49.45(29)
(29)
Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss.
49.46,
49.47, and
49.471.
49.45(29r)
(29r)
Behavioral health care coordination pilot projects. 49.45(29r)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29r)(b)
(b) Subject to par.
(c), the department shall develop and award at least 2 pilot projects lasting no more than 3 years each to test alternative, coordinated care delivery and Medical Assistance payment models designed to reduce costs of recipients of Medical Assistance under this subchapter who have significant or chronic mental illness. A health care provider that is awarded a pilot project shall target a Medical Assistance population of high volume or high intensity users of non-behavioral health medical services, such as individuals with more than 5 emergency department visits in a year or individuals who have frequent or longer than average inpatient hospital stays, who also have significant or chronic mental illness. The department may not limit eligibility for the pilot project or awards under this subsection on the basis that the health care provider that is awarded the pilot project serves a target population that includes individuals enrolled in a Medical Assistance health maintenance organization. Each pilot project under this subsection shall include either a Medical Assistance payment on a per member per month basis for a specified pilot project population that is in addition to existing payment for services provided under the Medical Assistance program, including services reimbursed on a fee-for-service basis and services provided under managed care, or shall include an alternative Medical Assistance payment for a specified pilot project. The department shall require health care providers that are awarded a pilot project to submit to the department interim and final reports analyzing differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports. The department shall award the pilot projects and allocate funding only to health care providers that meet all of the following criteria:
49.45(29r)(b)1.
1. The health care provider provides all of the following services directly or through an affiliated entity:
49.45(29r)(b)1.f.
f. Services of a care coordinator or navigator for each individual in the pilot project.
49.45(29r)(b)2.
2. The health care provider provides, directly or through an affiliated entity or contracted entity, the coordination of social services fostering the individual's recovery following an inpatient psychiatric discharge.
49.45(29r)(c)
(c) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot projects under par.
(b) beginning no earlier than January 1, 2016.
49.45(29r)(d)
(d) Subject to par.
(c), the department shall allocate a total state share amount of $600,000 plus any federal matching moneys as funding for all 3-year pilot projects under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot projects under this subsection.
49.45(29u)
(29u)
Psychiatric consultation reimbursement pilot project. 49.45(29u)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29u)(b)
(b) Subject to par.
(e), the department shall develop and award a pilot project lasting up to 3 years to test a new Medical Assistance payment model for adult recipients of Medical Assistance that is designed to encourage the provision of psychiatric consultations by psychiatrists to health care providers treating primary care issues and to selected specialty health care providers to help those providers manage and treat adults with mild to moderate mental illness and physical health needs. An applicant for the pilot project under this subsection shall submit a strategy to use the pilot project funding to improve mental health access in the applicant's service area and to reduce overall Medical Assistance costs. The department shall require the health care provider that is awarded the pilot project to submit to the department interim and final reports analyzing the differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports.
49.45(29u)(c)
(c) The department shall award a pilot project only to a health care provider that is an organization that provides outpatient psychiatric services and primary and specialty care outpatient services for physical health conditions. The department shall allocate funding to the health care provider that is awarded a pilot project or to individual psychiatrists providing care within the organization of the health care provider that is awarded a pilot project. The department shall allocate a total state share amount of $200,000 plus any federal matching moneys as funding for the 3-year pilot project under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot project under this subsection.
49.45(29u)(d)
(d) The department may limit a pilot project awarded to a health care provider described under par.
(c) to specific providers or clinics within the multispecialty outpatient clinic organization.
49.45(29u)(e)
(e) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot project under par.
(b) beginning no earlier than January 1, 2016.
49.45(29w)
(29w)
Mental health services. In providing mental health benefits under this subchapter, the department shall do all of the following:
49.45(29w)(a)
(a) Allow a severely emotionally disturbed child, as defined in sub.
(25) (a), to access in-home therapy without having to show a failure to succeed in outpatient therapy.
49.45(29w)(b)
(b) Allow qualifying families to participate in in-home therapy even if a child in that family is enrolled in a day treatment program.
49.45(29x)
(29x)
Emergency detention transport reimbursement. 49.45(29x)(a)(a) Subject to par.
(b), the department shall provide reimbursement as provided under s.
49.46 (2) (b) 3. to counties for transport of individuals who are recipients of medical assistance for purposes of emergency detention under s.
51.15 (2) as provided under s.
