49.46(1)(m)1.1. Except as provided in
subd. 2., any individual who is otherwise eligible under this subsection and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for medical assistance and if the department determines it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor's behalf.
49.46(1)(m)2.
2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with
subd. 1., the failure does not affect the minor's eligibility under this subsection.
49.46(1m)
(1m) Pilot project for working recipients of supplemental security income or social security disability income. The department shall request that the secretary of the federal department of health and human services and the commissioner of the federal social security administration waive the income and asset requirements for recipients of benefits under federal Title II or XVI to allow the department to conduct a pilot project to allow those recipients to work without losing eligibility for benefits under federal Title II or XVI or for medical assistance or medicare, as defined in
s. 49.45 (3) (L) 1. b. If the request is approved, the department may implement the program and may require participants in the program to pay, on a sliding scale, a copayment for the cost of the program.
49.46(1p)
(1p) Demonstration project for persons with HIV. The department shall request a waiver from the secretary of the federal department of health and human services to allow the department to provide under this section coverage of services specified under
sub. (2) for persons who have HIV infection, as defined in
s. 252.01 (2). If a waiver is granted and in effect, the department shall provide coverage for the services specified under
sub. (2) for persons who qualify under the terms of the waiver.
49.46(2)(a)(a) Except as provided in
par. (be), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits:
49.46(2)(a)2.
2. Early and periodic screening and diagnosis, including case management services, of persons under 21 years of age and all medical treatment and dentists' services found necessary by this screening and diagnosis.
49.46(2)(a)4.
4. The following medical services if prescribed by a physician:
49.46(2)(a)4.a.
a. Inpatient hospital services other than services in an institution for mental diseases, including psychiatric and alcohol or other drug abuse treatment services.
49.46(2)(a)4.b.
b. Services specified in this paragraph, provided by any hospital on an outpatient basis.
49.46(2)(a)4.d.
d. Home health services, subject to the limitation under
s. 49.45 (8), or, if a home health agency is unavailable, nursing services.
49.46(2)(a)6.
6. Premiums, deductibles and coinsurance and other cost-sharing obligations for items and services otherwise paid under this subsection that are required for enrollment in a group health plan, as specified in
sub. (1) (m), except that, if enrollment in the group health plan requires enrollment of family members who are not eligible under this subsection, the department shall pay, if it is cost-effective, for an ineligible family member only the premium that is required for enrollment in the group health plan.
49.46(2)(b)
(b) Except as provided in
pars. (be) and
(dc), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services:
49.46(2)(b)1.
1. Dentists' services, limited to basic services within each of the following categories:
49.46(2)(b)3.
3. Transportation by emergency medical vehicle to obtain emergency medical care, transportation by specialized medical vehicle to obtain medical care including the unloaded travel of the specialized medical vehicle necessary to provide that transportation, or transportation by common carrier or private motor vehicle to obtain medical care.
49.46(2)(b)6.e.
e. Subject to the limitation under
s. 49.45 (30r), inpatient hospital, skilled nursing facility and intermediate care facility services for patients of any institution for mental diseases who are under 21 years of age, are under 22 years of age and who were receiving these services immediately prior to reaching age 21, or are 65 years of age or older.
49.46(2)(b)6.f.
f. Medical day treatment services, mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist.
49.46(2)(b)6.fm.
fm. Subject to the limitations under
s. 49.45 (45), mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist, to an individual who is 21 years of age or older in the individual's home or in the community.
49.46(2)(b)6.g.
g. Nursing services, including services performed by a nurse practitioner, as defined in rules that the department shall promulgate.
49.46(2)(b)6.h.
h. Legend drugs, as listed in the Wisconsin medical assistance drug index.
49.46(2)(b)6.i.
i. Over-the-counter drugs listed by the department in the Wisconsin medical assistance drug index.
49.46(2)(b)6.L.
L. Mental health and psychosocial rehabilitative services, including case management services, provided by the staff of a community support program certified under
s. 49.45 (2) (a) 11.
49.46(2)(b)6.Lm.
Lm. Subject to the limitations under
s. 49.45 (30e), psychosocial services, including case management services, provided by the staff of a community-based psychosocial service program.
49.46(2)(b)6.m.
m. Respiratory care services for ventilator-dependent individuals.
49.46(2)(b)12.
12. Care coordination for women with high-risk pregnancies.
49.46(2)(b)13.
13. Care coordination and follow-up, including lead investigations, as defined in
s. 254.11 (8s), of persons having lead poisoning or lead exposure, as defined in
s. 254.11 (9).
49.46(2)(b)16.
16. Case management services for recipients with high-cost chronic health conditions or high-cost catastrophic health conditions, if the department operates a program under
s. 49.45 (43).
49.46(2)(b)17.
17. Services under
s. 49.45 (54) (b) for children participating in the early intervention program under
s. 51.44, that are provided by a special educator.
49.46(2)(be)
(be) Benefits for an individual eligible under
sub. (1) (a) 9. are limited to those services under
par. (a) or
(b) that are related to pregnancy, including postpartum services and family planning services, as defined in
s. 253.07 (1) (b), or related to other conditions which may complicate pregnancy.
