49.665(1)(b)
(b) “Child" means a person who is born and who is under the age of 19.
49.665(1)(c)
(c) “Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80 percent of the cost, excluding any deductibles or copayments that may be required under the plan.
49.665(1)(d)
(d) “Family" means a unit that consists of at least one child and his or her parent or parents, all of whom reside in the same household. “Family" includes the spouse of an individual who is a parent if the spouse resides in the same household as the individual.
49.665(1)(g)
(g) “Unborn child" means a person from the time of conception until it is born alive.
49.665(2)(a)1.1. The department of health services shall request a waiver from the secretary of the federal department of health and human services to permit the department of health services to implement, beginning not later than July 1, 1998, or the effective date of the waiver, whichever is later, a health care program under this section. If a waiver that is consistent with all of the provisions of this section, excluding sub.
(4) (a) 3m. and
(ap) and provisions related to sub.
(4) (ap), is granted and in effect, the department of health services shall implement the program under this section, subject to subd.
2. The department of health services may not implement the program under this section unless a waiver that is consistent with all of the provisions of this section, excluding sub.
(4) (a) 3m. and
(ap) and provisions related to sub.
(4) (ap), is granted and in effect.
49.665(2)(a)2.
2. The department may not implement sub.
(4) (ap) or provisions related to the coverage under sub.
(4) (ap) unless a state plan amendment authorizing the coverage under sub.
(4) (ap) is approved by the federal department of health and human services.
49.665(2)(b)
(b) If the department of health services determines that it needs a waiver to require the verification specified in sub.
(4) (a) 3m., the department shall request a waiver from the secretary of the federal department of health and human services and may not implement the verification requirement under sub.
(4) (a) 3m. unless the waiver is granted. If a waiver is required and is granted, the department of health services may implement the verification requirement under sub.
(4) (a) 3m. as appropriate. If a waiver is not required, the department of health services may require the verification specified in sub.
(4) (a) 3m. for eligibility determinations and annual review eligibility determinations made by the department, beginning on January 1, 2004.
49.665(3)
(3) Administration. Subject to sub.
(2) (a) 2., the department shall administer a program to provide the health services and benefits described in s.
49.46 (2) to persons that meet the eligibility requirements specified in sub.
(4). The department shall promulgate rules setting forth the application procedures and appeal and grievance procedures. The department may promulgate rules limiting access to the program under this section to defined enrollment periods. The department may also promulgate rules establishing a method by which the department may purchase family coverage offered by the employer of a member of an eligible family or of a member of an eligible child's household, or family or individual coverage offered by the employer of an eligible unborn child's mother or her spouse, under circumstances in which the department determines that purchasing that coverage would not be more costly than providing the coverage under this section.
49.665(4)(a)
(a) A family is eligible for health care coverage under this section if the family meets all of the following requirements:
49.665(4)(a)1.
1. The family's income does not exceed 185 percent of the poverty line, except as provided in par.
(at) and except that a family that is already receiving health care coverage under this section may have an income that does not exceed 200 percent of the poverty line. The department shall establish by rule the criteria to be used to determine income.
49.665(4)(a)2.
2. The family does not have access to employer-subsidized health care coverage.
49.665(4)(a)3.
3. The family has not had access to employer-subsidized health care coverage within the time period established by the department by rule, but not to exceed 18 months, immediately preceding application for health care coverage under this section. The department may establish exceptions to this time period restriction by rule.
49.665(4)(a)3m.
3m. Each member of the family who is employed provides verification from his or her employer, in the manner specified by the department, of his or her earnings, of whether the employer provides health care coverage for which the family is eligible, and of the amount that the employer pays, if any, towards the cost of the health care coverage, excluding any deductibles or copayments required under the coverage.
49.665(4)(a)4.
4. The family meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements.
49.665(4)(am)
(am) A child who does not reside with his or her parent is eligible for health care coverage under this section if the child meets all of the following requirements:
49.665(4)(am)1.
1. The child's income does not exceed 185 percent of the poverty line, except as provided in par.
(at) and except that a child that is already receiving health care coverage under this section may have an income that does not exceed 200 percent of the poverty line. The department shall use the criteria established under par.
(a) 1. to determine income under this subdivision.
49.665(4)(am)2.
2. The child does not have access to employer-subsidized health care coverage.
49.665(4)(am)3.
3. The child has not had access to employer-subsidized health care coverage within the time period established by the department under par.
