49.45(25g)(b)2.g.
g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.
49.45(25g)(b)2.h.
h. Systematic tracking of referrals using a paper or electronic system.
49.45(25g)(b)2.i.
i. Measuring the quality of the performance of the provider and of individuals who perform services on behalf of the provider, including with respect to provision of clinical services, patient outcomes, and patient safety.
49.45(25g)(b)2.j.
j. Reporting to employees and contractors of the provider and to other persons on the quality of the performance of the provider and of individuals who perform services on behalf of the provider.
49.45(25g)(c)
(c) The department's proposal under
par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under
par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under
par. (b) 1. or
2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011.
49.45(25g)(d)
(d) The department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under
42 USC 1396a, implement the proposal under
par. (b) beginning January 1, 2011.
49.45(25g)(e)
(e) A provider may not seek medical assistance reimbursement under this subsection and
sub. (25) (be) for the same services.
49.45(26)
(26) Managed care system. The department shall study alternatives for a system to manage the usage of alcohol and other drug abuse services, including day treatment services, provided under the medical assistance program. On or before September 1, 1988, the department shall submit a plan for a medical assistance alcohol and other drug abuse managed care system to the joint committee on finance. If the cochairpersons of the committee do not notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan within 14 working days after the date of the department's submittal, the department may implement the plan. If within 14 working days after the date of the department's submittal the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan, the department may not implement the plan until it is approved by the committee, as submitted or as modified. If a waiver from the secretary of the federal department of health and human services is necessary to implement the proposed plan, the department of health services may request the waiver, but it may not implement the waiver until it is authorized to implement the plan, as provided in this subsection.
49.45(27)
(27) Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under
8 USC 1255a (h) (3) or
42 USC 1396b (v).
49.45(29)
(29) Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under
ss. 49.46,
49.47, and
49.471.
49.45(29r)
(29r) Behavioral health care coordination pilot projects. 49.45(29r)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29r)(b)
(b) Subject to
par. (c), the department shall develop and award at least 2 pilot projects lasting no more than 3 years each to test alternative, coordinated care delivery and Medical Assistance payment models designed to reduce costs of recipients of Medical Assistance under this subchapter who have significant or chronic mental illness. A health care provider that is awarded a pilot project shall target a Medical Assistance population of high volume or high intensity users of non-behavioral health medical services, such as individuals with more than 5 emergency department visits in a year or individuals who have frequent or longer than average inpatient hospital stays, who also have significant or chronic mental illness. The department may not limit eligibility for the pilot project or awards under this subsection on the basis that the health care provider that is awarded the pilot project serves a target population that includes individuals enrolled in a Medical Assistance health maintenance organization. Each pilot project under this subsection shall include either a Medical Assistance payment on a per member per month basis for a specified pilot project population that is in addition to existing payment for services provided under the Medical Assistance program, including services reimbursed on a fee-for-service basis and services provided under managed care, or shall include an alternative Medical Assistance payment for a specified pilot project. The department shall require health care providers that are awarded a pilot project to submit to the department interim and final reports analyzing differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports. The department shall award the pilot projects and allocate funding only to health care providers that meet all of the following criteria:
49.45(29r)(b)1.
1. The health care provider provides all of the following services directly or through an affiliated entity:
49.45(29r)(b)1.f.
f. Services of a care coordinator or navigator for each individual in the pilot project.
49.45(29r)(b)2.
2. The health care provider provides, directly or through an affiliated entity or contracted entity, the coordination of social services fostering the individual's recovery following an inpatient psychiatric discharge.
49.45(29r)(c)
(c) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot projects under
par. (b) beginning no earlier than January 1, 2016.
49.45(29r)(d)
(d) Subject to
par. (c), the department shall allocate a total state share amount of $600,000 plus any federal matching moneys as funding for all 3-year pilot projects under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot projects under this subsection.
49.45(29u)
(29u) Psychiatric consultation reimbursement pilot project. 49.45(29u)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29u)(b)
(b) Subject to
par. (e), the department shall develop and award a pilot project lasting up to 3 years to test a new Medical Assistance payment model for adult recipients of Medical Assistance that is designed to encourage the provision of psychiatric consultations by psychiatrists to health care providers treating primary care issues and to selected specialty health care providers to help those providers manage and treat adults with mild to moderate mental illness and physical health needs. An applicant for the pilot project under this subsection shall submit a strategy to use the pilot project funding to improve mental health access in the applicant's service area and to reduce overall Medical Assistance costs. The department shall require the health care provider that is awarded the pilot project to submit to the department interim and final reports analyzing the differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports.
49.45(29u)(c)
(c) The department shall award a pilot project only to a health care provider that is an organization that provides outpatient psychiatric services and primary and specialty care outpatient services for physical health conditions. The department shall allocate funding to the health care provider that is awarded a pilot project or to individual psychiatrists providing care within the organization of the health care provider that is awarded a pilot project. The department shall allocate a total state share amount of $200,000 plus any federal matching moneys as funding for the 3-year pilot project under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot project under this subsection.
