49.49(7)(a)1.a.
a. The entity is the named licensee for the nursing home or intermediate care facility.
49.49(7)(a)1.b.
b. The entity is the certified provider under s.
49.45 (2) (a) 11. for the nursing home or intermediate care facility and is the recipient of medical assistance reimbursement for services provided by the nursing home or intermediate care facility.
49.49(7)(a)1.c.
c. The entity owns or leases the building in which the nursing home or intermediate care facility is located.
49.49(7)(a)1.d.
d. The entity provides or contracts for provision of nursing home or intermediate care facility services.
49.49(7)(a)1.e.
e. The entity controls admissions and discharges from the nursing home or intermediate care facility.
49.49(7)(a)1.f.
f. The entity allocates the costs of operating the nursing home or intermediate care facility, and of providing services to residents of the nursing home or intermediate care facility, among the political subdivisions that are parties to the contract and assesses each political subdivision that is a party to the contract the portion of the costs allocated to that political subdivision.
49.49(7)(a)2.
2. “Member" means a political subdivision that is a party to a contract to create a commission.
49.49(7)(a)3.
3. “Political subdivision" means a county, city, village, or town.
49.49(7)(b)
(b) A commission's imposition of an assessment on a member for the costs incurred by the commission to operate the nursing home or intermediate care facility and to provide services to residents of the nursing home or intermediate care facility is a charge internal to the commission and does not constitute billing a 3rd party for services provided on behalf of an individual.
49.49(7)(c)
(c) A member's payment of an assessment described under par.
(b) is a transfer of funds internal to the commission and does not constitute a purchase of services on behalf of an individual, regardless of whether the payment is made from the member's general fund, made pursuant to a purchase of services agreement between a member's human services department or other department and the commission, or by a combination of these payment methods.
49.49(7)(d)
(d) A commission's imposition of an assessment described under par.
(b), a member's payment of the assessment as described under par.
(c), and acceptance of the payment by the commission do not constitute conduct prohibited under s.
946.91 (6) or prohibited under s.
DHS 106.04 (3), Wis. Adm. Code, in effect on May 26, 2010. It is the intent of the legislature to create a mechanism whereby 2 or more political subdivisions may share in the operation, use, and funding of a nursing home or intermediate care facility without violating
42 USC 1320a-7b (d) or
42 USC 1396a (a) (25) (C).
49.49 Annotation
The only state of mind requirement for a violation of sub. (1) (a) 1. is the intentional making or causing the making of a false statement that appears in an application; that anyone actually received a medical assistance benefit need not be proved. State v. Williams,
179 Wis. 2d 80,
505 N.W.2d 468 (Ct. App. 1993).
49.49 Annotation
Sub. (3m) and related rules require medical assistance providers to refund only the amount paid by the medical assistance program on behalf of retroactively eligible persons. A private pay patient subsequently found retroactively eligible does not have a federally protected right to reimbursement from a medical assistance provider for the amount originally paid by the patient in excess of the medical assistance reimbursement. Keup v. DHFS,
2004 WI 16,
269 Wis. 2d 59,
675 N.W.2d 755,
02-0456.
49.49 Annotation
When the defendant hospital did not send bills directly to Medical Assistance patients, but rather filed liens against the patients' potential settlements with a tortfeasor's insurer, the liens did not constitute “direct charges upon" the patients and were therefore permissible under the plain language of the second prohibition in sub. (3m) (a). Gister v. American Family Mutual Ins. Co.
2012 WI 86,
342 Wis. 2d 496,
818 N.W.2d 880,
09-2795.
49.49 Annotation
Nursing home guarantor agreements may violate sub. (4) after a resident becomes certified Medicaid eligible.
76 Atty. Gen. 295.
49.493
49.493
Benefits under uninsured health plans. 49.493(1)(a)
(a) “Department or contract provider" means the department, the county providing the medical benefits or assistance or a health maintenance organization that has contracted with the department to provide the medical benefits or assistance.
49.493(1)(b)
(b) “Medical benefits or assistance" means medical benefits under s.
49.02 or
253.05 or medical assistance.
49.493(1)(c)
(c) “Uninsured health plan" means a partially or wholly uninsured plan, including a plan that is subject to
29 USC 1001 to
1461, providing health care benefits.
