49.45(25)(am)9.
9. Is a member of a family that has a child who is at risk of serious physical, mental or emotional dysfunction, as defined by the department.
49.45(25)(am)14.
14. Is a woman who is aged 45 to 64 and who is not a resident of a nursing home or otherwise receiving case management services under this paragraph.
49.45(25)(b)
(b) A county, city, village, town or, in a county having a population of 500,000 or more, the department may elect to make case management services under this subsection available in the county, city, village or town to one or more of the categories of beneficiaries under
par. (am) through the medical assistance program. A county, city, village, town or, in a county having a population of 500,000 or more, the department that elects to make the services available shall reimburse a case management provider for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government.
49.45(25)(be)
(be) A private nonprofit agency that is a certified case management provider may elect to provide case management services to medical assistance beneficiaries who have HIV infection, as defined in
s. 252.01 (2). The amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government shall be paid from the appropriation account under
s. 20.435 (1) (am).
49.45(25)(bg)
(bg) An independent living center, as defined in
s. 46.96 (1) (ah), that is a certified case management provider and satisfies the criteria in
s. 46.96 (3m) (a) 1. to
3. and
(am) may elect to provide case management services to one or more of the categories of medical assistance beneficiaries specified under
par. (am). The amount of allowable charges for the services under the medical assistance program that is not provided by the federal government shall be paid from nonfederal, public funds received by the independent living center from a county, city, village or town or from funds distributed as a grant under
s. 46.96.
49.45(25)(bj)
(bj) The department of corrections may elect to provide case management services under this subsection to persons who are under the supervision of that department under
s. 938.183,
938.34 (4h),
(4m), or
(4n), or
938.357 (4), who are Medical Assistance beneficiaries, and who meet one or more of the conditions specified in
par. (am). The amount of the allowable charges for those services under the Medical Assistance program that is not provided by the federal government shall be paid from the appropriation account under
s. 20.410 (3) (hm),
(ho), or
(hr).
49.45(25)(bm)
(bm) Case management services under this subsection may not be provided to a person under
par. (am) 7. unless any of the following is true:
49.45(25)(bm)1.
1. A team of mental health experts appointed by the case management provider determines that the person is a severely emotionally disturbed child. The team shall consist of at least 3 members. The case management provider shall appoint at least one member of the team who is a licensed psychologist or a physician specializing in psychiatry. The case management provider shall appoint at least 2 members of the team who are members of the professions of school psychologist, school social worker, registered nurse, social worker, child care worker, occupational therapist or teacher of emotionally disturbed children. The case management provider shall appoint as a member of the team at least one person who personally participated in a psychological evaluation of the child.
49.45(25)(bm)2.
2. Individuals who are designated by the coordinating committee have, or a service coordination agency has, determined under
s. 46.56 (8) (d) that the person is a child, as defined in
s. 46.56 (1) (bm), with emotional and behavioral disabilities.
49.45(25)(c)
(c) Except as provided in
pars. (b),
(be),
(bg), and
(bj), the department shall reimburse a provider of case management services 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(25g)(a)(a) In this subsection, "care coordination" includes coordination of outpatient medical care, specialty care, inpatient care, dental care, and mental health care and medical case management.
49.45(25g)(b)
(b) The department shall develop a proposal to increase medical assistance reimbursement to each provider that receives a grant under
s. 252.12 (2) (a) 8. and to which at least one of the following applies:
49.45(25g)(b)1.
1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
49.45(25g)(b)2.
2. The secretary determines that the provider performs well with respect to all of the following aspects of care:
49.45(25g)(b)2.a.
a. Adoption of written standards for patient access and patient communication.
49.45(25g)(b)2.b.
b. Use of data to show that standards for patient access and patient communication are satisfied.
49.45(25g)(b)2.c.
c. Use of paper or electronic charting tools to organize clinical information.
49.45(25g)(b)2.d.
d. Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
49.45(25g)(b)2.e.
e. Adoption and implementation of guidelines that are based on evidence for treatment and management of HIV-related conditions.
49.45(25g)(b)2.g.
g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.
49.45(25g)(b)2.h.
h. Systematic tracking of referrals using a paper or electronic system.
49.45(25g)(b)2.i.
i. Measuring the quality of the performance of the provider and of individuals who perform services on behalf of the provider, including with respect to provision of clinical services, patient outcomes, and patient safety.
49.45(25g)(b)2.j.
j. Reporting to employees and contractors of the provider and to other persons on the quality of the performance of the provider and of individuals who perform services on behalf of the provider.
49.45(25g)(c)
(c) The department's proposal under
par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under
par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under
par. (b) 1. or
2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011. The increases in reimbursement rates and monthly per-patient care coordination fees that are not provided by the federal government shall be paid from the appropriation under.
s. 20.435 (1) (am). If the department creates a policy under
sub. (2m) (c) 4., this paragraph does not apply to the extent it conflicts with the policy.
Effective date note
NOTE: Par. (c) is amended eff. 1-1-15 by
2011 Wis. Act 32 to read:
Effective date text
(c) The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (b) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011. The increases in reimbursement rates and monthly per-patient care coordination fees that are not provided by the federal government shall be paid from the appropriation under. s. 20.435 (1) (am).
