49.45(3)(d)
(d) No payment may be made for inpatient hospital services, skilled nursing home services, intermediate care facility services, tuberculosis institution services or inpatient mental institution services, unless the facility providing such services has in operation a utilization review program and meets federal regulations governing such utilization review program.
49.45(3)(dm)
(dm) After distribution of computer software has been made under
1993 Wisconsin Act 16, section 9126 (13h), no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under
s. 49.46,
49.47, or
49.471 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under
42 USC 1395.
49.45(3)(e)1.1. The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital's total reimbursement or payment to that which would be provided to an economically and efficiently operated facility.
49.45(3)(e)2.
2. A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented under
subd. 1. shall annually prepare a report of cost and other data in the manner prescribed by the department.
49.45(3)(e)3.
3. The department may adopt a prospective payment system under
subd. 1. which may include consideration of an average rate per diem, diagnosis-related groups or a hospital-specific prospective rate per discharge.
49.45(3)(e)4.
4. If the department maintains a retrospective reimbursement system under
subd. 1. for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital's fiscal year may not exceed the lower of the hospital's charges for the services or the actual and reasonable allowable costs to the hospital of providing the services, plus any disproportionate share funding that the hospital is qualified to receive under
42 USC 1396r-4.
49.45(3)(e)7.
7. The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under
sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under
42 USC 1320c to
1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
49.45(3)(e)7m.
7m. Notwithstanding
subd. 7., the daily reimbursement or payment rate for services at a hospital established under
s. 45.50 (10) provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to a Wisconsin veterans home operated by the department of veterans affairs under
s. 45.50.
49.45(3)(e)9.
9. Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital's reimbursement or payment rate under
subd. 1.
49.45(3)(e)10.
10. Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.
49.45(3)(e)10m.
10m. All facilities listed in a certificate of approval issued to the University of Wisconsin Hospitals and Clinics Authority under
s. 50.35 are a hospital for purposes of reimbursement under this section.
49.45(3)(e)10r.
10r. All facilities listed in a certificate of approval issued to a free-standing pediatric teaching hospital under
s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician clinic reimbursement rates to reimburse the facilities under this section for types of services for which, before July 1, 2009, the department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.
49.45(3)(e)11.
11. The department shall use a portion of the moneys collected under
s. 50.38 (2) (a) to pay for services provided by eligible hospitals, as defined in
s. 50.38 (1), other than critical access hospitals, under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under
s. 50.38 (2) (a) for fiscal year 2008-09 divided by 57.75 percent. For each state fiscal year after state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under
s. 50.38 (2) (a) for the fiscal year divided by 61.68 percent.
49.45(3)(e)12.
12. The department shall use a portion of the moneys collected under
s. 50.38 (2) (b) to pay for services provided by critical access hospitals under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For each state fiscal year, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under
s. 50.38 (2) (b) for the fiscal year divided by 61.68 percent.
49.45(3)(f)1.1. Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.
49.45(3)(f)2.
2. The department may deny any provider claim for reimbursement which cannot be verified under
subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in
s. 49.46 (2) or
49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
49.45(3)(f)2m.
2m. The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under
par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.
49.45(3)(f)3.
3. Contractors under
sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.
49.45(3)(fm)
(fm) The department shall seek, on behalf of dentists who are providers, federal reimbursement for the cost of any equipment that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of the cost of the equipment that is reimbursed by the federal government.
49.45(3)(g)1.1. The secretary may authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of statutes, regulations, or rules applicable to the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees authorized by the secretary under this paragraph shall be issued, and shall possess at all times while they are performing their investigatory or audit functions under this section, identification, signed by the secretary, that specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Under the request of a designated person and upon presentation of the person's authorization, providers and medical assistance recipients shall accord the person access to any provider personnel, records, books, or documents or other information needed. Under the written request of a designated person and upon presentation of the person's authorization, providers and recipients shall accord the person access to any needed patient health care records of a recipient. Authorized employees may hold hearings, administer oaths, take testimony, and perform all other duties necessary to bring the matter before the department for final adjudication and determination.
49.45(3)(g)2.
