49.45(30)
(30) Services provided by community support programs. 49.45(30)(b)
(b) The department shall reimburse a provider of services under
s. 49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.
49.45(30e)
(30e) Community-based psychosocial service programs. 49.45(30e)(a)(a)
When services are reimbursable. Services under
s. 49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
49.45(30e)(a)1.
1. Reimbursement for the services under
s. 49.46 (2) (b) 6. Lm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
49.45(30e)(a)2.
2. The county in which the individual resides elects to make the services under
s. 49.46 (2) (b) 6. Lm. available in the county through the medical assistance program.
49.45(30e)(a)3.
3. The individual's psychosocial health needs require more than outpatient counseling, but less than the services provided by a community support program under
s. 51.421.
49.45(30e)(a)4.
4. The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under
par. (b) 3.
49.45(30e)(b)
(b)
Rules. The department shall promulgate rules regarding all of the following:
49.45(30e)(b)3.
3. Requirements for certification of community-based psychosocial service programs.
49.45(30e)(b)4.
4. Any other conditions for coverage of community-based psychosocial services under the Medical Assistance Program.
49.45(30e)(c)
(c)
Provider reimbursement. A county that elects to make the services under
s. 49.46 (2) (b) 6. Lm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
49.45 Cross-reference
Cross Reference: See also ch.
HFS 36, Wis. adm. code.
49.45(30m)
(30m) Certain services for developmentally disabled. 49.45(30m)(a)(a) Except as provided in
par. (am), a county shall provide the portion of payment that is not provided by the federal government for all of the following services to individuals with developmental disability who are eligible for medical assistance:
49.45(30m)(a)2.
2. Services in an intermediate care facility for the mentally retarded, as defined in
s. 46.278 (1m) (am), other than a state center for the developmentally disabled.
49.45(30m)(am)
(am) The department shall provide the portion of the payment that is not provided by the federal government for any of the services specified in
par. (a) 1. to
3. that are provided to an individual with developmental disability who is eligible for medical assistance, as determined under the contract under
s. 46.279 (4m).
49.45(30m)(b)
(b) No payment under this section may be made for services specified under
par. (a) or
(am) unless the individual who receives the services is provided protective placement under s.
55.06 (9) (a), 2003 stats., or
s. 55.12, is provided emergency protective services under s.
55.05 (4), 2003 stats., or
s. 55.13, or is provided an emergency protective placement under s.
55.06 (11) (a), 2003 stats., or s.
55.135 or a temporary protective placement under s.
55.06 (11) (c), 2003 stats., or
s. 55.135 (5) or
55.055 (5).
49.45(30m)(c)
(c) No payment under this section may be made for services specified under
par. (a) 2. or
3. that are provided to an individual who was placed in or admitted to an intermediate facility, as defined in
s. 46.279 (1) (b), or nursing facility, as defined in
s. 46.279 (1) (c), unless one of the following applies:
49.45(30m)(c)1.
1. Any placement or admission that is made after April 30, 2005, complied with the requirements of
s. 46.279.
49.45(31)
(31) Eligibility for long-term care insurance beneficiaries. The department shall seek federal approval of, and federal financial participation in, a pilot project under which a person who is the beneficiary of a long-term care insurance policy that satisfies criteria established by the department may become eligible for medical assistance while exceeding the usual medical assistance resource limits.
49.45(32)
(32) Community care for the elderly. The department may request a waiver under
42 USC 1315 to permit the establishment of a community care for the elderly demonstration project to provide medical care, case management services, adult day care and other support services that promote independence and enhance the quality of life of frail elderly persons. If the waiver is approved, the department may establish the community care for the elderly demonstration project and pay a fixed per person fee for the services.
49.45(34)
(34) Medical assistance manual. The department shall prepare a medical assistance manual that is clear, comprehensive and consistent with this subchapter and
42 USC 1396a to
1396u and shall, no later than July 1, 1992, provide the manual to counties for use by county employees who administer the medical assistance program.