(a) 3. The department may establish exceptions to this subdivision.
49.665(4)(am)4.
4. The child meets all other requirements established by the department by rule. In establishing other eligibility criteria, the department may not include any health condition requirements.
49.665(4)(ap)
(ap) An unborn child whose mother is not eligible for health care coverage under par.
(a) or
(am) or for medical assistance under s.
49.46 or
49.47, except that she may be eligible for benefits under s.
49.45 (27), is eligible for health care coverage under this section, which shall be limited to coverage for prenatal care, if all of the following requirements are met:
49.665(4)(ap)1.
1. The income of the unborn child's mother, mother and her spouse, or mother and her family, whichever is applicable, does not exceed 185 percent of the poverty line, except as provided in par.
(at) and except that, if an unborn child is already receiving health care coverage under this section, the applicable specified person or persons may have an income that does not exceed 200 percent of the poverty line. The department shall establish by rule the criteria to be used to determine income.
49.665(4)(ap)3.
3. The unborn child's mother provides medical verification of her pregnancy, in the manner specified by the department.
49.665(4)(ap)4.
4. The unborn child and the mother of the unborn child meet all other requirements established by the department by rule except for any of the following:
49.665(4)(at)1.a.a. Except as provided in subd.
1. b., the department shall establish a lower maximum income level for the initial eligibility determination if funding under s.
20.435 (4) (jz),
(p), and
(x) is insufficient to accommodate the projected enrollment levels for the health care program under this section. The adjustment may not be greater than necessary to ensure sufficient funding.
49.665(4)(at)1.b.
b. The department may not lower the maximum income level for initial eligibility unless the department first submits to the joint committee on finance a plan for lowering the maximum income level. If, within 14 days after the date on which the plan is submitted to the joint committee on finance, the cochairpersons of the committee do not notify the secretary that the committee has scheduled a meeting for the purpose of reviewing the plan, the department shall implement the plan as proposed. If, within 14 days after the date on which the plan is submitted to the committee, the cochairpersons of the committee notify the secretary that the committee has scheduled a meeting to review the plan, the department may implement the plan only as approved by the committee.
49.665(4)(at)1.cm.
cm. Notwithstanding s.
20.001 (3) (b), if, after reviewing the plan submitted under subd.
1. b., the joint committee on finance determines that the amounts appropriated under s.
20.435 (4) (jz),
(p), and
(x) are insufficient to accommodate the projected enrollment levels, the committee may transfer appropriated moneys from the general purpose revenue appropriation account of any state agency, as defined in s.
20.001 (1), other than a sum sufficient appropriation account, to the appropriation account under s.
20.435 (4) (b) to supplement the health care program under this section if the committee finds that the transfer will eliminate unnecessary duplication of functions, result in more efficient and effective methods for performing programs, or more effectively carry out legislative intent, and that legislative intent will not be changed by the transfer.
49.665(4)(at)2.
2. If, after the department has established a lower maximum income level under subd.
1., projections indicate that funding under s.
20.435 (4) (jz),
(p), and
(x) is sufficient to raise the level, the department shall, by state plan amendment, raise the maximum income level for initial eligibility, but not to exceed 185 percent of the poverty line.
49.665(4)(at)3.
3. The department may not adjust the maximum income level of 200 percent of the poverty line for persons already receiving health care coverage under this section or for applicable persons specified in par.
(ap) 1. with respect to an unborn child already receiving health care coverage under this section.
49.665(4)(b)
(b) Notwithstanding fulfillment of the eligibility requirements under this subsection, no person is entitled to health care coverage under this section.
49.665(4)(c)
(c) No person may be denied health care coverage under this section solely because of a health condition of that person, of any family member of that person, or of the mother of an unborn child.
49.665(4)(d)
(d) An unborn child's eligibility for coverage under par.
(ap) shall not begin before the first day of the month in which the unborn child's mother provides the medical verification required under par.
(ap) 3. 49.665(4g)
(4g) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub.
(4m), the department shall develop and implement, for individuals who are eligible under sub.
(4), disease management programs. These programs shall have at least the following characteristics:
49.665(4g)(a)
(a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
49.665(4g)(b)
(b) Educating health care providers on health care process improvement by developing best practice models.
49.665(4g)(c)
(c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
49.665(4g)(d)
(d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
49.665(4g)(e)
(e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
49.665(4m)
(4m) Physical health risk assessment. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible under sub.
