49.45(3m)(b)3.
3. The department shall limit the maximum payment to hospitals such that all of the following are true for disproportionate share hospital payments under this subsection in a fiscal year:
49.45(3m)(b)3.b.
b. The amount of payment is in accordance with federal rules concerning the hospital specific limit.
49.45(3m)(c)
(c) If the department needs data to calculate the payments under this subsection other than the data available from the Medicaid Management Information System, the fiscal survey data, or the federal centers for Medicare and Medicaid services public records, the department shall collect the necessary data from hospitals.
49.45(3m)(d)
(d) The department shall seek any necessary approval from the federal department of health and human services to implement the hospital payment methodology described under
pars. (a) and
(b). If approval is necessary and approval from the federal department of health and human services is received, the department shall implement the payment methodology described under
pars. (a) and
(b). If approval is necessary and the department and the federal department of health and human services negotiate a methodology for making payments to hospitals with a disproportionate share of low-income patients that is different from the methodology described under
pars. (a) and
(b), the department, before implementing the negotiated payment methodology, shall submit to the joint committee on finance the negotiated payment methodology. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the submittal by the department that the committee has scheduled a meeting for the purpose of reviewing the negotiated payment methodology, the department may implement the negotiated payment methodology. If, within 14 working days after the date of the submittal by the department, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the negotiated payment methodology, the negotiated payment methodology may be implemented only on approval of the committee.
49.45(4)
(4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.
49.45(4m)
(4m) Financial record matching program. 49.45(4m)(a)1.
1. “Account" means a demand deposit account, checking account, negotiable withdrawal order account, savings account, time deposit account, or money market mutual fund account.
49.45(4m)(a)2.
2. “Applicant" means an individual applying for benefits under this subchapter.
49.45(4m)(a)4.
4. “Other individual" means an individual whose resources are required by law to be disclosed to determine the eligibility of an applicant or recipient.
49.45(4m)(a)5.
5. “Recipient" means an individual who receives benefits under this subchapter.
49.45(4m)(b)1.1. The department shall operate a financial record matching program under this subsection for the purpose of verifying the assets of applicants, recipients, and other individuals with respect to any program under this subchapter that requires asset verification.
49.45(4m)(b)2.
2. The department shall enter into agreements with financial institutions doing business in this state to operate the financial record matching program under this subsection. An agreement shall require the financial institution to participate in the financial record matching program by electing either the financial institution matching option under
par. (c) or the state matching option under
par. (d). Any changes to the conditions of the agreement shall be submitted by the financial institution or the department at least 60 days before the effective date of the change. The department shall furnish the financial institution with a signed copy of the agreement.
49.45(4m)(b)3.
3. The department shall reimburse a financial institution up to $125 per calendar quarter for participating in the financial record matching program under this subsection.
49.45(4m)(b)4.
4. To the extent feasible, the information to be exchanged under the matching program shall be provided by electronic data exchange as prescribed by the department in the agreement under
subd. 2.
49.45(4m)(c)
(c)
Financial institution matching option. If a financial institution with which the department has an agreement under
par. (b) elects the financial institution matching option under this paragraph, all of the following apply:
49.45(4m)(c)1.
1. At least once each calendar quarter, the department shall provide to the financial institution, in the manner specified in the agreement under
par. (b) 2., information regarding applicants, recipients, and other individuals. The information shall include names and social security or other taxpayer identification numbers.
49.45(4m)(c)2.
2. Based on the information received under
subd. 1., the financial institution shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution. If the financial institution determines that an applicant, recipient, or other individual has an ownership interest in an account at the financial institution, the financial institution shall provide the department with a notice containing the applicant's, recipient's, or other individual's name, address of record, social security number or other taxpayer identification number, and account information. The account information shall include the account number, the account type, the nature of the ownership interest in the account, and the balance of the account at the time that the record match is made. The notice under this subdivision shall be provided in the manner specified in the agreement under
par. (b) 2. and, to the extent feasible, by an electronic data exchange.
49.45(4m)(d)
(d)
State matching option. If a financial institution with which the department has an agreement under
par. (b) elects the state matching option under this paragraph, all of the following apply:
49.45(4m)(d)1.
1. At least once each calendar quarter, the financial institution shall provide the department with information concerning all accounts maintained at the financial institution. For each account maintained at the financial institution, the financial institution shall notify the department of the name and social security number or other tax identification number of each person having an ownership interest in the account, together with a description of each person's interest. The information required under this subdivision shall be provided in the manner specified in the agreement under
par. (b) 2. and, to the extent feasible, by an electronic data exchange.
49.45(4m)(d)2.
2. The department shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution providing information under
subd. 1. Upon the request of the department, the financial institution shall provide to the department, for each applicant, recipient, or other individual who matches information provided by the financial institution under
subd. 1., the address of record, the account number and account type, and the balance of the account.