49.45(35)
(35) Training for nonprofit organizations. The department shall provide training to employees and volunteers of private nonprofit organizations concerning medical assistance eligibility under
s. 49.47 of persons whose incomes exceed the levels under
s. 49.47 (4) (am) and
(c) 1. before consideration, under
s. 49.47 (4) (c) 2., of the level of those persons' medical expenses.
49.45(35m)
(35m) Computer system redesign. The department shall ensure that any redesign or replacement of the computer network that is used by counties on May 12, 1992, to determine eligibility for medical assistance includes the capability of determining eligibility for medical assistance under
s. 49.47 (4) (c) 2.
49.45(36)
(36) Homeless beneficiaries. The department or a county department under
s. 46.215,
46.22, or
46.23 may not place the word "homeless" on the medical assistance identification card of any person who is determined to be eligible for medical assistance benefits and who is homeless.
49.45(37)
(37) Plans of care. The department may seek a waiver of the requirement under
42 USC 1396n (c) (1) that the department review and approve every written plan of care developed for each individual who receives, under
42 USC 1396n (c) (1), home or community-based services under
ss. 49.46 (2) (b) 8. and
49.47 (6) (a) 1. The waiver of the requirement, if granted, shall apply to those county departments or private nonprofit agencies that administer the services and that the department finds and certifies have implemented effective quality assurance systems for service plan development and implementation. If the federal health care financing administration approves the department's request for waiver of the requirement, the department shall, in evaluating a quality assurance system for certification, consider all of the following:
49.45(37)(a)
(a) The adequacy, safety and comprehensiveness of plans of care developed for individuals and of the services provided to them.
49.45(37)(b)
(b) Opportunities for individuals to exercise choice and be involved in the provision of services.
49.45(37)(c)
(c) Overall conformance to required state and federal quality assurance standards.
49.45(37)(d)
(d) Factors in addition to those in
pars. (a) to
(c) that are required by the federal health care financing administration, if any.
49.45(38)
(38) Home or community-based services for disabled workers. The department shall request a waiver from the secretary of the federal department of health and human services to authorize federal financial participation for medical assistance coverage of persons described in
ss. 49.46 (1) (a) 14. and
49.47 (4) (as).
49.45(39)(a)1.
1. "School" means a public school described under
s. 115.01 (1), a charter school, as defined in
s. 115.001 (1), the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing. It includes school-operated early childhood programs for developmentally delayed and disabled 4-year-old and 5-year-old children.
49.45(39)(a)2.
2. "School medical services" means health care services that are provided in a school to children who are eligible for medical assistance that are appropriate to a school setting, as provided in the amendment to the state medical assistance plan under
par. (am).
49.45(39)(am)
(am)
Plan amendment. No later than September 30, 1995, the department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of
pars. (b) and
(c). If the amendment to the state plan is approved, school districts, cooperative educational service agencies, and the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin Educational Services Program for the Deaf and Hard of Hearing claim reimbursement under
pars. (b) and
(c).
Paragraphs (b) and
(c) do not apply unless the amendment to the state plan is approved and in effect. The department shall submit to the federal department of health and human services an amendment to the state plan if necessary to permit the application of
pars. (b) and
(c) to the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin Educational Services Program for the Deaf and Hard of Hearing.
49.45(39)(b)1.1. `Payment for school medical services.' If a school district or a cooperative educational service agency elects to provide school medical services and meets all requirements under
par. (c), the department shall reimburse the school district or the cooperative educational service agency for 60% of the federal share of allowable charges for the school medical services that it provides and, as specified in
subd. 2., for allowable administrative costs. If the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing elects to provide school medical services and meets all requirements under
par. (c), the department shall reimburse the department of public instruction for 60% of the federal share of allowable charges for the school medical services that the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing provides and, as specified in
subd. 2., for allowable administrative costs. A school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, claims for common carrier transportation costs as a school medical service unless the department receives notice from the federal health care financing administration that, under a change in federal policy, the claims are not allowed. If the department receives the notice, a school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, unreimbursed claims for common carrier transportation costs incurred before the date of the change in federal policy. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. All other expenses for the school medical services provided by a school district or a cooperative educational service agency shall be paid for by the school district or the cooperative educational service agency with funds received from state or local taxes. The school district, the Wisconsin Center for the Blind and Visually Impaired, the Wisconsin Educational Services Program for the Deaf and Hard of Hearing, or the cooperative educational service agency shall comply with all requirements of the federal department of health and human services for receiving federal financial participation.
