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)(br)
(br) If the federal department of health and human services approves the department's request to offer a benchmark plan under this paragraph, the department may enroll any child who is receiving services through the early intervention program under
s. 51.44 in a benchmark plan under this paragraph. The department may not require a child who is receiving services through the early intervention program under
s. 51.44 to enroll in a benchmark plan offered under this paragraph. The department may not charge a copayment to a child who is enrolled in the benchmark plan under this paragraph for services described in
par. (b) 19.
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 that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare 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 that 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. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.
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 that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare 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 that 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. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.
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 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;
2011 a. 10,
32;
2013 a. 20;
2013 a. 116 s.
29;
2013 a. 117 s.
2,
3.
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. 49.465(1)(1) In this section, "qualified provider" means a provider which satisfies the requirements under
42 USC 1396r-1 (b) (2), as determined by the department.
49.465(2)
(2) A pregnant woman is eligible for medical assistance benefits, as provided under
sub. (3), during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman's family income does not exceed the highest level for eligibility for benefits under
s. 49.46 (1) or
49.47 (4) (am) or
(c) 1. and ending as follows:
49.465(2)(a)
(a) If the woman applies for benefits under
s. 49.46 or
49.47 within the time required under
sub. (4), the day on which the department or the county department under
s. 46.215,
46.22 or
46.23 determines whether the woman is eligible for benefits under
s. 49.46 or
49.47.
49.465(2)(c)
(c) If the woman does not apply for benefits under
s. 49.46 or
49.47 within the time required under
sub. (4), the last day of the month following the month in which the provider makes the determination under this subsection.
49.465(3)
(3) The department shall audit and pay allowable charges to a provider certified under
s. 49.45 (2) (a) 11. for medical assistance on behalf of a recipient under this section only for ambulatory prenatal care covered under
s. 49.46 (2).
49.465(4)
(4) A woman who is determined to be eligible under this section shall apply for benefits under
s. 49.46 or
49.47 on or before the last day of the month following the month in which the qualified provider makes that determination.
49.465(5)
(5) A qualified provider which determines that a woman is eligible under this section shall do all of the following:
49.465(5)(a)
(a) Notify the department of that determination within 5 working days after the day the determination is made.
49.465(6)
(6) The department shall provide qualified providers with application forms for medical assistance under
ss. 49.46 and
49.47 and information on how to assist women in completing the forms.
49.468
49.468
Expanded medicare buy-in. 49.468(1)(b)
(b) For an elderly or disabled individual who is entitled to coverage under Part A of Medicare, entitled to coverage under Part B of Medicare, and who does not meet the eligibility criteria for Medical Assistance under
s. 49.46 (1),
49.465,
49.47 (4), or
49.471 but meets the limitations on income and resources under
par. (d), Medical Assistance shall pay the deductible and coinsurance portions of Medicare services under
42 USC 1395 to
1395zz that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.
49.468(1)(c)
(c) For an elderly or disabled individual who is only entitled to coverage under Part A of Medicare and who does not meet the eligibility criteria for Medical Assistance under
s. 49.46 (1),
49.465,
49.47 (4), or
49.471 but meets the limitations on income and resources under
par. (d), Medical Assistance shall pay the deductible and coinsurance portions of Medicare services under
42 USC 1395 to
1395i that 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 for premiums under Part A of Medicare, if applicable. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.
49.468(1)(d)
(d) Benefits under
par. (b) or
(c) are available for an individual who has resources that are equal to or less than 200% of the allowable resources as determined under
42 USC 1381 to
1385 and income that is equal to or less than 100% of the poverty line.
49.468(1)(e)
(e) In determining under this subsection the income of an individual who is entitled to a monthly social security benefit under
42 USC 401 to
433, the department shall exclude, from December until the month after the month in which the annual revision of the poverty line is published, the amount of the social security benefit attributable to a cost-of-living increase under
42 USC 415 (i).
49.468(1m)(a)(a) Beginning on January 1, 1993, for an elderly or disabled individual who is entitled to coverage under part A of medicare and is entitled to coverage under part B of medicare, does not meet the eligibility criteria for medical assistance under
s. 49.46 (1),
49.465,
49.47 (4), or
49.471 but meets the limitations on income and resources under
par. (b), medical assistance shall pay the monthly premiums under
42 USC 1395r.
49.468(1m)(b)
(b) Benefits under
par. (a) are available for an individual who has resources that are equal to or less than 200% of the allowable resources determined under
42 USC 1381 to
1385 and income that is greater than 100% of the poverty line but less than 120% of the poverty line.
49.468(2)(a)(a) Beginning on January 1, 1991, for a disabled working individual who is entitled under
P.L. 101-239, section 6012 (a), to coverage under part A of medicare and who does not meet the eligibility criteria for medical assistance under
s. 49.46 (1),
49.465,
49.47 (4), or
49.471 but meets the limitations on income and resources under
par. (b), medical assistance shall pay the monthly premiums for the coverage under part A of medicare, including late enrollment fees, if applicable.
49.468(2)(b)
(b) Benefits under
par. (a) are available for an individual who has resources that are equal to or less than 200% of the allowable resources under
42 USC 1381 to
1385 and income that is equal to or less than 200% of the poverty line.
49.47
49.47
Medical assistance; medically indigent. 49.47(1)
(1)
Purpose. Medical assistance as set forth herein shall be provided to persons over 65, if eligible under this section, all disabled children under 18, if eligible under this section, and persons who are blind or disabled, if eligible under this section.