51.15 (2) (e). The department shall establish criteria that any 3rd-party vendor that is not a law enforcement agency or ambulance service provider must meet in order for the county to obtain reimbursement for transport provided by that 3rd-party vendor under the Medical Assistance program.
49.45(29x)(b)
(b) The department shall request any necessary federal approval required to provide reimbursement under par.
(a), and, if approval is granted or if no federal approval is required, the department shall provide reimbursement as provided under par.
(a). If federal approval is necessary but not granted, the department may not provide reimbursement under par.
(a).
49.45(29y)
(29y)
Mental health consultation reimbursement. 49.45(29y)(a)1m.
1m. “Clinical consultation" means, for a student up to age 21, communication from a mental health professional or a qualified treatment trainee working under the supervision of a mental health professional to another individual who is working with the client or to a parent of the student to inform, inquire, and instruct regarding all of the following and to direct and coordinate clinical service components:
49.45(29y)(a)1m.b.
b. Strategies for effective engagement, care, and intervention for the client.
49.45(29y)(b)
(b) The department shall, subject to any approval necessary from the federal department of health and human services, reimburse clinical consultation from the Medical Assistance program under this subchapter.
49.45(29z)
(29z)
Buprenorphine prior authorization review. The department shall review its prior authorization policy on buprenorphine-containing products provided to Medical Assistance program recipients. On November 1, 2018, and every 6 months thereafter, the department shall submit to the standing committees of the legislature with jurisdiction over health under s.
13.172 (3) a report describing the department's findings on the prior authorization policy on buprenorphine-containing products and its progress on eliminating prior authorization requirements for buprenorphine-containing products in populations where removal of prior authorization is appropriate. The department is not required to submit the report under this subsection after the date the prior authorization requirement for use of buprenorphine-containing products by Medical Assistance program recipients is eliminated for all appropriate populations.
49.45(30)
(30)
Services provided by community support programs. 49.45(30)(b)
(b) The department shall reimburse a provider of services under s.
49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.
49.45(30c)
(30c)
Licensed treatment professionals. To the extent allowable by the federal department of health and human services, the department shall certify and reimburse under the Medical Assistance program under this subchapter licensed treatment professionals, as defined in s.
51.03 (6) (a), for mental health services provided at a school regardless of whether the school site is designated as a clinic office and regardless of whether the licensed treatment professional is employed by, a contractor of, or affiliated with a clinic. The department shall seek any approval necessary from the federal department of health and human services to provide reimbursement to licensed treatment professionals under this subsection.
49.45(30e)
(30e)
Community-based psychosocial service programs. 49.45(30e)(a)(a)
When services are reimbursable. Services under s.
49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
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 psychologists 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(30j)
(30j)
Reimbursement for peer recovery coach services. 49.45(30j)(a)1.
1. “Competent mental health professional” means a physician who has completed a residence in psychiatry; a psychologist; a private practice school psychologist licensed under ch.
455; a marriage and family therapist licensed under s.
457.10 or
457.11; a professional counselor licensed under s.
457.12 or
457.13; an advanced practice social worker granted a certificate under s.
457.08 (2); an independent social worker granted a certificate under s.
457.08 (3); a clinical social worker licensed under s.
457.08 (4); a clinical substance abuse counselor or independent clinical supervisor certified under s.
440.88, or any of these individuals practicing under a currently valid training or temporary license or certificate granted under applicable provisions of ch.
457. “Competent mental health professional" does not include an individual whose license or certificate is suspended, revoked, or voluntarily surrendered, or whose license or certificate is limited or restricted, when practicing in areas prohibited by the limitation or restriction.
49.45(30j)(a)2.
2. “Peer recovery coach” means an individual who practices in the recovery field and who provides support and assistance to individuals who are in treatment or recovery from mental illness or a substance use disorder.
49.45(30j)(b)
(b) The department shall reimburse under the Medical Assistance program under this subchapter any service provided by a peer recovery coach if the service satisfies all of the following conditions:
49.45(30j)(b)1.
1. The recipient of the service provided by a peer recovery coach is in treatment for or recovery from mental illness or a substance use disorder.
49.45(30j)(b)2.
2. The peer recovery coach provides the service under the supervision of a competent mental health professional who has been trained in all of the following subjects:
49.45(30j)(b)2.a.
a. Understanding the peer role in recovery and supporting clear and meaningful peer roles.