49.45(39)(b)2.
2. `Payment for school medical services administrative costs.' The department shall reimburse a school district or a cooperative educational service agency specified under
subd. 1. and shall reimburse the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing for 90% of the federal share of allowable administrative costs, using time studies, beginning in fiscal year 1999-2000. A school district or a cooperative educational service agency may submit, and the department of health and family services shall allow, claims for administrative costs incurred during the period that is up to 24 months before the date of the claim, if allowable under federal law.
49.45(39)(c)
(c)
Certification and reporting requirements. The department shall promulgate rules establishing specific certification and reporting requirements with respect to school medical services under this subsection.
49.45(40)
(40) Periodic record matches. If the department contracts with the department of workforce development under
s. 49.197 (5), the department shall cooperate with the department of workforce development in matching records of medical assistance recipients under
s. 49.32 (7).
49.45(41)
(41) Mental health crisis intervention services. 49.45(41)(a)(a) In this subsection, "mental health crisis intervention services" means services that are provided by a mental health crisis intervention program operated by, or under contract with, a county, if the county is certified as a medical assistance provider.
49.45(41)(b)
(b) If a county elects to become certified as a provider of mental health crisis intervention services, the county may provide mental health crisis intervention services under this subsection in the county to medical assistance recipients through the medical assistance program. A county that elects to provide the services shall pay the amount of the allowable charges for the services under the medical assistance program that is not provided by the federal government. The department shall reimburse the county under this subsection only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
49.45(42)
(42) Personal care services. Personal care services under
s. 49.46 (2) (b) 6. j. provided to an individual are reimbursable under medical assistance only if all of the following conditions are met:
49.45(42)(a)
(a) The provider of the personal care services receives prior authorization from the department for all personal care services that are provided to the individual in excess of 50 hours in a calendar year.
49.45(42)(b)
(b) The individual is not eligible to receive home health aide services under medicare, as defined in
sub. (3) (L) 1. b.
49.45(42m)
(42m) Physical and occupational therapy. 49.45(42m)(a)(a) If, in authorizing the provision of physical or occupational therapy services under
s. 49.46 (2) (b) 6. b., the department authorizes a reduced duration of services from the duration that the provider specifies in the authorization request, the department shall substantiate the reduction that the department made in the duration of the services if the provider of the services requests any additional authorizations for the provision of physical or occupational therapy services to the same individual.
49.45(42m)(b)
(b) The division of the department that is responsible for health care financing shall monitor compliance with the requirement under
par. (a) in concert with representatives of the Wisconsin Physical Therapy Association and the Wisconsin Occupational Therapy Association.
49.45(43)
(43) Case management services for high-cost recipients. The department may establish a program to provide case management services for medical assistance recipients with high-cost chronic health conditions or high-cost catastrophic health conditions. If the department establishes a program to provide these case management services, the department shall provide reimbursement for providers of these case management services under the medical assistance program.
49.45(44)
(44) Prenatal, postpartum and young child care coordination. Providers in Milwaukee County that are certified to provide care coordination services under
s. 49.46 (2) (b) 12. may be certified to provide to medical assistance recipients prenatal and postpartum care coordination services and care coordination services for children who have not attained the age of 7. A provider of those care coordination services shall provide to a person receiving those services the information relating to shaken baby syndrome and impacted babies required under
s. 253.15 (6). The department shall provide reimbursement for those care coordination services only if at least one of the following conditions is met:
49.45(44)(a)
(a) The recipient is a resident of Milwaukee County and has received services under
s. 49.46 (2) (b) 12. and is pregnant or has given birth within 8 weeks after the individual ceased to receive services under
s. 49.46 (2) (b) 12.
49.45(44)(b)
(b) The recipient is a resident of Milwaukee County, is pregnant and has received a risk assessment approved by the department.
49.45(44)(c)
(c) The recipient is a resident of Milwaukee County, has given birth within the 8 weeks immediately preceding the request for services under
s. 49.46 (2) (b) 12m. and has received a risk assessment approved by the department.
49.45(45)
(45) In-home and community mental health and alcohol and other drug abuse services. 49.45(45)(a)(a) Services under
s. 49.46 (2) (b) 6. fm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
49.45(45)(a)1.
1. Reimbursement for the services under
s. 49.46 (2) (b) 6. fm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
49.45(45)(a)2.
2. The county, city, town or village in which the individual resides elects to make the services under
s. 49.46 (2) (b) 6. fm. available in the county, city, town or village through the medical assistance program.
49.45(45)(b)
(b) A county, city, town or village that elects to make the services under
s. 49.46 (2) (b) 6. fm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
49.45(47)(a)(a) In this subsection, "adult day care center" means an entity that provides services for part of a day in a group setting to adults who need an enriched health-supportive or social experience and who may need assistance with activities of daily living, supervision or protection.
49.45(47)(b)
(b) No person may receive reimbursement under
s. 46.27 (11) for the provision of services to clients in an adult day care center unless the adult day care center is certified by the department under
sub. (2) (a) 11. as a provider of medical assistance.
49.45(47)(c)
(c) The biennial fee for the certification required under
par. (b) of an adult day care center is $100. Fees collected under this paragraph shall be credited to the appropriation account under
s. 20.435 (6) (jm).
49.45(47)(d)
(d) The department, by rule, may increase any fee specified in
par. (c).
49.45(48)
(48) Payment of medicare part B outpatient hospital services coinsurances. The department shall include in the state plan for medical assistance a methodology for payment of the medicare part B outpatient hospital services coinsurance amounts that are authorized under
ss. 49.46 (2) (c) 2.,
4., and
5m.,
49.468 (1) (b), and
49.47 (6) (a) 6. b.,
d., and
f.
49.45(49)
(49) Prescription drug prior authorization. 49.45(49)(a)(a) The secretary shall exercise his or her authority under
s. 15.04 (1) (c) to create a prescription drug prior authorization committee to advise the department on issues related to prior authorization decisions made concerning prescription drugs on behalf of medical assistance recipients. The secretary shall appoint as members at least all of the following:
49.45(49)(a)3.
3. One advocate for recipients of medical assistance who has sufficient medical background, as determined by the department, to evaluate a prescription drug's clinical effectiveness.
49.45(49)(b)
(b) The prescription drug prior authorization committee shall accept information or commentary from representatives of the pharmaceutical manufacturing industry in the committee's review of prior authorization policies.
49.45(49m)
(49m) Prescription drug cost controls; purchasing agreements. 49.45(49m)(b)
(b) The department may enter into a multi-state purchasing agreement with another state or a purchasing agreement with a purchaser of prescription drugs if the other state or purchaser agrees to participate in one or more of the activities specified in
par. (c) 1. to
4.
49.45(49m)(c)
(c) The department may design and implement a program to reduce the cost of prescription drugs and to maintain high quality in prescription drug therapies, which shall include all of the following:
49.45(49m)(c)1.
1. A list of the prescription drugs that are included as a benefit under
s. 49.46 (2) (b) 6. h. that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.
49.45(49m)(c)2.
2. Establishing supplemental rebates under agreements with prescription drug manufacturers for prescription drugs provided to recipients under Medical Assistance and Badger Care and to eligible persons under
s. 49.688 and, if it is possible to implement the program without adversely affecting supplemental rebates for Medical Assistance, Badger Care, and prescription drug assistance under
s. 49.688, to beneficiaries of participants under
par. (b).