(4) to receive a physical health risk assessment as part of the first physical examination the individual receives under Badger Care.
49.665(5)(ac)
(ac) In this subsection, “cost" means total cost-sharing charges, including premiums, copayments, coinsurance, deductibles, enrollment fees, and any other cost-sharing charges.
49.665(5)(ag)
(ag) Except as provided in pars.
(am),
(b), and
(bm), a family, a child who does not reside with his or her parent, or the mother of an unborn child, who receives health care coverage under this section shall pay a percentage of the cost of that coverage in accordance with a schedule established by the department by rule. The department may not establish or implement a schedule that requires a contribution, including the amounts required under par.
(am), of more than 5 percent of the income of the family, child, or applicable persons specified in sub.
(4) (ap) 1. towards the cost of the health care coverage provided under this section.
49.665(5)(am)
(am) Except as provided in pars.
(b) and
(bm), a child, a family member, or the mother of an unborn child, who receives health care coverage under this section shall pay the following cost-sharing amounts:
49.665(5)(b)
(b) The department may not require a family, child who does not reside with his or her parent, or applicable persons specified in sub.
(4) (ap) 1., with an income below 150 percent of the poverty line, to contribute to the cost of health care coverage provided under this section.
49.665(5)(bm)
(bm) If the federal department of health and human services notifies the department of health services that Native Americans may not be required to contribute to the cost of the health care coverage provided under this section, the department of health services may not require Native Americans to contribute to the cost of health care coverage under this section.
49.665(5)(c)
(c) The department may establish by rule requirements for wage withholding as a means of collecting a family's or an unborn child's mother's share of the cost of the health care coverage under this section.
49.665(5m)
(5m) Information about Badger Care recipients. The department shall obtain and share information about Badger Care health care program recipients as provided in s.
49.475.
49.665(7)
(7) Employer verification forms; forfeiture and penalty assessment. 49.665(7)(a)1.1. Notwithstanding sub.
(4) (a) 3m., the department shall mail information verification forms to the employers of the individuals required to provide the verifications under sub.
(4) (a) 3m. to obtain the information specified.
49.665(7)(a)2.
2. An employer that receives a verification form shall complete the form and return it to the department, by mail, with a postmark that is not more than 30 working days after the date on which the department mailed the form to the employer.
49.665(7)(a)3.
3. As an alternative to the method under subd.
2., an employer may, within 30 working days after the date on which the department mailed the form to the employer, return the completed form to the department by any electronic means approved by the department. The department must be able to determine, or the employer must be able to verify, the date on which the form was sent to the department electronically.
49.665(7)(b)1.1. Subject to subd.
3., an employer that does not comply with the requirements under par.
(a) 2. or
3. shall be required to pay a forfeiture of $50 for each verification form not returned in compliance with par.
(a) 2. or
3. 49.665(7)(b)2.
2. Subject to subd.
3., whenever the department imposes a forfeiture under subd.
1., the department shall also levy a penalty assessment of $50.
49.665(7)(b)3.
3. An employer with fewer than 250 employees may not be required to pay more than $1,000 in forfeitures and penalty assessments under this paragraph in any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in forfeitures and penalty assessments under this paragraph in any 6-month period.
49.665(7)(b)4.
4. All penalty assessments collected under subd.
2. shall be credited to the appropriation account under s.
20.435 (4) (jz) and all forfeitures collected under subd.
1. shall be credited to the common school fund.
49.665(7)(c)
(c) An employer may contest an assessment of forfeiture or penalty assessment under par.
(b) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by ch.
227.
49.68
49.68
Aid for treatment of kidney disease. 49.68(1)(1)
Declaration of policy. The legislature finds that effective means of treating kidney failure are available, including dialysis or artificial kidney treatment or transplants. It further finds that kidney disease treatment is prohibitively expensive for the overwhelming portion of the state's citizens. It further finds that public and private insurance coverage is inadequate in many cases to cover the cost of adequate treatment at the proper time in modern facilities. The legislature finds, in addition, that the incidence of the disease in the state is not so great that public aid may not be provided to alleviate this serious problem for a relatively modest investment. Therefore, it is declared to be the policy of this state to assure that all persons are protected from the destructive cost of kidney disease treatment by one means or another.
49.68(1m)
(1m) Definition. In this section, “recombinant human erythropoietin" means a bioengineered glycoprotein that has the same biological effects in stimulating red blood cell production as does the glycoprotein erythropoietin that is produced by the human body.