49.493(2)
(2) The providing of medical benefits or assistance constitutes an assignment to the department or contract provider, to the extent of the medical benefits or assistance provided, for benefits to which the recipient would be entitled under any uninsured health plan.
49.493(3)
(3) An uninsured health plan may not do any of the following:
49.493(3)(a)
(a) Exclude a person or a person's dependent from coverage under the uninsured health plan because the person or the dependent is eligible for medical assistance.
49.493(3)(b)
(b) Terminate its coverage of a person or a person's dependent because the person or the dependent is eligible for medical assistance.
49.493(3)(c)
(c) Provide different benefits of coverage to a person or the person's dependent because the person or the dependent is eligible for medical assistance than it provides to persons and their dependents who are not eligible for medical assistance.
49.493(3)(d)
(d) Impose on the department or contract provider, as assignee of a person or a person's dependent who is covered under the uninsured health plan and who is eligible for medical benefits or assistance, requirements that are different from those imposed on any other agent or assignee of a person who is covered under the uninsured health plan.
49.493(4)
(4) Benefits provided by an uninsured health plan shall be primary to medical benefits or assistance.
49.496
49.496
Recovery of correct medical assistance payments. 49.496(1)(af)
(af) “Decedent" means a deceased recipient or a deceased nonrecipient surviving spouse, whichever is applicable.
49.496(1)(b)
(b) “Home" means property in which a person has an ownership interest consisting of the person's dwelling and the land used and operated in connection with the dwelling.
49.496(1)(bk)
(bk) “Long-term care program" means any of the following:
49.496(1)(bk)2.
2. The self-directed services option that operates under a waiver from the secretary of the federal department of health and human services under
42 USC 1396n (c) in which an enrolled individual selects his or her own services and service providers.
49.496(1)(bk)3.
3. The family care partnership program that is an integrated health and long-term care program operated under an amendment to the state medical assistance plan under
42 USC 1396u-2 and a waiver under
42 USC 1396n (c).
49.496(1)(bw)
(bw) “Nonrecipient surviving spouse" means any person who was married to a recipient while the recipient was receiving services for which the cost may be recovered under sub.
(3) (a) and who survived the recipient.
49.496(1)(cm)
(cm) “Property of a decedent" means all real and personal property to which the recipient held any legal title or in which the recipient had any legal interest immediately before death, to the extent of that title or interest, including assets transferred to a survivor, heir, or assignee through joint tenancy, tenancy in common, survivorship, life estate, revocable trust, or any other arrangement, excluding an irrevocable trust.
49.496(1)(d)
(d) “Recipient" means a person who receives or received medical assistance.
49.496(2)
(2) Liens on the homes of nursing home residents and inpatients at hospitals. 49.496(2)(a)
(a) Except as provided in par.
(b), the department may obtain a lien on a recipient's home if the recipient resides in a nursing home, or if the recipient resides in a hospital and is required to contribute to the cost of care, and the recipient cannot reasonably be expected to be discharged from the nursing home or hospital and return home. The lien is for the amount of medical assistance paid on behalf of the recipient that is recoverable under sub.
(3) (a).
49.496(2)(b)
(b) The department may not obtain a lien under this subsection if any of the following persons lawfully reside in the home:
49.496(2)(b)2.
2. The recipient's child who is under age 21 or is disabled.
49.496(2)(b)3.
3. The recipient's sibling who has an ownership interest in the home and who has lived in the home continuously beginning at least 12 months before the recipient was admitted to the nursing home or hospital.
49.496(2)(c)
(c) Before obtaining a lien on a recipient's home under this subsection, the department shall do all of the following:
49.496(2)(c)1.
1. Notify the recipient in writing of its determination that the recipient cannot reasonably be expected to be discharged from the nursing home or hospital, its intent to impose a lien on the recipient's home and the recipient's right to a hearing on whether the requirements for the imposition of a lien are satisfied.
49.496(2)(c)2.
2. Provide the recipient with a hearing if he or she requests one.
49.496(2)(d)
(d) The department shall obtain a lien under this subsection by recording a lien claim in the office of the register of deeds of the county in which the home is located.
49.496(2)(e)
(e) The department may not enforce a lien under this subsection while the recipient lives unless the recipient sells the home and does not have a living child who is under age 21 or disabled or a living spouse.