2. The department shall promulgate rules to implement this paragraph.
49.45(3)(h)1m.1m. The failure or refusal of a provider to accord department auditors or investigators access as required under
par. (g) to any provider personnel, records, books, patient health care records of medical assistance recipients, or documents or other information requested constitutes grounds for decertification or suspension of the provider from participation in the medical assistance program. No payment may be made for services rendered by the provider following decertification, during the period of suspension, or during any period of provider failure or refusal to accord access as required under
par. (g).
49.45(3)(h)1n.
1n. The department shall promulgate rules to implement this paragraph.
49.45(3)(j)
(j) Reimbursement for administrative contract costs under this section is limited to the funds available under
s. 20.435 (4) (bm).
49.45(3)(k)
(k) If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in
s. 448.60 (3), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.
49.45(3)(L)2.
2. The department may not pay a provider for a designated health service that is authorized under this section or
s. 49.46,
49.47, or
49.471, that is provided as the result of a referral made to the provider by a physician and that, under
42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of
42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under
42 USC 1395nn.
49.45(3)(L)3.
3. A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under
42 USC 1395nn (f), as amended to August 10, 1993.
49.45(3)(L)4.
4. Any person who fails to comply with
subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.
49.45(3)(m)1.1. To be certified under
sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in
s. 340.01 (23g), that satisfies the requirements imposed under
s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under
s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under
s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under
s. 49.46 (2) (b) 3. or
49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.
49.45(3)(m)2.
2. A person who is certified to provide transportation by specialized medical vehicle under
sub. (2) (a) 11. shall ensure that every person who drives or serves as an attendant to passengers on a specialized medical vehicle, before driving or serving as an attendant, has current proficiency in the use of an automated external defibrillator, as defined in
s. 256.15 (1) (cr), achieved through instruction provided by an individual, organization, or institution of higher education that is approved under
s. 46.03 (38) to provide such instruction.
49.45(3)(n)
(n) This subsection does not apply if the department creates a policy under
sub. (2m) (c) 4., to the extent that the policy conflicts with this subsection.
49.45(4)
(4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.
49.45(4m)
(4m) Financial record matching program. 49.45(4m)(a)1.
1. "Account" means a demand deposit account, checking account, negotiable withdrawal order account, savings account, time deposit account, or money market mutual fund account.
49.45(4m)(a)2.
2. "Applicant" means an individual applying for benefits under this subchapter.
49.45(4m)(a)4.
4. "Other individual" means an individual whose resources are required by law to be disclosed to determine the eligibility of an applicant or recipient.
49.45(4m)(a)5.
5. "Recipient" means an individual who receives benefits under this subchapter.
49.45(4m)(b)1.1. The department shall operate a financial record matching program under this subsection for the purpose of verifying the assets of applicants, recipients, and other individuals with respect to any program under this subchapter that requires asset verification.
49.45(4m)(b)2.
2. The department shall enter into agreements with financial institutions doing business in this state to operate the financial record matching program under this subsection. An agreement shall require the financial institution to participate in the financial record matching program by electing either the financial institution matching option under
par. (c) or the state matching option under
par. (d). Any changes to the conditions of the agreement shall be submitted by the financial institution or the department at least 60 days before the effective date of the change. The department shall furnish the financial institution with a signed copy of the agreement.
49.45(4m)(b)3.
3. The department shall reimburse a financial institution up to $125 per calendar quarter for participating in the financial record matching program under this subsection.
49.45(4m)(b)4.
4. To the extent feasible, the information to be exchanged under the matching program shall be provided by electronic data exchange as prescribed by the department in the agreement under
subd. 2.
49.45(4m)(c)
(c)
Financial institution matching option. If a financial institution with which the department has an agreement under
par. (b) elects the financial institution matching option under this paragraph, all of the following apply:
49.45(4m)(c)1.
1. At least once each calendar quarter, the department shall provide to the financial institution, in the manner specified in the agreement under
par. (b) 2., information regarding applicants, recipients, and other individuals. The information shall include names and social security or other taxpayer identification numbers.
49.45(4m)(c)2.
2. Based on the information received under
subd. 1., the financial institution shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution. If the financial institution determines that an applicant, recipient, or other individual has an ownership interest in an account at the financial institution, the financial institution shall provide the department with a notice containing the applicant's, recipient's, or other individual's name, address of record, social security number or other taxpayer identification number, and account information. The account information shall include the account number, the account type, the nature of the ownership interest in the account, and the balance of the account at the time that the record match is made. The notice under this subdivision shall be provided in the manner specified in the agreement under
par. (b) 2. and, to the extent feasible, by an electronic data exchange.
