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 $127. 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(47)(e)
(e) If the department takes enforcement action against an adult day care center for violating a certification requirement established under
s. 49.45 (2) (a) 11., and the department subsequently conducts an on-site inspection of the adult day care center to review the adult day care center's action to correct the violation, the department may impose a $200 inspection fee on the adult day care center.
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
ss. 49.46 (2) (b) 6. h. and
49.471 (11) (a) 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 accounts under
s. 20.435 (4) (b) and
(gm) 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; federal funding for certain services. 49.45(52)(a)1.1. If the department provides the notice under
par. (c) selecting the payment procedure in this paragraph, 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,
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., except for services specified under
s. 49.46 (2) (b) 6. b. and
c. provided to children participating in the early intervention program under
s. 51.44. Payment adjustments under this paragraph shall include the state share of the payments. The total of any payment adjustments under this paragraph and Medical Assistance payments made from appropriation accounts under
s. 20.435 (4) (b),
(gm),
(o), and
(w), may not exceed applicable limitations on payments under
42 USC 1396a (a) (30) (A).
49.45(52)(a)2.
2. The department may require a county department or local health department to submit a certified cost report that meets the requirements of the federal department of health and human services for covered services described in
subd. 1.
49.45(52)(b)
(b) If the department provides the notice under
par. (c) selecting the payment procedure in this paragraph, all of the following apply:
49.45(52)(b)1.
1. Annually, a county department under
s. 46.215,
46.22,
46.23,
51.42, or
51.437 shall submit a certified cost report that meets the requirements of the federal department of health and human services 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., except for services specified under
s. 49.46 (2) (b) 6. b. and
c. provided to children participating in the early intervention program under
s. 51.44.
49.45(52)(b)2.
2. For services described under
subd. 1., the department shall base the amount of a claim for federal medical assistance funds on certified cost reports submitted by county departments under
subd. 1. to the extent the reports comply with federal requirements.
49.45(52)(b)3.
3. The department shall pay county departments a percentage of the federal funds claimed under
subd. 2. for services described under
subd. 1., which percentage is established in the most recent biennial budget.
49.45(52)(b)4.
4. The department may pay a local health department, as defined in
s. 250.01 (4), that submits certified cost reports for services described under
subd. 1. a percentage of the federal funds claimed for those services, which percentage is established in the most recent biennial budget.
49.45(52)(c)
(c) The department shall select a payment procedure under either
par. (a) or
(b) and may change which procedure under
par. (a) or
(b) is selected. The department shall notify each county department and local health department, as applicable, of the selected payment procedure before the date on which payment for services is made under that selected or newly selected procedure.
49.45(54)
(54) Therapy for children participating in the birth to 3 program. 49.45(54)(a)(a)
Federal share for county expenditures. If a county certifies to the department that the amount the county expended to provide services specified under
s. 49.46 (2) (b) 6. b. and
c. to children participating in the early intervention program under
s. 51.44 exceeds the amount the county received as reimbursement under this section, based on reimbursement rates established by the department for those services, and the federal government pays the state the federal share of Medical Assistance for the amount by which the county expenditures exceed the reimbursement, the department may disburse the federal share to the county. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under
s. 51.44 or for services under the disabled children's long-term support program, as defined in
s. 46.011 (1g).
49.45(54)(b)
(b)
Services provided by special educators. If a county provides services to assess and promote skill acquisition to children who are participating in the early intervention program under
s. 51.44 and the services are provided by a special educator who is a certified provider of medical assistance, the department shall reimburse the county the federal share of medical assistance for the county's allowable charges for providing the services. The county shall pay the remaining expenses for the services. The department shall promulgate rules establishing certification requirements for special educators who provide service under this paragraph, and requirements for county reporting of expenditures for services under this paragraph. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under
s. 51.44 or for services under the disabled children's long-term support program, as defined in
s. 46.011 (1g).
49.45(56)
(56) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under
sub. (57), the department shall develop and implement, for Medical Assistance recipients, disease management programs. These programs shall have at least the following characteristics:
49.45(56)(a)
(a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
49.45(56)(b)
(b) Educating health care providers on health care process improvement by developing best practice models.
49.45(56)(c)
(c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
49.45(56)(d)
(d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
49.45(56)(e)
(e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
49.45(57)
(57) Physical health risk assessment. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.
49.45(58)
(58) Program for all-inclusive care for the elderly. The department may administer the program of all-inclusive care for the elderly under
42 USC 1396u-4.
49.45(59)
(59) Health maintenance organization payments to hospitals. 49.45(59)(a)(a) The department shall, from the appropriation accounts under
s. 20.435 (4) (xc) and
(xe), pay each health maintenance organization with which it contracts to provide medical assistance a monthly amount that the health maintenance organization shall use to make payments to hospitals under
par. (b).