49.45(4m)(e)
(e)
Use of information by financial institution; penalty. A financial institution participating in the financial record matching program under this subsection, and the employees, agents, officers, and directors of the financial institution, may use information received from the department under
par. (c) only for the purpose of matching records and may use information provided by the department in requesting additional information under
par. (d) only for the purpose of providing the additional information. Neither the financial institution nor any employee, agent, officer, or director of the financial institution may disclose or retain information received from the department concerning applicants, recipients, or other individuals. Any person who violates this paragraph may be fined not less than $50 nor more than $1,000 or imprisoned in the county jail for not less than 10 days or more than one year or both.
49.45(4m)(f)
(f)
Use of information by department. The department may use information provided by a financial institution under this subsection only for matching records under
par. (d), for administering the financial record matching program under this subsection, and for determining eligibility or continued eligibility under this subchapter. The department may not disclose or retain information received from a financial institution under this subsection concerning account holders who are not applicants, recipients, or other individuals.
49.45(4m)(g)
(g)
Financial institution liability. A financial institution is not liable to any person for disclosing information to the department under this subsection or for any other action that the financial institution takes in good faith to comply with this subsection.
49.45(5)(a)(a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to
par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing.
49.45(5)(b)1.1. Upon receipt of a timely petition under
par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under
s. 46.215,
46.22, or
46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a certified copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:
49.45(5)(b)1.b.
b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.
49.45(5)(b)1.c.
c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department.
49.45(5)(b)2.
2. If a recipient requests a hearing within the timely notice period specified in
42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the county department of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced, or discontinued if:
49.45(5)(b)2.a.
a. The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient's behalf.
49.45(5)(b)2.b.
b. The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.
49.45(5)(b)3.
3. The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.
49.45(5m)
(5m) Supplemental funding for rural hospitals. 49.45(5m)(am)(am) Notwithstanding
sub. (3) (e), from the appropriation accounts under
s. 20.435 (4) (b),
(gm),
(o),
(w) and
(xc), the department shall distribute not more than $5,000,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under
42 USC 1396b (i) (3).
49.45(5m)(b)
(b) The supplemental funding for rural hospitals under
par. (am) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation to that utilization in other rural hospitals.
49.45(5r)
(5r) Supplemental funding for uncompensated care. Notwithstanding
sub. (3) (e), from the appropriation account under
s. 20.435 (4) (w), the department shall distribute $3,000,000 in each fiscal year to the University of Wisconsin Hospital and Clinics for care that is not otherwise compensated, except that the department may not make payments that exceed limitations based on customary charges under
42 USC 1396b (i) (3).
49.45(6b)
(6b) Centers for the developmentally disabled. From the appropriation under
s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Beginning in fiscal year 2009-10, following each placement made under
s. 46.275 that involves a relocation from a center for the developmentally disabled, the department shall reduce the reimbursement to the center by an amount, as determined by the department for each placement, that is equal to the nonfederal share of the costs for the placement under
s. 46.275.
49.45(6c)
(6c) Preadmission screening and resident review. 49.45(6c)(a)1.
1. “Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. “Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.
49.45(6c)(a)2.
2. “Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under
ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.
49.45(6c)(a)4.
4. “Developmental disability" means any of the following:
49.45(6c)(a)4.a.
a. Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.
49.45(6c)(a)6.
6. “Facility care" means services provided in a facility that are in conformity with
42 USC 1396r and that are payable under
sub. (6m).
49.45(6c)(b)
(b)
Preadmission screening. Except as provided in
par. (e), every individual who applies for admission to a facility or to an institution for mental diseases shall be screened to determine if the individual has developmental disability or mental illness. The department or an entity to which the department has delegated authority shall screen every individual who has been identified as having a developmental disability or mental illness to determine if the individual needs facility care. If the individual is determined to need facility care, the department or an entity to which the department has delegated authority shall also assess the individual to determine if he or she requires active treatment for developmental disability or active treatment for mental illness. If the department or entity determines that the individual requires active treatment for developmental disability, the department or entity shall determine whether the level of care required by the individual that is provided by a facility could be provided safely in an intermediate facility or under a plan that is developed under
s. 46.279 (4).
49.45(6c)(c)
(c)
Resident review. Except as provided in
par. (e), the department or an entity to which the department has delegated authority shall review every resident of a facility or institution for mental diseases who has a developmental disability or mental illness and who has experienced a significant change in his or her physical or mental condition to determine all of the following:
49.45(6c)(c)2.
2. Whether the resident requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(c)3.
3. If the department or entity determines under
subd. 1. that the resident needs facility care and under
subd. 2. that the resident requires active treatment for developmental disability, whether the level of care required by the resident that is provided by a facility could be provided safely in an intermediate facility or under a plan that is developed under
s. 46.279 (4).