49.45(29u)(d)
(d) The department may limit a pilot project awarded to a health care provider described under
par. (c) to specific providers or clinics within the multispecialty outpatient clinic organization.
49.45(29u)(e)
(e) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot project under
par. (b) beginning no earlier than January 1, 2016.
49.45(29w)(a)(a) In providing mental health benefits under this subchapter, the department shall do all of the following:
49.45(29w)(a)1.
1. Allow a severely emotionally disturbed child, as defined in
sub. (25) (a), to access in-home therapy without having to show a failure to succeed in outpatient therapy.
49.45(29w)(a)2.
2. Allow qualifying families to participate in in-home therapy even if a child in that family is enrolled in a day treatment program.
49.45(29w)(b)1.a.
a. “Mental health service" means a service that is covered under one of the Medical Assistance mental health or substance abuse benefits under
s. 49.46 (2) of outpatient mental health, outpatient substance abuse, pharmacologic management, mental health day treatment, substance abuse day treatment, crisis intervention, service provided by a community support program or community based-psychosocial service program, community recovery services, psychotherapy and alcohol and other drug abuse services, child or adolescent day treatment services, or any other mental health or substance abuse benefit described in
s. 49.46 (2).
49.45(29w)(b)1.b.
b. “Telehealth" is a service provided from a remote location using a combination of interactive video, audio, and externally acquired images through a networking environment between an individual at an originating site and a provider at a remote location with the service being of sufficient audio and visual fidelity and clarity as to be functionally equivalent to face-to-face contact. “Telehealth" does not include telephone conversations or Internet-based communications between providers or between providers and individuals.
49.45(29w)(b)2.
2. Mental health services provided through telehealth are reimbursable by the Medical Assistance program under this subchapter if the provider of the service through telehealth satisfies all of the following criteria:
49.45(29w)(b)2.a.
a. The provider is a certified provider of mental health services under Medical Assistance in this state and is an agency that is certified by the department as an emergency mental health service program, a comprehensive community services program, a mental health day treatment services program for children, a program organized under
s. 46.23,
51.42, or
51.437, an outpatient psychotherapy clinic, or a community support program or that is certified by the department to perform a community substance abuse prevention and treatment service, except for narcotic treatment service for opiate addiction.
49.45(29w)(b)2.ag.
ag. The provider and the individual providing the service comply with all Medical Assistance coverage policies and standards established by the department, rules, and federal statutes and regulations for each particular mental health service provided.
49.45(29w)(b)2.b.
b. The individual who is providing the service is currently licensed, certified, or registered in his or her profession in this state and is in good standing with the applicable examining board in this state for that individual's profession.
49.45(29w)(b)2.c.
c. The provider is located in the United States. The provider is not required to be located in this state.
49.45(30)
(30) Services provided by community support programs. 49.45(30)(b)
(b) The department shall reimburse a provider of services under
s. 49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.
49.45(30c)
(30c) Licensed treatment professionals. To the extent allowable by the federal department of health and human services, the department shall certify and reimburse under the Medical Assistance program under this subchapter licensed treatment professionals, as defined in
s. 51.03 (6) (a), for mental health services provided at a school regardless of whether the school site is designated as a clinic office and regardless of whether the licensed treatment professional is employed by, a contractor of, or affiliated with a clinic. The department shall seek any approval necessary from the federal department of health and human services to provide reimbursement to licensed treatment professionals under this subsection.
49.45(30e)
(30e) Community-based psychosocial service programs. 49.45(30e)(a)(a)
When services are reimbursable. Services under
s. 49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
49.45(30e)(a)1.
1. Reimbursement for the services under
s. 49.46 (2) (b) 6. Lm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.
49.45(30e)(a)2.
2. The county in which the individual resides elects to make the services under
s. 49.46 (2) (b) 6. Lm. available in the county through the medical assistance program.
49.45(30e)(a)3.
3. The individual's psychosocial health needs require more than outpatient counseling, but less than the services provided by a community support program under
s. 51.421.
49.45(30e)(a)4.
4. The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under
par. (b) 3.
49.45(30e)(b)
(b)
Rules. The department shall promulgate rules regarding all of the following:
49.45(30e)(b)3.
3. Requirements for certification of community-based psychosocial service programs.
49.45(30e)(b)4.
4. Any other conditions for coverage of community-based psychosocial services under the Medical Assistance Program.
49.45(30e)(c)
(c)
Provider reimbursement. A county that elects to make the services under
s. 49.46 (2) (b) 6. Lm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.
49.45 Cross-reference
Cross-reference: See also ch.
DHS 36, Wis. adm. code.
49.45(30e)(d)
(d)
Provision of services on regional basis. Notwithstanding
par. (c) and subject to
par. (e), in counties that elect to deliver the services under
s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to criteria established by the department, the department shall reimburse a provider of the services for the amount of the allowable charges for those services under the Medical Assistance program that is provided by the federal government and for the amount of the allowable charges that is not provided by the federal government.
