49.473(3)
(3) Prior to applying to the department or a county department for medical assistance, a woman is eligible for medical assistance as provided under
sub. (5) beginning on the date on which a qualified entity determines, on the basis of preliminary information, that the woman meets the requirements specified in
sub. (2) and ending on one of the following dates:
49.473(3)(a)
(a) If the woman applies to the department or a county department for medical assistance within the time limit required under
sub. (4), the day on which the department or county department determines whether the woman meets the requirements under
sub. (2).
49.473(3)(b)
(b) If the woman does not apply to the department or county department for medical assistance within the time limit required under
sub. (4), the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(4)
(4) A woman who a qualified entity determines under
sub. (3) is eligible for medical assistance shall apply to the department or county department no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(5)
(5) The department shall audit and pay, from the appropriation accounts under
s. 20.435 (4) (b),
(gm), and
(o), allowable charges to a provider who is certified under
s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under
sub. (2) for all benefits and services specified under
s. 49.46 (2), unless otherwise provided by the department by a policy created under
s. 49.45 (2m) (c).
Effective date note
NOTE: Sub. (5) is amended eff. 1-1-15 by
2011 Wis. Act 32 to read:
Effective date text
(5) The department shall audit and pay, from the appropriation accounts under s. 20.435 (4) (b), (gm), and (o), allowable charges to a provider who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under sub. (2) for all benefits and services specified under s. 49.46 (2).
49.473(6)
(6) A qualified entity that determines under
sub. (3) that a woman is eligible for medical assistance as provided under
sub. (5) shall do all of the following:
49.473(6)(a)
(a) Notify the department of the determination no later than 5 days after the date on which the determination is made.
49.473(6)(b)
(b) Inform the woman at the time of the determination that she is required to apply to the department or a county department for medical assistance no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.
49.473(7)
(7) The department shall provide qualified entities with application forms for medical assistance and information on how to assist women in completing the form.
49.475
49.475
Information about assistance program beneficiaries. 49.475(1)(c)
(c) "Pharmacy benefits management" means the administration or management of prescription drug benefits provided by an insurer or other 3rd party, including the performance of any of the following services:
49.475(1)(c)2.
2. Claims processing, retail network management, or payment of claims to pharmacies for prescription drugs dispensed to individuals.
49.475(1)(c)3.
3. Clinical formulary development and management services.
49.475(1)(c)5.
5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.
49.475(1)(d)
(d) "Pharmacy benefits manager" means an entity that performs pharmacy benefits management.
49.475(1)(e)
(e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:
49.475(1)(e)1.
1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.
49.475(1)(e)5.
5. A participant in the program of prescription drug assistance for elderly persons under
s. 49.688.
49.475(1)(f)
(f) "Third party" means an entity that by statute, rule, contract, or agreement is responsible for payment of a claim for a health care item or service, including any of the following:
49.475(1)(f)7.
7. An entity that administers benefits on behalf of another risk-bearing 3rd party, including a 3rd-party administrator, a fiscal intermediary, or a managed care contractor.
49.475(2)
(2) Requirements of 3rd parties. As a condition of doing business in this state, a 3rd party shall do all of the following:
49.475(2)(a)
(a) Upon the department's request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:
49.475(2)(a)1.
1. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.
49.475(2)(a)2.
2. If
subd. 1. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.
49.475(2)(b)
(b) Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department's right to recover any 3rd-party payment made for which assignment has not been accepted.
49.475(2)(c)
(c) Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.
49.475(2)(d)
(d) If all of the following apply, agree not to deny a claim submitted by the department under
par. (b) solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:
49.475(2)(d)1.
1. The department submits the claim less than 36 months after the date on which the health care item or service was provided.
49.475(2)(d)2.
2. Action by the department to enforce the department's rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.
49.475(2m)
(2m) Limits on information to be provided. 49.475(2m)(a)(a) The information that the department may request under this section is limited to the information specified in
sub. (2) (a) and does not include an employer's name unless that information is necessary for the department or a provider to obtain 3rd-party payment for an item or service.