49.47(2)
(2) Definitions. As used in this section, unless the context indicates otherwise:
49.47(2)(a)
(a) "Beneficiary" means a person eligible for, and a recipient of, medical assistance under this section.
49.47(2)(b)
(b) "Illness" means a bodily disorder, bodily injury, disease or mental disease. All illnesses existing simultaneously which are due to the same or related causes shall be considered "one illness." Successive periods of illness less than 6 months apart, which are due to the same or related causes, shall also be considered "one illness."
49.47(3)(a)(a) At any time any resident of this state who believes himself or herself medically indigent and qualified for aid under this section may make application, on forms prescribed by the department. If eligibility is questionable by reason of the information contained on the application or is incomplete, further investigation shall be made to determine eligibility.
49.47(3)(b)
(b) The agency shall promptly review the application and shall issue a certificate to the individual showing eligibility when eligibility has been established.
49.47(3)(c)
(c) The department shall simplify applications for benefits for pregnant women and children under
sub. (4) and shall make the simplified applications available in the offices of health care providers.
49.47(4)(a)(a) Any individual who meets the limitations on income and resources under
pars. (b) to
(c) and who complies with
pars. (cm) and
(cr) shall be eligible for medical assistance under this section if such individual is:
49.47(4)(a)1.
1. Under 21 years of age and resides in an intermediate care facility, skilled nursing facility, or inpatient psychiatric hospital. The department shall apply the definition of family income in
s. 49.471 (1) (f) to make determinations of income under this subdivision.
49.47(4)(a)4.
4. Blind or totally and permanently disabled as defined under federal Title XVI.
49.47(4)(ag)
(ag) Any individual whose income does not exceed the limits under
par. (c) and who complies with
par. (cm) is eligible for medical assistance under this section if the individual is one of the following:
49.47(4)(ag)2.
2. Pregnant and the woman's pregnancy is medically verified Eligibility continues to the last day of the month in which the 60th day after the last day of the pregnancy falls.
49.47(4)(am)
(am) An individual who does not meet the limitation on income in
par. (c) is eligible for medical assistance under this section if the individual is one of the following:
49.47(4)(am)1.
1. A pregnant woman whose family income does not exceed 155% of the poverty line for a family the size of the woman's family, except that if a waiver under
par. (j) or a change in the approved state plan under
s. 49.46 (1) (am) 2. is in effect, the income limit is 185% of the poverty line for a family the size of the woman's family in each state fiscal year after the 1994-95 state fiscal year.
49.47(4)(am)2.
2. A child who is under 6 years of age and whose family income does not exceed 155% of the poverty line for a family the size of the child's family, except that if a waiver under
par. (j) or a change in the approved state plan under
s. 49.46 (1) (am) 2. is in effect, the income limit is 185% of the poverty line for a family the size of the child's family in each state fiscal year after the 1994-95 state fiscal year.
49.47(4)(am)3.
3. A child who is under one year of age, whose mother was determined to be eligible under
subd. 1. and who lives with his or her mother.
49.47(4)(as)
(as) A person is eligible for benefits under this section if all of the following apply:
49.47(4)(as)1.
1. The person would meet the financial and other eligibility requirements for home or community-based services under
s. 46.27 (11),
46.277, or
46.2785 or under the family care benefit if a waiver is in effect under
s. 46.281 (1d) but for the fact that the person engages in substantial gainful activity under
42 USC 1382c (a) (3).
49.47(4)(as)2.
2. A waiver under
s. 49.45 (38) is in effect or federal law authorizes federal financial participation for medical assistance coverage of the person.
49.47(4)(av)1.1. In this paragraph, "migrant worker" means any person who temporarily leaves a principal place of residence outside of this state and comes to this state for not more than 10 months in a year to accept seasonal employment in the planting, cultivating, raising, harvesting, handling, drying, packing, packaging, processing, freezing, grading or storing of any agricultural or horticultural commodity in its unmanufactured state. "Migrant worker" does not include any of the following:
49.47(4)(av)1.a.
a. A person who is employed only by a state resident if the resident or the resident's spouse is related to the person as the child, parent, grandchild, grandparent, brother, sister, aunt, uncle, niece, nephew, or the spouse of any such relative.
49.47(4)(av)1.b.
b. A student who is enrolled or, during the past 6 months has been enrolled, in any school, college or university unless the student is a member of a family or household which contains a migrant worker.
49.47(4)(av)1.c.
c. Any other person qualifying for an exemption under rules promulgated by the department.
49.47(4)(av)2.
2. The department shall request a waiver from the secretary of the federal department of health and human services to allow the application of
subd. 3. The waiver shall also seek a waiver from those federal quality control standards under the medical assistance program that the department determines to be necessary in order to make the application of
subd. 3. feasible.
Subdivision 3. applies only while the waiver under this subdivision is in effect.
49.47(4)(av)3.
3. In determining the eligibility for a migrant worker and his or her dependents for medical assistance under this section, the department shall do all of the following:
49.47(4)(av)3.a.
a. Grant the migrant worker and his or her dependents eligibility for medical assistance in this state, if the migrant worker and his or her dependents have a valid medical assistance identification card issued in another state and the migrant worker completes a Wisconsin medical assistance application provided by the department. Eligibility under this
subd. 3. a. continues for the period specified on the identification card issued in the other state. The department shall notify the other state that the migrant worker and his or her dependents are eligible for medical assistance in Wisconsin.
49.47(4)(av)3.b.
b. Determine medical assistance eligibility using an income-averaging method described in the waiver under
subd. 2., if the migrant worker and his or her dependents do not meet the income limitations under
par. (c) using prospective budgeting.
