Chapter 49

49.45(23b)(b)5. 5. Disenroll from Medical Assistance under sub. (23) for 6 months any individual who does not pay a required premium under subd. 2. and any individual who is required under subd. 1. to participate in a community engagement activity but who does not participate for 48 aggregate months in the community engagement activity.

49.45(23b)(c) (c)

49.45(23b)(c)1. 1. Persons who are eligible for the demonstration project under sub. (23) and who have monthly household income that exceeds 50 percent of the poverty line shall pay a monthly premium amount of $8 per household. A person who is eligible to receive an item or service furnished by an Indian health care provider is exempt from the premium requirement under this subdivision.

49.45(23b)(c)2. 2. The department may disenroll under par. (b) 5. a person for nonpayment of a required monthly premium only at annual eligibility redetermination after providing notice and reasonable opportunity for the person to pay. If a person who is disenrolled for nonpayment of premiums pays all owed premiums or becomes exempt from payment of premiums, he or she may reenroll in Medical Assistance under sub. (23).

49.45(23b)(c)3. 3. The department shall reduce the amount of the required household premium by up to half for a recipient of Medical Assistance under sub. (23) who does not engage in certain behaviors that increase health risks or who attests to actively managing certain unhealthy behaviors.

49.45(23b)(d) (d) The department shall comply with any other requirements not specified elsewhere in this subsection that are imposed by the federal department of health and human services in its approval effective October 31, 2018.

49.45(23b)(e) (e) Before December 31, 2023, the demonstration project requirements under this subsection may not be withdrawn and the department may not request from the federal government withdrawal, suspension, or termination of the demonstration project requirements under this subsection unless legislation has been enacted specifically allowing for the withdrawal, suspension, or termination.

49.45(23b)(f) (f) The department shall comply with all applicable timing in and requirements of s. 20.940.

49.45(24) (24) Primary care provider pilot. The department may request a waiver from the secretary of the federal department of health and human services under 42 USC 1396n (b) (1) to permit the establishment of a primary care provider pilot project. If the waiver is granted, the department may establish a primary care provider pilot project under which primary care providers act as case managers for medical assistance beneficiaries. If the department establishes a primary care provider pilot project, it shall reimburse a case manager for the allowable charges for case management services provided to a beneficiary participating in the pilot project.

49.45(24g) (24g) Physician practice payment pilot.

49.45(24g)(a) (a) The department shall develop a proposal to increase medical assistance reimbursement to providers to which at least one of the following applies:

49.45(24g)(a)1. 1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.

49.45(24g)(a)2. 2. The secretary determines that the provider performs well with respect to all of the following aspects of care:

49.45(24g)(a)2.a. a. Adoption of written standards for patient access and patient communication.

49.45(24g)(a)2.b. b. Use of data to show that standards for patient access and patient communication are satisfied.

49.45(24g)(a)2.c. c. Use of paper or electronic charting tools to organize clinical information.

49.45(24g)(a)2.d. d. Use of data to identify diagnoses and conditions among the provider’s patients that have a lasting detrimental effect on health.

49.45(24g)(a)2.e. e. Adoption and implementation of guidelines that are based on evidence for treatment and management of at least 3 chronic conditions.

49.45(24g)(a)2.f. f. Active support of patient self-management.

49.45(24g)(a)2.g. g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.

49.45(24g)(a)2.h. h. Systematic tracking of referrals using a paper or electronic system.

49.45(24g)(a)2.i. i. Measuring the quality of the performance of the physician practice and of individual physicians within the practice, including with respect to provision of clinical services, patient outcomes, and patient safety.

49.45(24g)(a)2.j. j. Reporting to members of the physician practice and to other persons on the quality of the performance of the physician practice and of individual physicians.

49.45(24g)(c) (c) The department’s proposal under par. (a) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or 2., and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than July 1, 2011.

49.45(24g)(d) (d) The department shall submit the proposal under par. (a) to the joint committee on finance. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department’s submittal that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal beginning January 1, 2010. If, within 14 working days after the date of the department’s submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department may implement the proposal only upon approval of the committee. If the committee reviews the proposal and approves it, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal beginning January 1, 2010.

49.45(24g)(e) (e) By October 1, 2012, the department shall, if it was required under par. (d) to increase reimbursement to providers that satisfy a condition under par. (a) 1. or 2., submit a report to the joint committee on finance on whether the increased reimbursement results in net cost reductions for the Medical Assistance program under this subchapter and a recommendation as to whether to continue the increased reimbursement. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department’s submittal that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may implement its recommendation. If, within 14 working days after the date of the department’s submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may discontinue the increased reimbursement only upon the approval of the committee.

49.45(24j) (24j) Medical home pilot projects.

49.45(24j)(a) (a) The department may administer the medical home initiative as a service delivery mechanism to provide and coordinate care for individuals who are eligible for a Medical Assistance program under this subchapter that provides services under a fee-for-service model. The department may administer a medical home initiative to serve individuals who are members of any of the following populations:

49.45(24j)(a)1. 1. Children who are in out-of-home care or are receiving adoption assistance under 42 USC 670 to 679c.

49.45(24j)(a)2. 2. Pregnant women.

49.45(24j)(a)3. 3. Individuals who are exiting mental health facilities or correctional facilities.

49.45(24j)(a)4. 4. Individuals with a diagnosis of serious mental illness or substance abuse disorder.

49.45(24j)(a)5. 5. Adults with two or more chronic medical conditions.

49.45(24j)(a)6. 6. Other groups of individuals with conditions that the department determines would benefit from services through a medical home.

49.45(24j)(b) (b) The department shall provide to individuals through any medical home initiative administered under this subsection the benefits described under s. 49.46 (2) (a) and (b). The department may provide to individuals though any medical home initiative administered under this subsection benefits in addition to the standard plan benefits that are targeted to the population receiving services through the medical home.

49.45(24j)(c) (c) The department may elect to administer any medical home initiative under this subsection in a limited geographical area.

49.45(24j)(d) (d) The department may make an all-inclusive payment to the provider offering services through a medical home.

49.45(24j)(e) (e) If the federal department of health and human services approves the department’s request to administer a medical home initiative, the department shall automatically enroll an individual who is eligible for a medical home initiative under this subsection in the medical home initiative. At any time after the first 6 months of enrollment in the medical home initiative, the individual who is enrolled in the medical home initiative may opt out of participation in the medical home initiative.

49.45(24k) (24k) Dental reimbursement pilot project.

49.45(24k)(a) (a)

49.45(24k)(a)1. 1. Subject to approval of the federal department of health and human services under par. (b), the department, as a pilot project, shall distribute moneys allocated in each fiscal year for the purpose of increasing the reimbursement rate under Medical Assistance for pediatric dental care and adult emergency dental services, as defined by the department, that are provided in Brown, Marathon, Polk, and Racine counties. If, after increasing the reimbursement rate for counties specified in this subdivision, the moneys allocated for this purpose exceed $100,000, the department shall increase the reimbursement rate under Medical Assistance for pediatric dental care and adult emergency dental services in other counties, as determined by the department, where Medical Assistance recipients have the greatest need for pediatric dental care and adult emergency dental services.

49.45(24k)(a)2. 2. For dental services provided on a fee-for-service basis as of July 1, 2015, the reimbursement rate increase specified in subd. 1. shall be distributed on a fee-for-service basis. For dental services provided as of July 1, 2015, by a health maintenance organization that contracts with the department to provide Medical Assistance services at a capitated rate, the department shall distribute the reimbursement rate increase under subd. 1. to the health maintenance organization. The department shall include in a contract with a health maintenance organization that provides dental services described in subd. 1. in the counties specified in subd. 1. a requirement that the health maintenance organization reimburse providers of services in accordance with the reimbursement rate increase pilot project under subd. 1. The department may not distribute the reimbursement rate increase under subd. 1. to federally qualified health centers that receive a grant under 42 USC 254b.

49.45(24k)(b) (b) The department shall request any waiver from and submit any amendments to the state Medical Assistance plan to the federal department of health and human services necessary for the reimbursement rate increase pilot project under par. (a). If any necessary waiver request or state plan amendment request is approved, the department shall implement par. (a) beginning on the effective date of the waiver or plan amendment.

49.45(24k)(c) (c) No later than January 1, 2020, and biennially thereafter, the department shall submit a report to the chief clerk of each house of the legislature under s. 13.172 (2), each standing committee of the legislature with jurisdiction over health or public benefits under s. 13.172 (3), and the joint committee on finance that includes all of the following information on the pilot project under this subsection:

49.45(24k)(c)1. 1. The number of Medical Assistance recipients who received services under the pilot program in total and specified by those who received pediatric care and who received adult emergency dental services.

49.45(24k)(c)2. 2. An estimate of the potential reduction in health care costs and emergency department use by Medical Assistance recipients due to the pilot project.

49.45(24k)(c)3. 3. The feasibility of continuing the pilot project and expanding the project in specific areas of the state or statewide.

49.45(24k)(c)4. 4. The amount of moneys distributed under the pilot project and, if moneys allocated for the pilot project were not distributed, a summary on why the moneys were not distributed.

49.45(24k)(c)5. 5. An analysis of Medical Assistance recipient populations who received services under the pilot project and populations who may benefit from the pilot project.

49.45(24m) (24m) Home health care and personal care pilot program. From the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), in order to test the feasibility of instituting a system of reimbursement for providers of home health care and personal care services for medical assistance recipients that is based on competitive bidding, the department shall:

49.45(24m)(a) (a) By September 1, 1990, select a county in this state and solicit bids from providers of home health care and personal care services in that county for the provision, on a contractual basis, of home health and personal care services authorized under ss. 49.46 (2) (a) 4. d. and (b) 6. j. and 49.47 (6) (a) 1.

49.45(24m)(b) (b) Award contracts for the provision of home health care and personal care services from the bids received under par. (a) only if the department determines that the contracts would result in a lower cost alternative to fee-for-service reimbursement.

49.45(24n) (24n) Reimbursement for dental services by facilities serving individuals with disabilities.

49.45(24n)(a) (a) Subject to approval of the federal department of health and human services under par. (b), the department shall distribute moneys in each fiscal year to increase the Medical Assistance reimbursement rates for all eligible dental services rendered by facilities that provide at least 90 percent of their dental services to individuals with cognitive and physical disabilities, as determined by the department. Under this subsection, the enhanced reimbursement rates for dental services would equal 200 percent of the Medical Assistance reimbursement rates that would otherwise be paid for these dental services.

49.45(24n)(b) (b) The department shall request any waiver from and submit any amendments to the state Medical Assistance plan to the federal department of health and human services necessary for the Medical Assistance reimbursement rate increase under par. (a). If any necessary waiver request or state plan amendment request is approved, the department shall implement par. (a) beginning on the effective date of the waiver or plan amendment.

49.45(24s) (24s) Family planning project.

49.45(24s)(a) (a) The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to provide optional services for family planning, as defined in s. 253.07 (1) (a), under medical assistance [to any female between the ages of 15 and 44 whose family income does not exceed 200 percent of the poverty line for a family the size of the female’s family]. The department shall implement any waiver granted.

Effective date note NOTE: Par. (a) was created by 2011 Wis. Act 32, section 1441b, eff. 7-1-11 and amended by 2011 Wis Act 32, section 1441bg, eff. 1-1-15. Although the language in brackets was removed from the creation of par. (a) in section 1441b by the governor’s partial veto, the amendment by section 1441bg of par. (a) does not reflect the removal of that language.

49.45(24s)(b) (b) The department shall request a waiver, or an amendment to the waiver requested under par. (a), from the secretary of the federal department of health and human services to require all of the following:

49.45(24s)(b)1. 1. As a condition of receiving services under par. (a), parental notification for family planning services for any female under 18 years of age.

49.45(24s)(b)2. 2. The department to determine eligibility to receive family planning services under par. (a) for a female under 18 years of age using the family income of the female’s parent or guardian instead of only the female’s income.

49.45(25) (25) Case management services.

49.45(25)(a) (a) In this subsection, “severely emotionally disturbed child” means an individual under 21 years of age who has emotional and behavioral problems that:

49.45(25)(a)1. 1. Are severe in degree;

49.45(25)(a)2. 2. Are expected to persist for at least one year;

49.45(25)(a)3. 3. Substantially interfere with the individual’s functioning in his or her family, school or community and with his or her ability to cope with the ordinary demands of life; and

49.45(25)(a)4. 4. Cause the individual to need services from 2 or more agencies or organizations that provide social services or services or treatment for mental health, juvenile justice, child welfare, special education or health.

