49.472(3)(f)
(f) The individual maintains premium payments calculated by the department in accordance with
sub. (4), unless the individual is exempted from premium payments under
sub. (4) (b) or
(5).
49.472(3)(g)
(g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals.
49.472(3)(h)
(h) The individual meets all other requirements established by the department by rule.
49.472(4)(a)(a) Except as provided in
par. (b) and
sub. (5), an individual who is eligible for medical assistance under
sub. (3) and receives medical assistance shall pay a monthly premium to the department. The department shall establish the monthly premiums by rule in accordance with the following guidelines:
49.472(4)(a)1.
1. The premium for any individual may not exceed the sum of the following:
49.472(4)(a)1.a.
a. Three and one-half percent of the individual's earned income after the disregards specified in
subd. 2m.
49.472(4)(a)1.b.
b. One hundred percent of the individual's unearned income after the deductions specified in
subd. 2.
49.472(4)(a)2.
2. In determining an individual's unearned income under
subd. 1., the department shall disregard all of the following:
49.472(4)(a)2.a.
a. A maintenance allowance established by the department by rule. The maintenance allowance may not be less than the sum of $20, the federal supplemental security income payment level determined under
42 USC 1382 (b) and the state supplemental payment determined under
s. 49.77 (2m).
49.472(4)(a)2.b.
b. Medical and remedial expenses and impairment-related work expenses.
49.472(4)(a)2m.
2m. If the disregards under
subd. 2. exceed the unearned income against which they are applied, the department shall disregard the remainder in calculating the individual's earned income.
49.472(4)(a)3.
3. The department may reduce the premium by 25% for an individual who is covered by private health insurance.
49.472(4)(b)
(b) The department may waive monthly premiums that are calculated to be below $10 per month. The department may not assess a monthly premium for any individual whose income level, after adding the individual's earned income and unearned income, is below 150% of the poverty line.
49.472(5)
(5) Community options participants. From the appropriation under
s. 20.435 (7) (bd), the department may pay all or a portion of the monthly premium calculated under
sub. (4) (a) for an individual who is a participant in the community options program under
s. 46.27 (11).
49.472(6)(a)(a) Notwithstanding
sub. (4) (a) 3., from the appropriation accounts under
s. 20.435 (4) (b),
(gm), or
(w), the department shall, on the part of an individual who is eligible for medical assistance under
sub. (3), pay premiums for or purchase individual coverage offered by the individual's employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.
49.472(6)(b)
(b) If federal financial participation is available, from the appropriation accounts under
s. 20.435 (4) (b),
(gm), or
(w), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under
sub. (3).
49.472(7)
(7) Department duties. The department shall do all of the following:
49.472(7)(a)
(a) Determine eligibility, or contract with a county department, as defined in 49.45 (6c) (a) 3., or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with
sub. (3).
49.472(7)(b)
(b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.
49.472 Cross-reference
Cross-reference: See also chs.
DHS 103 and
107 and s.
DHS 103.087, Wis. adm. code.
49.473
49.473
Medical assistance; women diagnosed with breast or cervical cancer or precancerous conditions. 49.473(2)
(2) A woman is eligible for medical assistance as provided under
sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:
49.473(2)(c)
(c) The woman is not eligible for health care coverage that qualifies as creditable coverage in
42 USC 300gg (c), excluding the coverage specified in
42 USC 300gg (c) (1) (F).
49.473(2)(d)
(d) The woman has been screened for breast or cervical cancer under a breast and cervical cancer early detection program that is authorized under a grant received under
42 USC 300k.
49.473(2)(e)
(e) The woman requires treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix.
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).
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; electronic submission of claims. 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)(ac)(ac) As a condition of doing business in this state, a 3rd party shall do all of the following:
49.475(2)(ac)1.
1. 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)(ac)1.a.
a. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.
49.475(2)(ac)1.b.
b. If
subd. 1. a. 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)(ac)2.
2. 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)(ac)3.
3. 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)(ac)4.
4. If all of the following apply, agree not to deny a claim submitted by the department under
subd. 2. 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)(ac)4.a.
a. 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)(ac)4.b.
b. 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(2)(bc)
(bc) A 3rd party shall accept the submission of claims from the department under
par. (ac) 2. in electronic form and shall timely pay the claims in the manner provided in
s. 628.46 (1) and
(2). For purposes of timely payment of claims under this paragraph, "written notice" under
s. 628.46 (1) includes receipt of a claim in electronic form.
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) (ac) 1. 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) (ac) 1. 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) (ac) 1., 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.