49.45(25g)(d)
(d) The department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under
42 USC 1396a, implement the proposal under
par. (b) beginning January 1, 2011.
49.45(25g)(e)
(e) A provider may not seek medical assistance reimbursement under this subsection and
sub. (25) (be) for the same services.
49.45(26)
(26) Managed care system. The department shall study alternatives for a system to manage the usage of alcohol and other drug abuse services, including day treatment services, provided under the medical assistance program. On or before September 1, 1988, the department shall submit a plan for a medical assistance alcohol and other drug abuse managed care system to the joint committee on finance. If the cochairpersons of the committee do not notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan within 14 working days after the date of the department's submittal, the department may implement the plan. If within 14 working days after the date of the department's submittal the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan, the department may not implement the plan until it is approved by the committee, as submitted or as modified. If a waiver from the secretary of the federal department of health and human services is necessary to implement the proposed plan, the department of health services may request the waiver, but it may not implement the waiver until it is authorized to implement the plan, as provided in this subsection.
49.45(27)
(27) Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under
8 USC 1255a (h) (3) or
42 USC 1396b (v), unless otherwise provided by the department by a policy created under
sub. (2m) (c).
Effective date note
NOTE: Sub. (27) is amended eff. 1-1-15 by
2011 Wis. Act 32 to read:
Effective date text
(27) Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v).
49.45(29)
(29) Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under
ss. 49.46,
49.47, and
49.471.
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.
DHS 36, Wis. adm. code.
49.45(30f)
(30f) Psychotherapy and alcohol and other drug abuse services. The department shall include licensed mental health professionals, as defined in
s. 632.89 (1) (dm), and licensed psychologists, as defined in
s. 455.01 (4), as providers of psychotherapy and of alcohol and other drug abuse services. Except for services provided under
sub. (30e), the department may not require that licensed mental health professionals or licensed psychologists be supervised; may not require that clinical psychotherapy or alcohol and other drug abuse services be provided under a certified program; and, notwithstanding
subs. (9) and
(9m), may not require that a physician or other health care provider first prescribe psychotherapy or alcohol and other drug abuse services to be provided by a licensed mental health professional or licensed psychologist before the professional or psychologist may provide the services to the recipient. This subsection does not affect the department's powers under
ch. 50 or
51 to establish requirements for facilities that are licensed, certified, or operated by the department.
49.45(30g)(a)(a)
When services are reimbursable. Community recovery services under
s. 49.46 (2) (b) 6. Lo. provided to an individual are reimbursable under the Medical Assistance program only if all of the following conditions are met:
49.45(30g)(a)2.
2. The county in which the individual resides elects to provide the community recovery services under
s. 49.46 (2) (b) 6. Lo. through the Medical Assistance program.
49.45(30g)(a)3.
3. The individual, the community recovery services, and the community recovery services provider meet any condition set forth in the approved amendment to the medical assistance plan submitted under
42 USC 1396n (i).
49.45(30g)(b)
(b)
Limit on the amount of reimbursement. If community recovery services are reimbursable under
par. (a), the department shall reimburse each participating county for the portion of the federal share of allowable charges for the community recovery services provided by the county that exceeds that county's proportionate share of $600,000 in fiscal year 2010-2011 and for 95 percent of the federal share of allowable charges for the community recovery services provided by the county in each fiscal year thereafter. The portion of the federal share of allowable charges not reimbursed to counties shall be transferred to the appropriation account under
s. 20.435 (5) (kx).
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 persons with an intellectual disability, as defined in
s. 46.278 (1m) (am), other than a state center for the developmentally disabled.
49.45(30m)(am)1.1. 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)(am)2.
2. For individuals receiving the family care benefit under
s. 46.286, the care management organization that manages the family care benefit for the recipient shall pay the portion of the payment that is not covered by the federal government for services that are described under
par. (a) 1. and are covered services under the family care benefit; the department shall pay the remainder of the portion of the payment that is not covered by the federal government.
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(30r)
(30r) Services in a mental health institute. A county shall provide the portion of payment that is not provided by the federal government for services under
s. 49.46 (2) (b) 6. e. in a mental health institute under
s. 51.05.
49.45(31)
(31) Long-Term Care Partnership Program. 49.45(31)(a)(a) The department shall submit to the federal department of health and human services, not later than 3 months after October 27, 2007, an amendment to the state medical assistance plan that establishes in this state a Long-Term Care Partnership Program, as described in this subsection, and shall implement the program if the amendment to the state plan is approved. Under the program, the department shall exclude an amount equal to the amount of benefits that an individual receives under a qualifying long-term care insurance policy, as described in
par. (b), when determining any of the following:
49.45(31)(a)1.
1. The individual's resources for purposes of determining the individual's eligibility for medical assistance.
49.45(31)(a)2.
2. The amount to be recovered from the individual's estate if the individual receives medical assistance.
49.45(31)(b)
(b) To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:
49.45(31)(b)1.
1. The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.
49.45(31)(b)3.
3. The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in
42 USC 1396p (b) (5).
49.45(31)(b)5.
5. The commissioner of insurance certifies to the department that the policy meets the criteria under
subds. 2. to
4.
49.45(31)(c)1.1. The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.
