49.46(1)(k)2.
2. If a child eligible for benefits under
par. (a) 11. is receiving inpatient services covered under
sub. (2) on the day before the birthday on which the child attains the age of 19 and, but for attaining that age, the child would remain eligible for benefits under
par. (a) 11., the child remains eligible for benefits until the end of the stay for which the inpatient services are furnished.
49.46(1)(L)
(L) For the purposes of
par. (a) 9. to
12., “income" includes income that would be used in determining eligibility for aid to families with dependent children under
s. 49.19, except to the extent that that determination is inconsistent with
42 USC 1396a (a)
17., and excludes income that would be excluded in determining eligibility for aid to families with dependent children under
s. 49.19. For the purposes of
par. (am), “income" shall be determined in accordance with the approved state plan for services under
42 USC 1396.
49.46(1)(m)1.1. Except as provided in
subd. 2., any individual who is otherwise eligible under this subsection and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for medical assistance and if the department determines it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor's behalf.
49.46(1)(m)2.
2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with
subd. 1., the failure does not affect the minor's eligibility under this subsection.
49.46(1m)
(1m) Pilot project for working recipients of supplemental security income or social security disability income. The department shall request that the secretary of the federal department of health and human services and the commissioner of the federal social security administration waive the income and asset requirements for recipients of benefits under federal Title II or XVI to allow the department to conduct a pilot project to allow those recipients to work without losing eligibility for benefits under federal Title II or XVI or for medical assistance or medicare, as defined in
s. 49.45 (3) (L) 1. b. If the request is approved, the department may implement the program and may require participants in the program to pay, on a sliding scale, a copayment for the cost of the program.
49.46(1p)
(1p) Demonstration project for persons with HIV. The department shall request a waiver from the secretary of the federal department of health and human services to allow the department to provide under this section coverage of services specified under
sub. (2) for persons who have HIV infection, as defined in
s. 252.01 (2). If a waiver is granted and in effect, the department shall provide coverage for the services specified under
sub. (2) for persons who qualify under the terms of the waiver.
49.46(2)(a)(a) Except as provided in
par. (be), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits:
49.46(2)(a)2.
2. Early and periodic screening and diagnosis, including case management services, of persons under 21 years of age and all medical treatment and dentists' services found necessary by this screening and diagnosis.
49.46(2)(a)4.
4. The following medical services if prescribed by a physician:
49.46(2)(a)4.a.
a. Inpatient hospital services other than services in an institution for mental diseases, including psychiatric and alcohol or other drug abuse treatment services.
49.46(2)(a)4.b.
b. Services specified in this paragraph, provided by any hospital on an outpatient basis.
49.46(2)(a)4.d.
d. Home health services, subject to the limitation under
s. 49.45 (8), or, if a home health agency is unavailable, nursing services.
49.46(2)(a)6.
6. Premiums, deductibles and coinsurance and other cost-sharing obligations for items and services otherwise paid under this subsection that are required for enrollment in a group health plan, as specified in
sub. (1) (m), except that, if enrollment in the group health plan requires enrollment of family members who are not eligible under this subsection, the department shall pay, if it is cost-effective, for an ineligible family member only the premium that is required for enrollment in the group health plan.
49.46(2)(b)
(b) Except as provided in
pars. (be) and
(dc), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services:
49.46(2)(b)1.
1. Dentists' services, limited to basic services within each of the following categories:
49.46(2)(b)3.
3. Transportation by emergency medical vehicle to obtain emergency medical care, transportation by specialized medical vehicle to obtain medical care including the unloaded travel of the specialized medical vehicle necessary to provide that transportation, or transportation by common carrier or private motor vehicle to obtain medical care.
49.46(2)(b)6.e.
e. Subject to the limitation under
s. 49.45 (30r), inpatient hospital, skilled nursing facility and intermediate care facility services for patients of any institution for mental diseases who are under 21 years of age, are under 22 years of age and who were receiving these services immediately prior to reaching age 21, or are 65 years of age or older.
49.46(2)(b)6.f.
f. Medical day treatment services, mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist.
49.46(2)(b)6.fm.
fm. Subject to the limitations under
s. 49.45 (45), mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist, to an individual who is 21 years of age or older in the individual's home or in the community.
49.46(2)(b)6.g.
g. Nursing services, including services performed by a nurse practitioner, as defined in rules that the department shall promulgate.
49.46(2)(b)6.h.
h. Legend drugs, as listed in the Wisconsin medical assistance drug index.
49.46(2)(b)6.i.
i. Over-the-counter drugs listed by the department in the Wisconsin medical assistance drug index.
49.46(2)(b)6.L.
L. Mental health and psychosocial rehabilitative services, including case management services, provided by the staff of a community support program certified under
s. 49.45 (2) (a) 11.
49.46(2)(b)6.Lm.
Lm. Subject to the limitations under
s. 49.45 (30e), psychosocial services, including case management services, provided by the staff of a community-based psychosocial service program.
49.46(2)(b)6.m.
m. Respiratory care services for ventilator-dependent individuals.
49.46(2)(b)12.
12. Care coordination for women with high-risk pregnancies.
49.46(2)(b)12t.
12t. Subject to the limitations under
s. 49.45 (30x), licensed midwife services provided by a certified professional midwife licensed under
s. 440.982.
49.46(2)(b)13.
13. Care coordination and follow-up, including lead investigations, as defined in
s. 254.11 (8s), of persons having lead poisoning or lead exposure, as defined in
s. 254.11 (9).
49.46(2)(b)14m.
14m. Subject to
par. (bt), substance abuse treatment services provided by a medically monitored treatment service or a transitional residential treatment service.
49.46(2)(b)16.
16. Case management services for recipients with high-cost chronic health conditions or high-cost catastrophic health conditions, if the department operates a program under
s. 49.45 (43).
49.46(2)(b)17.
17. Services under
s. 49.45 (54) (b) for children participating in the early intervention program under
s. 51.44, that are provided by a special educator.
49.46(2)(b)19.
19. Subject to
par. (br), services provided by early intervention teachers, home trainers, parent-to-parent mentors, and developmental specialists to children in the benchmark plan under
par. (br).
49.46(2)(b)20.
20. Subject to
s. 49.45 (24j), any additional services, as determined by the department, that are targeted to a population enrolled in a medical home initiative under
s. 49.45 (24j).
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)(bt)1.1. For the purposes of
par. (b) 14m., a “medically monitored treatment service" is a 24-hour, community-based service providing observation, monitoring, and treatment by a multidisciplinary team under supervision of a physician, with a minimum of 12 hours of counseling provided per week for each patient.
49.46(2)(bt)2.
2. For the purposes of
par. (b) 14m., a “transitional residential treatment service" is a clinically supervised, peer-supported, therapeutic environment with clinical involvement providing substance abuse treatment in the form of counseling for 3 to 11 hours provided per week for each patient.
49.46(2)(bt)3.
3. If approval by the federal department of health and human services of a state plan amendment or waiver request is necessary for federal reimbursement of the services under
par. (b) 14m., the department is not required to pay for services described in
par. (b) 14m. if the department does not receive the necessary approval.
49.46(2)(bt)4.
4. The department may not provide reimbursement for services under
par. (b) 14m. that are provided before July 1, 2016, or before the date of approval of the state plan amendment or waiver request described under
subd. 3., whichever is later.
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 percent of the poverty line, as established under
42 USC 9902 (2).