49.45(6c)(d)1.1. No payment may be made under
sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under
s. 49.46,
49.47, or
49.471, who has developmental disability or mental illness and for whom under
par. (b) or
(c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under
par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.
49.45(6c)(d)2.
2. Payment may be made under
sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under
s. 49.46,
49.47, or
49.471 and who has developmental disability or mental illness and is determined under
par. (b) or
(c) to need facility care, regardless of whether it is determined under
par. (b) or
(c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)1.1. Payment under
sub. (6m) may be made to a facility and no screening under
par. (b) or review under
par. (c) is required for an individual who is medically diagnosed as having developmental disability or mental illness, and who is not a danger to himself or herself or to others, if, immediately after release from a hospital, the individual enters the facility, as part of a medically prescribed period of recovery, for a period not to exceed 30 days and the admission is approved by the department or an entity to which the department has delegated authority.
49.45(6c)(e)2.
2. Payment under
sub. (6m) may be made to a facility or institution for mental diseases for an individual who is 65 years of age or older, is medically diagnosed as having developmental disability or mental illness, is not a danger to himself or herself or to others and is competent to make an independent decision, if, following screening under
par. (b) or review under
par. (c), all of the following apply:
49.45(6c)(e)2.a.
a. It is determined that the individual needs facility care and requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)2.b.
b. The individual chooses not to participate in active treatment.
49.45(6c)(f)
(f)
Hearing. An individual for whom admission to a facility or institution for mental diseases is denied under
par. (b) or for whom a determination under
par. (c) results in prohibition of payment to a facility or institution for mental diseases under
par. (d) and relocation from the facility to a facility or institution for mental diseases may request a hearing from the department.
49.45(6c)(g)
(g)
Rule making. The department shall promulgate all of the following rules:
49.45(6c)(g)1.
1. Establishing criteria and procedures for a determination by the department under
par. (d) that a resident be relocated from a facility after March 31, 1990, and before December 31, 1993.
49.45(6h)
(6h) Liability for disallowances. If the department or the federal health care financing administration finds a skilled nursing facility or intermediate care facility in this state that provides care to medical assistance recipients for which the facility receives reimbursement under
sub. (6m) to be an institution for mental diseases, the facility shall be liable for any retroactive federal medicaid disallowances for services provided after the date of the finding.
49.45(6j)
(6j) Limitation on certain facility coverage. The department shall determine, under a method devised by the department, the average population during the period from January 1, 1987, to June 30, 1988, of persons in each skilled nursing facility or an intermediate care facility who are mentally ill and are aged 21 to 64, except persons under 22 years of age who were receiving medical assistance services in the facility prior to reaching age 21 and continuously thereafter. Beginning July 1, 1988, the payment under
sub. (6m) for services provided by a facility to persons who are mentally ill and are within the age limitations specified in this subsection may not exceed the payment for the average population of these persons in that facility, as determined by the department.
49.45(6m)(a)2.
2. “Cost center" means a group of similar facility expenses.
49.45(6m)(a)3.
3. “Facility" means a nursing home or a community-based residential facility that is licensed under
s. 50.03 and that is certified by the department as a provider of medical assistance.
49.45(6m)(a)6.
6. “Resource Utilization Groupings " means a comparative resource utilization grouping that classifies each facility resident based on information obtained from performing, for the resident, a minimum data set assessment developed by the federal Centers for Medicare and Medicaid Services.
49.45(6m)(ag)
(ag) Payment for care provided in a facility under this subsection made under
s. 20.435 (4) (b),
(gm),
(o),
(pa), or
(w) shall, except as provided in
pars. (bg),
(bm), and
(br), be determined according to a prospective payment system updated annually by the department. The payment system shall implement standards that are necessary and proper for providing patient care and that meet quality and safety standards established under
subch. II of ch. 50 and
ch. 150. The payment system shall reflect all of the following:
49.45(6m)(ag)1.
1. A prudent buyer approach to payment for services, under which a reasonable price recognizing selected factors that influence costs is paid for service that is of acceptable quality.
49.45(6m)(ag)2.
2. Except as provided in
subd. 3r., standards established by the department that shall be based upon allowable costs incurred by facilities in the state as available from information submitted under
par. (c) 3. and compiled by the department.
49.45(6m)(ag)3m.
3m. For each state fiscal year, rates that shall be set by the department based on information from cost reports for costs specified under
par. (am) 1. bm.,
4.,
5m., and
6. for the most recently completed fiscal year of the facility.
49.45(6m)(ag)3p.
3p. For all costs specified under
par. (am) 1. bm., an acuity-based payment rate system to which all of the following applies:
