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.
49.45(30r)
(30r) Services in a mental health institute. A county shall provide the portion of payment that is not provided by the federal government for services under s.
49.46 (2) (b) 6. e. in a mental health institute under s.
51.05.
49.45(30x)(a)
(a)
Provider reimbursement. Beginning January 1, 2016, services under s.
49.46 (2) (b) 12t. provided to an individual are reimbursable under the Medical Assistance program if an amendment to the state medical assistance plan approved by the federal department of health and human services permits reimbursement under s.
49.46 (2) (b) 12t. 49.45(30x)(b)
(b)
Plan amendment. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of par.
(a). The department may not pay reimbursement under par.
(a) unless the amendment to the state plan allowing reimbursement under s.
49.46 (2) (b) 12t. is approved and in effect.
49.45(31)
(31) Long-Term Care Partnership Program. 49.45(31)(a)(a) The department shall submit to the federal department of health and human services, not later than 3 months after October 27, 2007, an amendment to the state medical assistance plan that establishes in this state a Long-Term Care Partnership Program, as described in this subsection, and shall implement the program if the amendment to the state plan is approved. Under the program, the department shall exclude an amount equal to the amount of benefits that an individual receives under a qualifying long-term care insurance policy, as described in par.
(b), when determining any of the following:
49.45(31)(a)1.
1. The individual's resources for purposes of determining the individual's eligibility for medical assistance.
49.45(31)(a)2.
2. The amount to be recovered from the individual's estate if the individual receives medical assistance.
49.45(31)(b)
(b) To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:
49.45(31)(b)1.
1. The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.
49.45(31)(b)3.
3. The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in
42 USC 1396p (b) (5).
49.45(31)(b)5.
5. The commissioner of insurance certifies to the department that the policy meets the criteria under subds.
2. to
4. 49.45(31)(c)1.1. The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.
49.45(31)(c)2.
2. The training program approved under this paragraph shall include initial training that is not less than 8 hours long and ongoing training sessions that are not less than 4 hours long per session. Individuals who sell long-term care insurance policies shall be required to attend an ongoing training session every 24 months after the initial training. The commissioner may approve the initial and ongoing training sessions for continuing education requirements under s.
628.04 (3).
49.45(31)(c)3.
3. The training under this paragraph shall cover at a minimum long-term care insurance, long-term care services, qualified partnerships, and the relationship between qualified partnerships and other public and private coverage of long-term care costs.
49.45(31)(d)
(d) An insurer that issues a long-term care insurance policy described in par.
(b) shall be required to submit reports to the secretary of the federal department of health and human services, in accordance with regulations developed by the secretary, that include notice of when benefits are paid under the policy, the amount of the benefits, notice of the termination of the policy, and any other information required by the secretary.
49.45(31)(e)1.1. Notwithstanding par.
(b) (intro.), the department, when making a determination under par.
(a) 1. or
2. with respect to an individual, shall disregard an amount equal to the insurance benefit payments that are made to or on behalf of the individual under a qualified long-term care insurance policy under
26 USC 7702B (b) that was purchased in a state that had a state plan amendment that provided for a qualified state long-term care partnership, as defined in
42 USC 1396p (b) (1) (C) (iii), at the time of the purchase of the policy.
49.45(31)(e)2.
2. The department shall comply with standards established by the federal department of health and human services in accordance with section 6021 (b) of the federal Deficit Reduction Act of 2005.
49.45(32)
(32) Community care for the elderly. The department may request a waiver under
42 USC 1315 to permit the establishment of a community care for the elderly demonstration project to provide medical care, case management services, adult day care and other support services that promote independence and enhance the quality of life of frail elderly persons. If the waiver is approved, the department may establish the community care for the elderly demonstration project and pay a fixed per person fee for the services.
49.45(34)
(34) Medical assistance manual. The department shall prepare a medical assistance manual that is clear, comprehensive and consistent with this subchapter and
42 USC 1396a to
1396u and shall, no later than July 1, 1992, provide the manual to counties for use by county employees who administer the medical assistance program.
49.45(35m)
(35m) Computer system redesign. The department shall ensure that any redesign or replacement of the computer network that is used by counties on May 12, 1992, to determine eligibility for medical assistance includes the capability of determining eligibility for medical assistance under s.
49.47 (4) (c) 2. 49.45(36)
(36) Homeless beneficiaries. The department or a county department under s.
46.215,
46.22, or
46.23 may not place the word “homeless" on the medical assistance identification card of any person who is determined to be eligible for medical assistance benefits and who is homeless.
49.45(37)
(37) Plans of care. The department may seek a waiver of the requirement under
42 USC 1396n (c) (1) that the department review and approve every written plan of care developed for each individual who receives, under
42 USC 1396n (c) (1), home or community-based services under ss.
49.46 (2) (b) 8. and
49.47 (6) (a) 1. The waiver of the requirement, if granted, shall apply to those county departments or private nonprofit agencies that administer the services and that the department finds and certifies have implemented effective quality assurance systems for service plan development and implementation. If the federal health care financing administration approves the department's request for waiver of the requirement, the department shall, in evaluating a quality assurance system for certification, consider all of the following:
49.45(37)(a)
(a) The adequacy, safety and comprehensiveness of plans of care developed for individuals and of the services provided to them.
49.45(37)(b)
(b) Opportunities for individuals to exercise choice and be involved in the provision of services.
49.45(37)(c)
(c) Overall conformance to required state and federal quality assurance standards.
49.45(37)(d)
(d) Factors in addition to those in pars.
(a) to
(c) that are required by the federal health care financing administration, if any.
