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).
49.45(49m)(c)4.
4. Any other activity to reduce the cost of or expenditures for prescription drugs and maintain high quality in prescription drug therapies.
49.45(49m)(d)
(d) The department may enter into a contract with an entity to perform any of the duties and exercise any of the powers of the department under this subsection.
49.45(50)(a)(a) In this subsection, "disease management" means an integrated and systematic approach for managing the health care needs of patients who are at risk of or are diagnosed with a specific disease, using all of the following:
49.45(50)(a)6.
6. Other tools and resources to reduce overall costs and improve measurable outcomes.
49.45(50)(b)
(b) The department may contract with an entity, under the department's request-for-proposal procedures, to engage in disease management activities on behalf of recipients of medical assistance.
49.45(51)
(51) Medical care transportation services. 49.45(51)(a)(a) By November 1 annually, the department shall provide to the department of revenue information concerning the estimated amounts of supplements payable from the appropriation under
s. 20.435 (4) (b) to specific local governmental units for the provision of transportation for medical care, as specified under
s. 49.46 (2) (b) 3., during the fiscal year. Beginning November 1, 2004, the information that the department provides under this paragraph shall include any adjustments necessary to reflect actual claims submitted by service providers in the previous fiscal year.
49.45(51)(b)
(b) On the date that is the 3rd Monday in November, the department shall annually pay to specific local governmental units the estimated net amounts specified in
par. (a).
49.45(52)
(52) Payment adjustments. Beginning on January 1, 2003, the department may, from the appropriation account under
s. 20.435 (7) (b), make Medical Assistance payment adjustments to county departments under
s. 46.215,
46.22,
46.23, or
51.42, or
51.437 or to local health departments, as defined in
s. 250.01 (4), as appropriate, for covered services under
s. 49.46 (2) (a) 2. and
4. d. and
f. and
(b) 6. b.,
c.,
f.,
fm.,
g.,
j.,
k.,
L.,
Lm., and
m.,
9.,
12.,
12m.,
13.,
15., and
16. Payment adjustments under this subsection shall include the state share of the payments. The total of any payment adjustments under this subsection and Medical Assistance payments made from appropriation accounts under
s. 20.435 (4) (b),
(gp),
(o), and
(w) may not exceed applicable limitations on payments under
42 USC 1396a (a) (30) (A).
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;
2005 a. 22;
2005 a. 25 ss.
1120 to
1149f,
2503 to
2510;
2005 a. 107,
165,
253,
254,
264,
301,
340,
386,
441.
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,
98-0294.
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,
01-2877.
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.