49.45(59)(b)
(b) Health maintenance organizations shall pay all of the moneys they receive under
par. (a) to eligible hospitals, as defined in
s. 50.38 (1), within 15 days after receiving the moneys. The department shall specify in contracts with health maintenance organizations to provide medical assistance a method that health maintenance organizations shall use to allocate the amounts received under
par. (a) among eligible hospitals based on the number of discharges from inpatient stays and the number of outpatient visits for which the health maintenance organization paid such a hospital in the previous month for enrollees who are recipients of medical assistance. Payments under this paragraph shall be in addition to any amount that a health maintenance organization is required by agreement between the health maintenance organization and a hospital to pay the hospital for providing services to the health maintenance organization's enrollees.
49.45(59)(c)
(c) Each health maintenance organization that provides medical assistance shall report to the department each month the amount it paid each hospital under
par. (b) and the percentage of the total payments it made under
par. (b) that it paid to each hospital.
49.45(59)(d)
(d) Each health maintenance organization that provides medical assistance shall report monthly to each hospital to which the health maintenance organization makes payments under
par. (b) such information regarding the payments that the department specifies in its contract with the health maintenance organization to provide medical assistance.
49.45(59)(e)1.1. If the department determines that a health maintenance organization has not complied with a requirement under
pars. (b) to
(d), the department shall order the health maintenance organization to comply with the requirement within 15 days after the department's determination of noncompliance.
49.45(59)(e)2.
2. The department may terminate a contract with a health maintenance organization to provide medical assistance if the health maintenance organization fails to comply with a requirement under
pars. (b) to
(d).
49.45(59)(e)3.
3. The department may audit a health maintenance organization to determine whether the health maintenance organization has complied with the requirements under
pars. (b) to
(d).
49.45(59)(f)
(f) The department shall specify in contracts with health maintenance organizations to provide medical assistance the method for adjusting payments under
par. (b) to correct a health maintenance organization's inaccurate counting of inpatient discharges or outpatient visits in calculating a monthly payment to a hospital under
par. (b).
49.45(59)(g)
(g) If a health maintenance organization and hospital do not agree on the amount of a monthly payment that the health maintenance organization is required to pay the hospital under
par. (b), either the health maintenance organization or the hospital, within 6 months after the first day of the month in which the payment is due, may request that the department determine the amount of the payment. The department shall determine the amount of the payment within 60 days after the request for a determination is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under
ch. 227 on the department's determination.
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;
2007 a. 20 ss.
1513 to
1559h,
9121 (6) (a);
2007 a. 90,
97,
104,
141,
153;
2009 a. 2,
28,
113,
177,
180,
190,
221,
334,
342;
2011 a. 10,
32,
120,
126,
158,
192,
209,
258;
2011 a. 260 s.
81;
2013 a. 20,
92;
2013 a. 116 ss.
2,
3,
29,
30;
2013 a. 117 ss.
2,
4;
2013 a. 130;
2013 a. 165 s.
114;
2013 a. 226.
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
Sub. (2) (a) 9. does not direct the department to promulgate rules regarding conditions of reimbursement, but instead to include those conditions in a contract with the provider. A department handbook provision requiring odometer readings was a condition of reimbursement, not an administrative rule requiring promulgation. Meda-Care Vans of Waukesha, Inc. v. Division of Hearings and Appeals,
2007 WI App 140,
302 Wis. 2d 499,
736 N.W.2d 147,
05-2979.
49.45 Annotation
Medicaid reimbursement is governed by the "Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates" adopted by the department under sub. (6m). Sub. (6m) (e) requires the department to establish an appeals mechanism within the department to review petitions for modifications to any payment under sub. (6m). The "Methods" provides that the nursing home appeals board is available for redress in the event a facility has extraordinary fiscal circumstances. The department does not have the authority to grant an increased reimbursement rate absent appeals board approval. Park Manor, Ltd. v. Department of Health and Family Services,
2007 WI App 176,
304 Wis. 2d 512,
737 N.W.2d 88,
06-2311.
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
Poverty is not a constitutionally suspect classification. Encouraging childbirth except in the most urgent circumstances is rationally related to the legitimate governmental objective of protecting potential life. Medical assistance discussed. Harris v. McRae,
448 U.S. 297 (1980).
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)(ar)
(ar) "Community spouse" means the spouse of either the institutionalized person or the noninstitutionalized person.
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).