49.45(38)
(38) Home or community-based services for disabled workers. The department shall request a waiver from the secretary of the federal department of health and human services to authorize federal financial participation for medical assistance coverage of persons described in ss.
49.46 (1) (a) 14. and
49.47 (4) (as).
49.45(39)(a)1.
1. “School" means a public school described under s.
115.01 (1), a charter school, as defined in s.
115.001 (1), the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing. It includes school-operated early childhood programs for developmentally delayed and disabled 4-year-old and 5-year-old children.
49.45(39)(a)2.
2. “School medical services" means health care services that are provided in a school to children who are eligible for medical assistance that are appropriate to a school setting, as provided in the amendment to the state medical assistance plan under par.
(am).
49.45(39)(am)
(am)
Plan amendment. No later than September 30, 1995, the department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of pars.
(b) and
(c). If the amendment to the state plan is approved, school districts, cooperative educational service agencies, and the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin Educational Services Program for the Deaf and Hard of Hearing claim reimbursement under pars.
(b) and
(c). Paragraphs
(b) and
(c) do not apply unless the amendment to the state plan is approved and in effect. The department shall submit to the federal department of health and human services an amendment to the state plan if necessary to permit the application of pars.
(b) and
(c) to the Wisconsin Center for the Blind and Visually Impaired and the Wisconsin Educational Services Program for the Deaf and Hard of Hearing.
49.45(39)(b)1.1. `Payment for school medical services.' If a school district or a cooperative educational service agency elects to provide school medical services and meets all requirements under par.
(c), the department shall reimburse the school district or the cooperative educational service agency for 60 percent of the federal share of allowable charges for the school medical services that it provides and, as specified in subd.
2., for allowable administrative costs. If the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing elects to provide school medical services and meets all requirements under par.
(c), the department shall reimburse the department of public instruction for 60 percent of the federal share of allowable charges for the school medical services that the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing provides and, as specified in subd.
2., for allowable administrative costs. A school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, claims for common carrier transportation costs as a school medical service unless the department receives notice from the federal health care financing administration that, under a change in federal policy, the claims are not allowed. If the department receives the notice, a school district, cooperative educational service agency, the Wisconsin Center for the Blind and Visually Impaired, or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing may submit, and the department shall allow, unreimbursed claims for common carrier transportation costs incurred before the date of the change in federal policy. The department shall promulgate rules establishing a methodology for making reimbursements under this paragraph. All other expenses for the school medical services provided by a school district or a cooperative educational service agency shall be paid for by the school district or the cooperative educational service agency with funds received from state or local taxes. The school district, the Wisconsin Center for the Blind and Visually Impaired, the Wisconsin Educational Services Program for the Deaf and Hard of Hearing, or the cooperative educational service agency shall comply with all requirements of the federal department of health and human services for receiving federal financial participation.
49.45(39)(b)2.
2. `Payment for school medical services administrative costs.' The department shall reimburse a school district or a cooperative educational service agency specified under subd.
1. and shall reimburse the department of public instruction on behalf of the Wisconsin Center for the Blind and Visually Impaired or the Wisconsin Educational Services Program for the Deaf and Hard of Hearing for 90 percent of the federal share of allowable administrative costs, using time studies, beginning in fiscal year 1999-2000. A school district or a cooperative educational service agency may submit, and the department of health services shall allow, claims for administrative costs incurred during the period that is up to 24 months before the date of the claim, if allowable under federal law.
49.45(39)(c)
(c)
Certification and reporting requirements. The department shall promulgate rules establishing specific certification and reporting requirements with respect to school medical services under this subsection.
49.45(39m)
(39m) State plan amendment for pharmacist reimbursement. The department shall submit to the federal department of health and human services an amendment to the state Medical Assistance plan to permit Medical Assistance reimbursement to pharmacists who meet the training requirements specified by the department to administer vaccines, as determined by the department, to a person 6 to 18 years of age. The department shall provide Medical Assistance reimbursement under this subsection if the federal department of health and human services approves the amendment to the state Medical Assistance plan. A pharmacist or pharmacy shall enroll in the federal Vaccines for Children Program under
42 USC 1396s to be eligible for Medical Assistance reimbursement under this subsection.
49.45(40)
(40) Periodic record matches. If the department contracts with the department of children and families under s.
49.197 (5), the department shall cooperate with the department of children and families in matching records of medical assistance recipients under s.
49.32 (7).
49.45(41)
(41) Mental health crisis intervention services. 49.45(41)(a)(a) In this subsection, “mental health crisis intervention services" means services that are provided by a mental health crisis intervention program operated by, or under contract with, a county, if the county is certified as a medical assistance provider.
49.45(41)(b)
(b) If a county elects to become certified as a provider of mental health crisis intervention services, the county may provide mental health crisis intervention services under this subsection in the county to medical assistance recipients through the medical assistance program. A county that elects to provide the services shall pay the amount of the allowable charges for the services under the medical assistance program that is not provided by the federal government. The department shall reimburse the county under this subsection 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(42)(c)
(c) The department may charge a fee to certify a provider of personal care services described under par.
(d) 3. e., except that no fee may be imposed on an individual who is eligible for the veterans fee waiver program under s.
45.44. Fees collected under this paragraph shall be credited to the appropriation account under s.
20.435 (6) (jm).
49.45(42)(d)
(d) Personal care services under s.
49.46 (2) (b) 6. j. provided to an individual are reimbursable under medical assistance only if all of the following conditions are met:
49.45(42)(d)1.
1. The provider of the personal care services receives prior authorization from the department for all personal care services that are provided to the individual in excess of 50 hours in a calendar year.