49.45(25)(am) (am) Except as provided under pars. (be), (bg), and (bj) and sub. (24), case management services under s. 49.46 (2) (b) 9. and (bm) are reimbursable under Medical Assistance only if provided to a Medical Assistance beneficiary who receives case management services from or through a certified case management provider in a county, city, village, or town that elects, under par. (b), to make the services available and who meets at least one of the following conditions:

49.45(25)(am)1. 1. Has a developmental disability, as defined under s. 51.01 (5) (a).

49.45(25)(am)2. 2. Has a serious and persistent mental illness.

49.45(25)(am)3. 3. Has Alzheimer’s disease, as defined under s. 46.87 (1) (a).

49.45(25)(am)4. 4. Is an alcoholic, as defined under s. 51.01 (1h).

49.45(25)(am)5. 5. Is drug dependent, as defined under s. 51.01 (8b).

49.45(25)(am)6. 6. Is physically disabled, as defined by the department.

49.45(25)(am)7. 7. Is a severely emotionally disturbed child.

49.45(25)(am)8. 8. Is age 65 or over.

49.45(25)(am)9. 9. Is a member of a family that has a child who is at risk of serious physical, mental or emotional dysfunction, as defined by the department.

49.45(25)(am)10. 10. Has HIV infection, as defined in s. 252.01 (2).

49.45(25)(am)11. 11. Is a child who is eligible for early intervention services under s. 51.44.

49.45(25)(am)12. 12. Is infected with tuberculosis.

49.45(25)(am)13. 13. Is a child with asthma.

49.45(25)(am)14. 14. Is a woman who is aged 45 to 64 and who is not a resident of a nursing home or otherwise receiving case management services under this paragraph.

49.45(25)(b) (b) A county, city, village, town or, in a county having a population of 750,000 or more, the department may elect to make case management services under this subsection available in the county, city, village or town to one or more of the categories of beneficiaries under par. (am) through the medical assistance program. A county, city, village, town or, in a county having a population of 750,000 or more, the department that elects to make the services available shall reimburse a case management provider for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government.

49.45(25)(be) (be) A private nonprofit agency that is a certified case management provider may elect to provide case management services to medical assistance beneficiaries who have HIV infection, as defined in s. 252.01 (2). The amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.435 (1) (am).

49.45(25)(bg) (bg) An independent living center, as defined in s. 46.96 (1) (ah), that is a certified case management provider and satisfies the criteria in s. 46.96 (3m) (a) 1. to 3. and (am) may elect to provide case management services to one or more of the categories of medical assistance beneficiaries specified under par. (am). The amount of allowable charges for the services under the medical assistance program that is not provided by the federal government shall be paid from nonfederal, public funds received by the independent living center from a county, city, village or town or from funds distributed as a grant under s. 46.96.

49.45(25)(bj) (bj) The department of corrections may elect to provide case management services under this subsection to persons who are under the supervision of that department under s. 938.183, 938.34 (4h), or 938.357 (3) or (4), who are Medical Assistance beneficiaries, and who meet one or more of the conditions specified in par. (am). The amount of the allowable charges for those services under the Medical Assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.410 (3) (hm), (ho), or (hr).

49.45(25)(bm) (bm) Case management services under this subsection may not be provided to a person under par. (am) 7. unless any of the following is true:

49.45(25)(bm)1. 1. A team of mental health experts appointed by the case management provider determines that the person is a severely emotionally disturbed child. The team shall consist of at least 3 members. The case management provider shall appoint at least one member of the team who is a licensed psychologist or a physician specializing in psychiatry. The case management provider shall appoint at least 2 members of the team who are members of the professions of school psychologist, school social worker, registered nurse, social worker, child care worker, occupational therapist or teacher of emotionally disturbed children. The case management provider shall appoint as a member of the team at least one person who personally participated in a psychological evaluation of the child.

49.45(25)(bm)2. 2. Individuals who are designated by the coordinating committee have, or a service coordination agency has, determined under s. 46.56 (8) (d) that the person is a child, as defined in s. 46.56 (1) (bm), with emotional and behavioral disabilities.