
49.665(4)(at)3.
3. The department may not adjust the maximum income level of 200% of the poverty line for persons already receiving health care coverage under this section.
49.665(4)(b)
(b) Notwithstanding fulfillment of the eligibility requirements under this subsection, no person is entitled to health care coverage under this section.
49.665(4)(c)
(c) No person may be denied health care coverage under this section solely because of a health condition of that person or of any family member of that person.
49.665(5)(ac)(ac) In this subsection, "cost" means total cost-sharing charges, including premiums, copayments, coinsurance, deductibles, enrollment fees, and any other cost-sharing charges.
49.665(5)(ag)
(ag) Except as provided in
pars. (am),
(b), and
(bm), a family, or child who does not reside with his or her parent, who receives health care coverage under this section shall pay a percentage of the cost of that coverage in accordance with a schedule established by the department by rule. The department may not establish or implement a schedule that requires a family or child to contribute, including the amounts required under
par. (am), more than 5% of the family's or child's income towards the cost of the health care coverage provided under this section.
49.665(5)(am)
(am) Except as provided in
pars. (b) and
(bm), a child or family member who receives health care coverage under this section shall pay the following cost-sharing amounts:
49.665(5)(b)
(b) The department may not require a family, or child who does not reside with his or her parent, with an income below 150% of the poverty line to contribute to the cost of health care coverage provided under this section.
49.665(5)(bm)
(bm) If the federal department of health and human services notifies the department of health and family services that Native Americans may not be required to contribute to the cost of the health care coverage provided under this section, the department of health and family services may not require Native Americans to contribute to the cost of health care coverage under this section.
49.665(5)(c)
(c) The department may establish by rule requirements for wage withholding as a means of collecting the family's share of the cost of the health care coverage under this section.
49.665(5m)
(5m) Information about badger care recipients. 49.665(5m)(b)
(b) 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:
49.665(5m)(b)1.
1. Information that the department needs to identify recipients of badger care who satisfy any of the following:
49.665(5m)(b)1.b.
b. Would be eligible for benefits under a disability insurance policy if the recipient were enrolled as a dependent of a person insured under the disability insurance policy.
49.665(5m)(b)2.
2. Information required for submittal of claims under the insurer's disability insurance policy.
49.665(5m)(b)3.
3. The types of benefits provided by the disability insurance policy.
49.665(5m)(c)
(c) Upon requesting an insurer to provide the information under
par. (b), the department shall enter into a written agreement with the insurer that satisfies all of the following:
49.665(5m)(c)2.
2. Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.
49.665(5m)(d)1.1. An insurer shall provide the information requested under
par. (b) 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 subsection.
49.665(5m)(d)2.
2. An insurer shall provide the information requested under
par. (b) within 30 days after receiving the department's request if the department has previously requested the insurer to disclose information under this subsection.
49.665(5m)(d)3.
3. If an insurer fails to comply with
subd. 1. or
2., 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).
49.665(6)
(6) Annual report. Not later than October 1 of each year, the department shall submit a report to the legislature under
s. 13.172 (2) that summarizes enrollment in and cost of the health care program under this section and any other information that the department determines is pertinent information regarding the program under this section.
49.68
49.68
Aid for treatment of kidney disease. 49.68(1)
(1)
Declaration of policy. The legislature finds that effective means of treating kidney failure are available, including dialysis or artificial kidney treatment or transplants. It further finds that kidney disease treatment is prohibitively expensive for the overwhelming portion of the state's citizens. It further finds that public and private insurance coverage is inadequate in many cases to cover the cost of adequate treatment at the proper time in modern facilities. The legislature finds, in addition, that the incidence of the disease in the state is not so great that public aid may not be provided to alleviate this serious problem for a relatively modest investment. Therefore, it is declared to be the policy of this state to assure that all persons are protected from the destructive cost of kidney disease treatment by one means or another.
49.68(1m)
(1m) In this section, "recombinant human erythropoietin" means a bioengineered glycoprotein that has the same biological effects in stimulating red blood cell production as does the glycoprotein erythropoietin that is produced by the human body.
49.68(2)
(2) Duties of department. The department shall:
49.68(2)(a)
(a) Promulgate rules setting standards for operation and certification of dialysis and renal transplantation centers and home dialysis equipment and suppliers.