49.45(30e)(e)1.1. Prior to implementing, and receiving funding for implementing, the regional basis provision of services under
par. (d), the department shall submit to the joint committee on finance, no later than March 1, 2014, a request for the release of funds and a report on its proposal for implementation that includes all of the following:
49.45(30e)(e)1.a.
a. A description of the criteria that the department will apply in its regionalization model.
49.45(30e)(e)1.b.
b. A description of how the regions will be established and the degree of county participation in that process.
49.45(30e)(e)1.c.
c. An updated list of the counties that have indicated, by the date of the report, that they will offer the services under
s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to the criteria established by the department.
49.45(30e)(e)1.d.
d. An evaluation of the estimated long-term costs of the proposed regional model.
49.45(30e)(e)2.
2. If the cochairpersons of the committee do not notify the department within 14 working days after the date that the department submits the report and the funding request that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released and the department may implement its proposal for the regional basis provision of services on July 1, 2014. If, within 14 working days after the date that the department submits the report and the funding request, the cochairpersons notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released, and the department may implement its proposal for the regional basis provision of services, only upon approval of the committee.
49.45(30f)
(30f) Psychotherapy and alcohol and other drug abuse services. The department shall include licensed mental health professionals, as defined in
s. 632.89 (1) (dm), and licensed psychologists, as defined in
s. 455.01 (4), as providers of psychotherapy and of alcohol and other drug abuse services. Except for services provided under
sub. (30e), the department may not require that licensed mental health professionals or licensed psychologists be supervised; may not require that clinical psychotherapy or alcohol and other drug abuse services be provided under a certified program; and, notwithstanding
subs. (9) and
(9m), may not require that a physician or other health care provider first prescribe psychotherapy or alcohol and other drug abuse services to be provided by a licensed mental health professional or licensed psychologist before the professional or psychologist may provide the services to the recipient. This subsection does not affect the department's powers under
ch. 50 or
51 to establish requirements for facilities that are licensed, certified, or operated by the department.
49.45(30g)(a)(a)
When services are reimbursable. Community recovery services under
s. 49.46 (2) (b) 6. Lo. provided to an individual are reimbursable under the Medical Assistance program only if all of the following conditions are met:
49.45(30g)(a)1.
1. An approved amendment to the state medical assistance plan permits reimbursement for the services under
s. 49.46 (2) (b) 6. Lo. in the manner provided under this subsection.
49.45(30g)(a)2.
2. The county in which the individual resides elects to provide the community recovery services under
s. 49.46 (2) (b) 6. Lo. through the Medical Assistance program.
49.45(30g)(a)3.
3. The individual, the community recovery services, and the community recovery services provider meet any condition set forth in the approved amendment to the medical assistance plan.
49.45(30g)(b)
(b)
Limit on the amount of reimbursement. If community recovery services are reimbursable under
par. (a), the department shall reimburse each participating county for the portion of the federal share of allowable charges for the community recovery services provided by the county that exceeds that county's proportionate share of $600,000 in fiscal year 2010-2011 and for 95 percent of the federal share of allowable charges for the community recovery services provided by the county in each fiscal year thereafter. The portion of the federal share of allowable charges not reimbursed to counties shall be transferred to the appropriation account under
s. 20.435 (5) (kx).
49.45(30m)
(30m) Certain services for developmentally disabled. 49.45(30m)(a)(a) Except as provided in
par. (am), a county shall provide the portion of payment that is not provided by the federal government for all of the following services to individuals with developmental disability who are eligible for medical assistance:
49.45(30m)(a)2.
2. Services in an intermediate care facility for persons with an intellectual disability, as defined in
s. 46.278 (1m) (am), other than a state center for the developmentally disabled.
49.45(30m)(am)1.1. The department shall provide the portion of the payment that is not provided by the federal government for any of the services specified in
par. (a) 1. to
3. that are provided to an individual with developmental disability who is eligible for medical assistance, as determined under the contract under
s. 46.279 (4m).
49.45(30m)(am)2.
2. For individuals receiving the family care benefit under
s. 46.286, the care management organization that manages the family care benefit for the recipient shall pay the portion of the payment that is not covered by the federal government for services that are described under
par. (a) 1. and are covered services under the family care benefit; the department shall pay the remainder of the portion of the payment that is not covered by the federal government.
49.45(30m)(b)
(b) No payment under this section may be made for services specified under
par. (a) or
(am) unless the individual who receives the services is provided protective placement under s.
55.06 (9) (a), 2003 stats., or
s. 55.12, is provided emergency protective services under s.
55.05 (4), 2003 stats., or
s. 55.13, or is provided an emergency protective placement under s.
55.06 (11) (a), 2003 stats., or s.
55.135 or a temporary protective placement under s.
55.06 (11) (c), 2003 stats., or
s. 55.135 (5) or
55.055 (5).
49.45(30m)(c)
(c) No payment under this section may be made for services specified under
par. (a) 2. or
3. that are provided to an individual who was placed in or admitted to an intermediate facility, as defined in
s. 46.279 (1) (b), or nursing facility, as defined in
s. 46.279 (1) (c), unless one of the following applies:
49.45(30m)(c)1.
1. Any placement or admission that is made after April 30, 2005, complied with the requirements of
s. 46.279.