49.68(2)
(2) Duties of department. The department shall:
49.68(2)(a)
(a) Promulgate rules setting standards for operation and certification of dialysis and renal transplantation centers and home dialysis equipment and suppliers.
49.68(2)(b)
(b) Promulgate rules setting standards for acceptance and certification of patients into the treatment phase of the program.
49.68(2)(c)
(c) Promulgate rules concerning reasonable cost and length of treatment programs.
49.68(2)(d)
(d) Aid in preparing educational programs and materials informing the public as to chronic renal disease and the prevention and treatment thereof.
49.68(3)
(3) Aid to kidney disease patients. 49.68(3)(a)(a) Subject to s.
49.687 (1m), any permanent resident of this state who suffers from chronic renal disease may be accepted into the dialysis treatment phase of the renal disease control program if the resident meets standards set by rule under sub.
(2) and s.
49.687.
49.68(3)(b)
(b) From the appropriation accounts under ss.
20.435 (4) (e) and
(je), the state shall pay, at a rate determined by the department under par.
(e), for medical treatment that is required as a direct result of chronic renal disease of certified patients from the date of certification, including administering recombinant human erythropoietin to appropriate patients, whether the treatment is rendered in an approved facility in the state or in a dialysis or transplantation center that is approved as such by a contiguous state, subject to the conditions specified under par.
(d). Approved facilities may include a hospital in-center dialysis unit or a nonhospital dialysis center that is closely affiliated with a home dialysis program supervised by an approved facility. Aid shall also be provided for all reasonable expenses incurred by a potential living-related donor, including evaluation, hospitalization, surgical costs, and postoperative follow-up to the extent that these costs are not reimbursable under the federal medicare program or other insurance. In addition, all expenses incurred in the procurement, transportation, and preservation of cadaveric donor kidneys shall be covered to the extent that these costs are not otherwise reimbursable. All donor-related costs are chargeable to the recipient and reimbursable under this subsection.
49.68(3)(c)
(c) Disbursement and collection of all funds under this subsection shall be by the department or by a fiscal intermediary, in accordance with a contract with a fiscal intermediary. The costs of the fiscal intermediary under this paragraph shall be paid from the appropriation under s.
20.435 (1) (a).
49.68(3)(d)1.1. No aid may be granted under this subsection unless the recipient has no other form of aid available from the federal medicare program, from private health, accident, sickness, medical, and hospital insurance coverage, or from other health care coverage specified by rule under s.
49.687 (1m). If insufficient aid is available from other sources and if the recipient has paid an amount equal to the annual medicare deductible amount specified in subd.
2., the state shall pay the difference in cost to a qualified recipient. If at any time sufficient federal or private insurance aid or other health care coverage becomes available during the treatment period, state aid under this subsection shall be terminated or appropriately reduced. Any patient who is eligible for the federal medicare program shall register and pay the premium for medicare medical insurance coverage where permitted, and shall pay an amount equal to the annual medicare deductible amounts required under
42 USC 1395e and
1395L (b), prior to becoming eligible for state aid under this subsection.
49.68(3)(d)2.
2. Aid under this subsection is only available after the patient pays an annual amount equal to the annual deductible amount required under the federal medicare program. This subdivision requires an inpatient who seeks aid first to pay an annual deductible amount equal to the annual medicare deductible amount specified under
42 USC 1395e and requires an outpatient who seeks aid first to pay an annual deductible amount equal to the annual medicare deductible amount specified under
42 USC 1395L (b).
49.68(3)(d)3.
3. No payment shall be made under this subsection for any portion of medical treatment costs or other expenses that are payable under any state, federal, or other health care coverage program, including a health care coverage program specified by rule under s.
49.687 (1m), or under any grant, contract, or other contractual arrangement.
49.68(3)(e)
(e) Payment for services provided under this section shall be at a rate determined by the department that does not exceed the allowable charges under the federal Medicare program. In no case shall state rates for individual service elements exceed the federally defined allowable costs. The rate of charges for services not covered by public and private insurance shall not exceed the reasonable charges as established by Medicare fee determination procedures. A person that provides to a patient a service for which aid is provided under this section shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section. The state may not pay for the cost of travel, lodging, or meals for persons who must travel to receive inpatient and outpatient dialysis treatment for kidney disease. This paragraph shall not apply to donor related costs as defined in par.
(b).
