Chapter 49

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) (39) School medical services.

49.45(39)(a) (a) Definitions. In this subsection:

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) (b) School medical services.

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) Crisis intervention services.

49.45(41)(a) (a) In this subsection, “crisis intervention services” means crisis intervention services for the treatment of mental illness, intellectual disability, substance abuse, and dementia that are provided by any of the following:

49.45(41)(a)1. 1. A crisis urgent care and observation facility certified under s. 51.036.

49.45(41)(a)2. 2. A 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 crisis intervention services under par. (a) 2., the county may provide 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(41)(c) (c) Notwithstanding par. (b), if a county elects, pursuant to par. (a) 2., to deliver crisis intervention services under the Medical Assistance program on a regional basis according to criteria established by the department, all of the following apply:

49.45(41)(c)1. 1. After January 1, 2020, the department shall require the county to annually contribute for the crisis intervention services an amount equal to 75 percent of the annual average of the county’s expenditures for crisis intervention services under this subsection as determined by the department.

49.45(41)(c)2. 2. The department shall reimburse the provider of crisis intervention services in the county the amount of allowable charges for those services under the Medical Assistance program, including both the federal share and nonfederal share of those charges, that exceeds the amount of the county contribution required under subd. 1.

49.45(41)(c)3. 3. If a county submits a certified cost report under sub. (52) (b) to claim federal medical assistance funds, the claim based on certified costs made by a county for amounts under subd. 2. cannot include any part of the nonfederal share of the amount under subd. 2.

49.45(41)(d) (d) The department shall, in accordance with all procedures set forth under s. 20.940, request a waiver under 42 USC 1315 or submit a Medical Assistance state plan amendment to the federal department of health and human services to obtain any necessary federal approval required to provide reimbursement to crisis urgent care and observation facilities certified under s. 51.036 for crisis intervention services under this subsection. If the department determines submission of a state plan amendment is appropriate, the department shall, notwithstanding whether the expected fiscal effect of the amendment is $7,500,000 or more, submit the amendment to the joint committee on finance for review in accordance with the procedures under sub. (2t). If federal approval is granted or no federal approval is required, the department shall provide reimbursement under s. 49.46 (2) (b) 15. If federal approval is necessary but is not granted, the department may not provide reimbursement for crisis intervention services provided by crisis urgent care and observation facilities.

49.45(42) (42) Personal care services.

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.

49.45(42)(d)2. 2. The individual is not eligible to receive home health services under medicare, as defined in sub. (3) (L) 1. b.

49.45(42)(d)3. 3. The provider of the personal care services is one of the following:

49.45(42)(d)3.a. a. An independent living center meeting the criteria to receive a grant under s. 46.96.

49.45(42)(d)3.b. b. A county department under s. 46.215, 46.22, 46.23, 51.42, or 51.437.

49.45(42)(d)3.c. c. A federally recognized American Indian tribe or band certified to provide services to medical assistance beneficiaries.

49.45(42)(d)3.d. d. A home health agency licensed under s. 50.49.

49.45(42)(d)3.e. e. Any other entity certified under sub. (2) (a) 11. to provide personal care services under s. 49.46 (2) (b) 6. j.

49.45(42m) (42m) Physical and occupational therapy.

49.45(42m)(a) (a) If, in authorizing the provision of physical or occupational therapy services under s. 49.46 (2) (b) 6. b. or 49.471 (11) (i), the department authorizes a reduced duration of services from the duration that the provider specifies in the authorization request, the department shall substantiate the reduction that the department made in the duration of the services if the provider of the services requests any additional authorizations for the provision of physical or occupational therapy services to the same individual.

49.45(42m)(b) (b) The division of the department that is responsible for health care financing shall monitor compliance with the requirement under par. (a) in concert with representatives of the Wisconsin Physical Therapy Association and the Wisconsin Occupational Therapy Association.