49.68(2)(b)
(b) Promulgate rules setting standards for acceptance and certification of patients into the treatment phase of the program.
49.68(2)(c)
(c) Promulgate rules concerning reasonable cost and length of treatment programs.
49.68(2)(d)
(d) Aid in preparing educational programs and materials informing the public as to chronic renal disease and the prevention and treatment thereof.
49.68(3)
(3) Aid to kidney disease patients. 49.68(3)(a)(a) Subject to
s. 49.687 (1m), any permanent resident of this state who suffers from chronic renal disease may be accepted into the dialysis treatment phase of the renal disease control program if the resident meets standards set by rule under
sub. (2) and
s. 49.687.
49.68(3)(b)
(b) From the appropriation accounts under
ss. 20.435 (4) (e) and
(je), the state shall pay the cost of medical treatment required as a direct result of chronic renal disease of certified patients from the date of certification, including the cost of administering recombinant human erythropoietin to appropriate patients, whether the treatment is rendered in an approved facility in the state or in a dialysis or transplantation center which is approved as such by a contiguous state, subject to the conditions specified under
par. (d). Approved facilities may include a hospital in-center dialysis unit or a nonhospital dialysis center which is closely affiliated with a home dialysis program supervised by an approved facility. Aid shall also be provided for all reasonable expenses incurred by a potential living-related donor, including evaluation, hospitalization, surgical costs and postoperative follow-up to the extent that these costs are not reimbursable under the federal medicare program or other insurance. In addition, all expenses incurred in the procurement, transportation and preservation of cadaveric donor kidneys shall be covered to the extent that these costs are not otherwise reimbursable. All donor-related costs are chargeable to the recipient and reimbursable under this subsection.
49.68(3)(c)
(c) Disbursement and collection of all funds under this subsection shall be by the department or by a fiscal intermediary, in accordance with a contract with a fiscal intermediary. The costs of the fiscal intermediary under this paragraph shall be paid from the appropriation under
s. 20.435 (1) (a).
49.68(3)(d)1.1. No aid may be granted under this subsection unless the recipient has no other form of aid available from the federal medicare program, from private health, accident, sickness, medical, and hospital insurance coverage, or from other health care coverage specified by rule under
s. 49.687 (1m). If insufficient aid is available from other sources and if the recipient has paid an amount equal to the annual medicare deductible amount specified in
subd. 2., the state shall pay the difference in cost to a qualified recipient. If at any time sufficient federal or private insurance aid or other health care coverage becomes available during the treatment period, state aid under this subsection shall be terminated or appropriately reduced. Any patient who is eligible for the federal medicare program shall register and pay the premium for medicare medical insurance coverage where permitted, and shall pay an amount equal to the annual medicare deductible amounts required under
42 USC 1395e and
1395L (b), prior to becoming eligible for state aid under this subsection.
49.68(3)(d)2.
2. Aid under this subsection is only available after the patient pays an annual amount equal to the annual deductible amount required under the federal medicare program. This subdivision requires an inpatient who seeks aid first to pay an annual deductible amount equal to the annual medicare deductible amount specified under
42 USC 1395e and requires an outpatient who seeks aid first to pay an annual deductible amount equal to the annual medicare deductible amount specified under
42 USC 1395L (b).
49.68(3)(d)3.
3. No payment shall be made under this subsection for any portion of medical treatment costs or other expenses that are payable under any state, federal, or other health care coverage program, including a health care coverage program specified by rule under
s. 49.687 (1m), or under any grant, contract, or other contractual arrangement.
49.68(3)(e)
(e) State aids for services provided under this section shall be equal to the allowable charges under the federal Medicare program. In no case shall state rates for individual service elements exceed the federally defined allowable costs. The rate of charges for services not covered by public and private insurance shall not exceed the reasonable charges as established by medicare fee determination procedures. A person that provides to a patient a service for which aid is provided under this section shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section. The state may not pay for the cost of travel, lodging, or meals for persons who must travel to receive inpatient and outpatient dialysis treatment for kidney disease. This paragraph shall not apply to donor related costs as defined in
par. (b).
49.68 Cross-reference
Cross Reference: See also ch.
HFS 152, Wis. adm. code.
49.682
49.682
Recovery from estates.