49.475(2m)(b)
(b) If information under
sub. (2) (a) may be available from more than one source that includes an employer operating a self-insured plan, the department shall seek the information first from a 3rd-party administrator or other entity identified in
sub. (1) (f) 7. or pharmacy benefits manager before seeking the information from the employer.
49.475(2m)(c)
(c) Information obtained under this section may be used only for the purposes specified in this section and in federal law on 3rd-party liability in Medical Assistance programs.
49.475(3)
(3) Written agreement. Upon requesting a 3rd party to provide the information under
sub. (2) (a), the department and the 3rd party shall enter into a written agreement that satisfies all of the following:
49.475(3)(a)
(a) Identifies the detailed format of the information to be provided to the department.
49.475(3)(b)
(b) Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.
49.475(3)(c)
(c) Specifies how the 3rd party's reimbursable costs under
sub. (5) will be determined and specifies the manner of payment.
49.475(4)
(4) Deadline for response; enforcement. 49.475(4)(a)(a) A 3rd party shall provide the information requested under
sub. (2) (a) within 180 days after receiving the department's request if it is the first time that the department has requested the 3rd party to disclose information under this section.
49.475(4)(b)
(b) A 3rd party shall provide the information requested under
sub. (2) (a) within 30 days after receiving the department's request if the department has previously requested the 3rd party to disclose information under this section.
49.475(4)(c)
(c) If an insurer fails to comply with
par. (a) or
(b), the department may notify the commissioner of insurance, and the commissioner of insurance may initiate enforcement proceedings against the insurer under
s. 601.41 (4) (a).
49.475(4)(d)
(d) If a 3rd party other than an insurer fails to comply with
par. (a) or
(b), the department may so notify the attorney general.
49.475(5)
(5) Reimbursement of costs. From the appropriations under
s. 20.435 (4) (bm) and
(pa), the department shall reimburse a 3rd party that provides information under
sub. (2) (a) for the 3rd party's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of the information.
49.475(6)
(6) Sharing information. The department of health services shall provide to the department of children and families, for purposes of the medical support liability program under
s. 49.22, any information that the department of health services receives under this section. The department of children and families may allow a county child support agency under
s. 59.53 (5) or a tribal child support agency access to the information, subject to the use and disclosure restrictions under
s. 49.83, and shall consult with the department of health services regarding procedures and methods to adequately safeguard the confidentiality of the information provided under this subsection.
49.48
49.48
Denial, nonrenewal and suspension of certification of service providers based on certain delinquency in payment. 49.48(1)(1) Except as provided in
sub. (1m), the department shall require each applicant to provide the department with the applicant's social security number, if the applicant is an individual, as a condition of issuing or renewing a certification under
s. 49.45 (2) (a) 11. as an eligible provider of services.
49.48(1m)
(1m) If an individual who applies for or to renew a certification under
sub. (1) does not have a social security number, the individual, as a condition of obtaining the certification, shall submit a statement made or subscribed under oath or affirmation to the department that the applicant does not have a social security number. The form of the statement shall be prescribed by the department of children and families. A certification issued or renewed in reliance upon a false statement submitted under this subsection is invalid.
49.48(2)
(2) The department may not disclose any information received under
sub. (1) to any person except to the department of children and families for the purpose of making certifications required under
s. 49.857.
49.48(3)
(3) The department shall deny an application for the issuance or renewal of a certification specified in
sub. (1), shall suspend a certification specified in
sub. (1) or may, under a memorandum of understanding under
s. 49.857 (2), restrict a certification specified in
sub. (1) if the department of children and families certifies under
s. 49.857 that the applicant for or holder of the certificate is delinquent in the payment of court-ordered payments of child or family support, maintenance, birth expenses, medical expenses or other expenses related to the support of a child or former spouse or fails to comply, after appropriate notice, with a subpoena or warrant issued by the department of children and families or a county child support agency under
s. 59.53 (5) and related to paternity or child support proceedings.