49.45(43) (43) Case management services for high-cost recipients. The department may establish a program to provide case management services for medical assistance recipients with high-cost chronic health conditions or high-cost catastrophic health conditions. If the department establishes a program to provide these case management services, the department shall provide reimbursement for providers of these case management services under the medical assistance program.

49.45(44) (44) Prenatal, postpartum and young child care coordination. Providers in Milwaukee County that are certified to provide care coordination services under s. 49.46 (2) (b) 12. may be certified to provide to medical assistance recipients prenatal and postpartum care coordination services and care coordination services for children who have not attained the age of 7. Providers in the city of Racine that are certified to provide care coordination services under s. 49.46 (2) (b) 12. and are participating in a program under s. 253.16 may be certified to provide to medical assistance recipients prenatal and postpartum care coordination services and care coordination services for children who have not attained the age of 2. A provider of those care coordination services shall provide to a person receiving those services the information relating to shaken baby syndrome and impacted babies required under s. 253.15 (6). The department shall provide reimbursement for those care coordination services only if at least one of the following conditions is met:

49.45(44)(a) (a) The recipient is a resident of Milwaukee County or the city of Racine and has received services under s. 49.46 (2) (b) 12. and is pregnant or has given birth within 8 weeks after the individual ceased to receive services under s. 49.46 (2) (b) 12.

49.45(44)(b) (b) The recipient is a resident of Milwaukee County or the city of Racine, is pregnant and has received a risk assessment approved by the department.

49.45(44)(c) (c) The recipient is a resident of Milwaukee County or the city of Racine, has given birth within the 8 weeks immediately preceding the request for services under s. 49.46 (2) (b) 12m. and has received a risk assessment approved by the department.

49.45(44m) (44m) Extension of parent eligibility when child dies. The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to extend the eligibility of a parent, for up to 90 days, under the Medical Assistance program under this subchapter or the Badger Care health care program under s. 49.665 if the parent’s child dies while both the parent and the child are covered under the Medical Assistance program or the Badger Care health care program and the parent would lose eligibility solely due to the death of the child. The department shall implement any waiver that is granted.

49.45(45) (45) In-home and community mental health and alcohol and other drug abuse services.

49.45(45)(a) (a) Services under s. 49.46 (2) (b) 6. fm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:

49.45(45)(a)1. 1. Reimbursement for the services under s. 49.46 (2) (b) 6. fm. 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(45)(a)2. 2. The county, city, town or village in which the individual resides elects to make the services under s. 49.46 (2) (b) 6. fm. available in the county, city, town or village through the medical assistance program.

49.45(45)(b) (b) A county, city, town or village that elects to make the services under s. 49.46 (2) (b) 6. fm. 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(47) (47) Adult day care centers.

49.45(47)(a) (a) In this subsection, “adult day care center” means an entity that provides services for part of a day in a group setting to adults who need an enriched health-supportive or social experience and who may need assistance with activities of daily living, supervision or protection.

49.45(47)(b) (b) No person may receive reimbursement for the provision of services to clients in an adult day care center unless the adult day care center is certified by the department under sub. (2) (a) 11. as a provider of medical assistance.

49.45(47)(c) (c) The biennial fee for the certification required under par. (b) of an adult day care center is $127. Fees collected under this paragraph shall be credited to the appropriation account under s. 20.435 (6) (jm).

49.45(47)(d) (d) The department, by rule, may increase any fee specified in par. (c).

49.45(47)(dm) (dm) Every 24 months, on a schedule determined by the department, an adult day care center shall submit through an online system prescribed by the department a report in the form and containing the information that the department requires, including payment of any fee due under par. (c). If a complete report is not timely filed, the department shall issue a warning to the operator of the adult day care center. The department may revoke an adult day care center’s certification for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department.

49.45(47)(e) (e) If the department takes enforcement action against an adult day care center for violating a certification requirement established under sub. (2) (a) 11., and the department subsequently conducts an on-site inspection of the adult day care center to review the adult day care center’s action to correct the violation, the department may impose a $200 inspection fee on the adult day care center.

49.45(47m) (47m) Family Care funding.