49.496(2)(f)
(f) The department may not enforce a lien under this subsection after the death of the recipient as long as any of the following survive the recipient:
49.496(2)(f)3.
3. A child of any age who resides in the home, if that child resided in the home for at least 24 months before the recipient was admitted to the nursing home or hospital and provided care to the recipient that delayed the recipient's admission to the nursing home or hospital.
49.496(2)(f)4.
4. A sibling who resides in the home, if the sibling resided in the home for at least 12 months before the recipient was admitted to the nursing home or hospital.
49.496(2)(g)
(g) The department may enforce a lien imposed under this subsection by foreclosure in the same manner as a mortgage on real property.
49.496(2)(h)
(h) The department shall file a release of a lien imposed under this subsection if the recipient is discharged from the nursing home or hospital and returns to live in the home.
49.496(3)(a)
(a) Except as provided in par.
(b), the department shall file a claim against the estate of a recipient, and against the estate of a nonrecipient surviving spouse, for all of the following, subject to the exclusion of any amounts under the Long-Term Care Partnership Program established under s.
49.45 (31), unless already recovered by the department under this section:
49.496(3)(a)1.
1. The amount of medical assistance paid on behalf of the recipient while the recipient resided in a nursing home or while the recipient was an inpatient in a hospital and was required to contribute to the cost of care.
49.496(3)(a)2.
2. The following medical assistance services paid on behalf of the recipient after the recipient attained 55 years of age:
49.496(3)(a)2.am.
am. All services provided to an individual while the individual is participating in a long-term care program.
49.496(3)(ad)
(ad) The amount the department may claim against an estate of a recipient, or an estate of a nonrecipient surviving spouse, for services that are described under par.
(a) 2. am. and that are provided by a managed long-term care program funded by capitated payments is equal to the amount of the capitated payment for the recipient.
49.496(3)(ag)
(ag) The affidavit of a person designated by the secretary to administer this subsection is evidence of the amount of the claim.
49.496(3)(aj)1.1. Property that is subject to the department's claim under par.
(a) in the estate of a recipient or in the estate of a nonrecipient surviving spouse is all property of a decedent that is included in the estate.
49.496(3)(aj)2.
2. There is a presumption, consistent with s.
766.31, which may be rebutted, that all property in the estate of a nonrecipient surviving spouse was marital property held with the recipient and that 100 percent of the property in the estate of the nonrecipient surviving spouse is subject to the department's claim under par.
(a).
49.496(3)(am)
(am) The court shall reduce the amount of a claim under par.
(a) by up to the amount specified in s.
861.33 (2) if necessary to allow the decedent's heirs or the beneficiaries of the decedent's will to retain the following personal property:
49.496(3)(am)1.
1. The decedent's wearing apparel and jewelry held for personal use.
49.496(3)(am)3.
3. Other tangible personal property not used in trade, agriculture or other business, not to exceed in value the amount specified in s.
861.33 (1) (a) 4. 49.496(3)(b)
(b) A claim under par.
(a) is not allowable if the decedent has a surviving child who is under age 21 or disabled or a surviving spouse.
49.496(3)(c)1.1. If the department's claim is not allowable because of par.
(b) and the estate includes an interest in any real property, including a home, the court exercising probate jurisdiction shall, in the final judgment or summary findings and order, assign the interest in the real property subject to a lien in favor of the department for the amount described in par.
(a). The personal representative or petitioner for summary settlement or summary assignment of the estate shall record the final judgment as provided in s.
863.29,
867.01 (3) (h), or
867.02 (2) (h).
49.496(3)(c)2.
2. If the department's claim is not allowable because of par.
(b), the estate includes an interest in any real property, including a home, and the personal representative closes the estate by sworn statement under s.
865.16, the personal representative shall stipulate in the statement that the real property is assigned subject to a lien in favor of the department for the amount described in par.
(a). The personal representative shall record the statement in the same manner as described in s.
863.29, as if the statement were a final judgment.
49.496(3)(d)
(d) The department may not enforce a lien under par.
(c) as long as any of the following survive the decedent:
49.496(3)(dm)
(dm) All of the following apply to a lien under par.
(c) that the department may not enforce because of par.
(d):