49.485
49.485
False claims. Whoever knowingly presents or causes to be presented to any officer, employee, or agent of this state a false claim for medical assistance shall forfeit not less than $5,000 nor more than $10,000, plus 3 times the amount of the damages that were sustained by the state or would have been sustained by the state, whichever is greater, as a result of the false claim. The attorney general may bring an action on behalf of the state to recover any forfeiture incurred under this section.
49.485 History
History: 2007 a. 20.
49.49
49.49
Medical assistance offenses. 49.49(1)(a)(a)
Prohibited conduct. No person, in connection with a medical assistance program, may:
49.49(1)(a)1.
1. Knowingly and willfully make or cause to be made any false statement or representation of a material fact in any application for any benefit or payment.
49.49(1)(a)2.
2. Knowingly and willfully make or cause to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment.
49.49(1)(a)3.
3. Having knowledge of the occurrence of any event affecting the initial or continued right to any such benefit or payment or the initial or continued right to any such benefit or payment of any other individual in whose behalf he or she has applied for or is receiving such benefit or payment, conceal or fail to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized.
49.49(1)(a)4.
4. Having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully convert such benefit or payment or any part thereof to a use other than for the use and benefit of such other person.
49.49(1)(b)
(b)
Penalties. Violators of this subsection may be punished as follows:
49.49(1)(b)1.
1. In the case of such a statement, representation, concealment, failure, or conversion by any person in connection with the furnishing by that person of items or services for which medical assistance is or may be made, a person violating this subsection is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in
s. 939.50 (3) (h), the person may be fined not more than $25,000.
49.49(1)(b)2.
2. In the case of such a statement, representation, concealment, failure, or conversion by any other person, a person convicted of violating this subsection may be fined not more than $10,000 or imprisoned for not more than one year in the county jail or both.
49.49(1)(c)
(c)
Damages. If any person is convicted under this subsection, the state shall have a cause of action for relief against such person in an amount 3 times the amount of actual damages sustained as a result of any excess payments made in connection with the offense for which the conviction was obtained. Proof by the state of a conviction under this section in a civil action shall be conclusive regarding the state's right to damages and the only issue in controversy shall be the amount, if any, of the actual damages sustained. Actual damages shall consist of the total amount of excess payments, any part of which is paid by state funds. In any such civil action the state may elect to file a motion in expedition of the action. Upon receipt of the motion, the presiding judge shall expedite the action.
49.49(2)
(2) Kickbacks, bribes and rebates. 49.49(2)(a)(a)
Solicitation or receipt of remuneration. Any person who solicits or receives any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind, in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a medical assistance program, or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a medical assistance program, is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in
s. 939.50 (3) (h), the person may be fined not more than $25,000.
49.49(2)(b)
(b)
Offer or payment of remuneration. Whoever offers or pays any remuneration including any kickback, bribe, or rebate directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a medical assistance program, or to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service or item for which payment may be made in whole or in part under a medical assistance program, is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in
s. 939.50 (3) (h), the person may be fined not more than $25,000.
49.49(2)(c)
(c)
Exceptions. This subsection shall not apply to:
49.49(2)(c)1.
1. A discount or other reduction in price obtained by a provider of services or other entity under
chs. 46 to
51 and
58 if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity under a medical assistance program.
49.49(2)(c)2.
2. Any amount paid by an employer to an employee who has a bona fide employment relationship with such employer for employment in the provision of covered items or services.
49.49(3)
(3) Fraudulent certification of facilities. No person may knowingly and willfully make or cause to be made, or induce or seek to induce the making of, any false statement or representation of a material fact with respect to the conditions or operation of any institution or facility in order that such institution or facility may qualify either upon initial certification or upon recertification as a hospital, skilled nursing facility, intermediate care facility, or home health agency. A person who violates this subsection is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in
s. 939.50 (3) (h), the person may be fined not more than $25,000.