49.45(4m)(d)
(d)
State matching option. If a financial institution with which the department has an agreement under
par. (b) elects the state matching option under this paragraph, all of the following apply:
49.45(4m)(d)1.
1. At least once each calendar quarter, the financial institution shall provide the department with information concerning all accounts maintained at the financial institution. For each account maintained at the financial institution, the financial institution shall notify the department of the name and social security number or other tax identification number of each person having an ownership interest in the account, together with a description of each person's interest. The information required under this subdivision shall be provided in the manner specified in the agreement under
par. (b) 2. and, to the extent feasible, by an electronic data exchange.
49.45(4m)(d)2.
2. The department shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution providing information under
subd. 1. Upon the request of the department, the financial institution shall provide to the department, for each applicant, recipient, or other individual who matches information provided by the financial institution under
subd. 1., the address of record, the account number and account type, and the balance of the account.
49.45(4m)(e)
(e)
Use of information by financial institution; penalty. A financial institution participating in the financial record matching program under this subsection, and the employees, agents, officers, and directors of the financial institution, may use information received from the department under
par. (c) only for the purpose of matching records and may use information provided by the department in requesting additional information under
par. (d) only for the purpose of providing the additional information. Neither the financial institution nor any employee, agent, officer, or director of the financial institution may disclose or retain information received from the department concerning applicants, recipients, or other individuals. Any person who violates this paragraph may be fined not less than $50 nor more than $1,000 or imprisoned in the county jail for not less than 10 days or more than one year or both.
49.45(4m)(f)
(f)
Use of information by department. The department may use information provided by a financial institution under this subsection only for matching records under
par. (d), for administering the financial record matching program under this subsection, and for determining eligibility or continued eligibility under this subchapter. The department may not disclose or retain information received from a financial institution under this subsection concerning account holders who are not applicants, recipients, or other individuals.
49.45(4m)(g)
(g)
Financial institution liability. A financial institution is not liable to any person for disclosing information to the department under this subsection or for any other action that the financial institution takes in good faith to comply with this subsection.
49.45(5)(a)(a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to
par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing.
49.45(5)(b)1.1. Upon receipt of a timely petition under
par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under
s. 46.215,
46.22, or
46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a certified copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:
49.45(5)(b)1.b.
b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.
49.45(5)(b)1.c.
c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department.
49.45(5)(b)2.
2. If a recipient requests a hearing within the timely notice period specified in
42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the county department of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced, or discontinued if:
49.45(5)(b)2.a.
a. The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient's behalf.
49.45(5)(b)2.b.
b. The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.
49.45(5)(b)3.
3. The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.
49.45(5m)
(5m) Supplemental funding for rural hospitals. 49.45(5m)(am)(am) Notwithstanding
sub. (3) (e), from the appropriation accounts under
s. 20.435 (4) (b),
(gm),
(o),
(w) and
(xc), the department shall distribute not more than $5,000,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under
42 USC 1396b (i) (3).
49.45(5m)(b)
(b) The supplemental funding for rural hospitals under
par. (am) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation to that utilization in other rural hospitals.
49.45(5r)
(5r) Supplemental funding for uncompensated care. Notwithstanding
sub. (3) (e), from the appropriation account under
s. 20.435 (4) (w), the department shall distribute $3,000,000 in each fiscal year to the University of Wisconsin Hospital and Clinics for care that is not otherwise compensated, except that the department may not make payments that exceed limitations based on customary charges under
42 USC 1396b (i) (3).
49.45(6b)
(6b) Centers for the developmentally disabled. From the appropriation under
s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Beginning in fiscal year 2009-10, following each placement made under
s. 46.275 that involves a relocation from a center for the developmentally disabled, the department shall reduce the reimbursement to the center by an amount, as determined by the department for each placement, that is equal to the nonfederal share of the costs for the placement under
s. 46.275.
49.45(6c)
(6c) Preadmission screening and resident review. 49.45(6c)(a)1.
1. "Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. "Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.
49.45(6c)(a)2.
2. "Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under
ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.
49.45(6c)(a)4.
4. "Developmental disability" means any of the following:
49.45(6c)(a)4.a.
a. Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.