49.46(2)(bm)
(bm) Benefits for an individual who is eligible for medical assistance only under
sub. (1) (a) 15. are limited to those services related to tuberculosis that are described in
42 USC 1396a (z) (2).
49.46(2)(c)2.
2. For an individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare, meets the eligibility criteria under
sub. (1) and meets the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums payable under
42 USC 1395v; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.46(2)(c)3.
3. For an individual who is only entitled to coverage under part A of medicare, meets the eligibility criteria under
sub. (1) and meets the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which are not paid under
42 USC 1395 to
1395i, including those medicare services that are not included in the approved state plan for services under
42 USC 1396; the monthly premiums, if applicable, under
42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare.
49.46(2)(c)4.
4. For an individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare and meets the eligibility criteria for medical assistance under
sub. (1), but does not meet the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which are not paid under
42 USC 1395 to
1395zz, including those medicare services that are not included in the approved state plan for services under
42 USC 1396. Payment of coinsurance for a service under part B of medicare under
42 USC 1395j to
1395w, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.46(2)(c)5.
5. For an individual who is only entitled to coverage under part A of medicare and meets the eligibility criteria for medical assistance under
sub. (1), but does not meet the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which are not paid under
42 USC 1395 to
1395i, including those medicare services that are not included in the approved state plan for services under
42 USC 1396.
49.46(2)(c)5m.
5m. For an individual who is only entitled to coverage under part B of medicare and meets the eligibility criteria under
sub. (1), but does not meet the limitation on income under
subd. 6., medical assistance shall include payment of the deductible and coinsurance portions of medicare services under
42 USC 1395j to
1395w, including those medicare services that are not included in the approved state plan for services under
42 USC 1396. Payment of coinsurance for a service under part B of medicare, other than payment of coinsurance for outpatient hospital services, may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.46(2)(c)6.
6. The income limitation under this paragraph is income that is equal to or less than 100% of the poverty line, as established under
42 USC 9902 (2).
49.46(2)(cm)1.1. Beginning on January 1, 1993, for an individual who is entitled to coverage under part A of medicare, is entitled to coverage under part B of medicare, meets the eligibility criteria under
sub. (1) and meets the limitation on income under
subd. 2., medical assistance shall pay the monthly premiums under
42 USC 1395r.
49.46(2)(cm)2.
2. Benefits under
subd. 1. are available for an individual whose income is greater than 100% of the poverty line but less than 120% of the poverty line.
49.46(2)(d)
(d) Benefits authorized under this subsection may not include payment for that part of any service payable through 3rd-party liability or any federal, state, county, municipal or private benefit system to which the beneficiary is entitled. "Benefit system" does not include any public assistance program such as, but not limited to, Hill-Burton benefits under
42 USC 291c (e), in effect on April 30, 1980, or relief funded by a relief block grant.
49.46(2)(dc)
(dc) For an individual who is eligible for medical assistance and who is eligible for coverage under Part D of Medicare under
42 USC 1395w-101 et seq., benefits under
par. (b) 6. h. do not include payment for any Part D drug, as defined in
42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in
42 CFR 423.4, covers the Part D drug.
49.46(2)(dm)
(dm) Benefits under this section may not include payment for services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this paragraph, the department shall define "convalescent leave" and "conditional release" by rule.
49.46(2)(f)
(f) Benefits under this subsection may not include payment for gastric bypass surgery or gastric stapling surgery unless it is performed because of a medical emergency.
49.46 History
History: 1971 c. 125,
211,
215;
1973 c. 90,
147;
1975 c. 39;
1977 c. 29 ss.
592m,
1656 (18);
1977 c. 389,
418;
1979 c. 34,
221;
1981 c. 20,
93,
317;
1983 a. 27;
1983 a. 189 s.
329 (5);
1983 a. 245 ss.
10,
15;
1983 a. 538;
1985 a. 29,
120,
176,
253;
1987 a. 27,
307,
339,
399,
413;
1989 a. 9;
1989 a. 31 ss.
1454d to
1460 and
2909g,
2909i;
1989 a. 122,
173,
333,
336,
351;
1991 a. 39,
178,
269,
316;
1993 a. 16,
99,
269,
277,
446,
450,
491;
1995 a. 27,
77,
164,
289,
303,
457;
1997 a. 27,
35,
105,
237;
1999 a. 9;
2001 a. 16;
2003 a. 33;
2005 a. 25,
253;
2007 a. 20,
91;
2009 a. 28,
221.
49.46 Cross-reference
Cross-reference: See also chs.
DHS 102,
103, and
107, Wis. adm. code.
49.46 Annotation
A categorically needy person applying for assistance under this section was not required to comply with divestment requirements. Sinclair v. DHSS,
77 Wis. 2d 322,
253 N.W.2d 245 (1977).
49.46 Annotation
Sub. (1) (b) and s. 49.47 (6) (d) limit retroactive medical assistance payments to services received not more than 3 months prior to the date the application was submitted. St. Paul Ramsey Medical Center v. DHSS,
186 Wis. 2d 37,
519 N.W.2d 706 (Ct. App. 1994).
49.46 AnnotationStates need not fund nontherapeutic abortions. Beal v. Doe,
432 U.S. 438.
49.465
49.465
Presumptive medical assistance eligibility.