49.45(47m)(a) (a) In this subsection, “care management organization” means a care management organization under contract with the department of health services as described under s. 46.284.

49.45(47m)(b) (b) The department shall collaborate with care management organizations and the federal centers for Medicare and Medicaid services to develop an allowable payment mechanism to increase the direct care and services portion of the capitation rates to address the direct caregiver workforce challenges in the state.

49.45(47m)(d) (d) The department may not implement the plan developed under this subsection unless the department receives federal approval. The department may supplement the appropriation under s. 20.435 (4) (b) from the appropriation under s. 20.865 (4) (a) for implementation of the payment mechanism under par. (b). The department may only use moneys for the payment mechanism under par. (b). Notwithstanding s. 13.101, the joint committee on finance is not required before making a supplementation under this paragraph.

49.45(48) (48) Payment of medicare part B outpatient hospital services coinsurances. The department shall include in the state plan for medical assistance a methodology for payment of the medicare part B outpatient hospital services coinsurance amounts that are authorized under ss. 49.46 (2) (c) 2., 4., and 5m., 49.468 (1) (b), 49.47 (6) (a) 6. b., d., and f., and 49.471 (6) (j) 1.

49.45(49) (49) Prescription drug prior authorization.

49.45(49)(a) (a) The secretary shall exercise his or her authority under s. 15.04 (1) (c) to create a prescription drug prior authorization committee to advise the department on issues related to prior authorization decisions made concerning prescription drugs on behalf of medical assistance recipients. The secretary shall appoint as members at least all of the following:

49.45(49)(a)1. 1. Two physicians, as defined in s. 448.01 (5), who are currently in practice.

49.45(49)(a)2. 2. Two pharmacists, as defined in s. 450.01 (15).

49.45(49)(a)3. 3. One advocate for recipients of medical assistance who has sufficient medical background, as determined by the department, to evaluate a prescription drug’s clinical effectiveness.

49.45(49)(b) (b) The prescription drug prior authorization committee shall accept information or commentary from representatives of the pharmaceutical manufacturing industry in the committee’s review of prior authorization policies.

49.45(49g) (49g) Billing for prescription drugs.

49.45(49g)(a) (a) In this subsection:

49.45(49g)(a)1d. 1d. “Abortion” has the meaning given in s. 253.10 (2) (a).

49.45(49g)(a)1g. 1g. “Abortion provider” means a person that provides abortion services or is an affiliate of a person that provides abortion services.

49.45(49g)(a)1m. 1m. “Covered entity” has the meaning given in 42 USC 256b (a) (4) (C) and (K).

49.45(49g)(a)2. 2. “Prescription drug” has the meaning given in s. 450.01 (20).

49.45(49g)(b) (b) When billing the Medical Assistance program under this subchapter for reimbursement for a prescription drug, a covered entity that is an abortion provider shall bill the actual acquisition cost of the prescription drug for which coverage is provided under s. 49.46 (2) (b) 6. h. and a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h.

49.45(49m) (49m) Prescription drug cost controls; purchasing agreements.

49.45(49m)(a) (a) In this section:

49.45(49m)(a)1. 1. “Brand name” has the meaning given in s. 450.12 (1) (a).

49.45(49m)(a)2. 2. “Generic name” has the meaning given in s. 450.12 (1) (b).

49.45(49m)(a)3. 3. “Prescription drug” has the meaning given in s. 450.01 (20).

49.45(49m)(b) (b) The department may enter into a multi-state purchasing agreement with another state or a purchasing agreement with a purchaser of prescription drugs if the other state or purchaser agrees to participate in one or more of the activities specified in par. (c) 1. to 4.

49.45(49m)(c) (c) The department may design and implement a program to reduce the cost of prescription drugs and to maintain high quality in prescription drug therapies, which shall include all of the following:

49.45(49m)(c)1. 1. A list of the prescription drugs that are included as a benefit under ss. 49.46 (2) (b) 6. h. and 49.471 (11) (a) that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.