Chapter 49

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.

49.45(49m)(c)2. 2. Establishing supplemental rebates under agreements with prescription drug manufacturers for prescription drugs provided to recipients under Medical Assistance and Badger Care and to eligible persons under s. 49.688 and, if it is possible to implement the program without adversely affecting supplemental rebates for Medical Assistance, Badger Care, and prescription drug assistance under s. 49.688, to beneficiaries of participants under par. (b).

49.45(49m)(c)3. 3. Utilization management and fraud and abuse controls.

49.45(49m)(c)4. 4. Any other activity to reduce the cost of or expenditures for prescription drugs and maintain high quality in prescription drug therapies.

49.45(49m)(d) (d) The department may enter into a contract with an entity to perform any of the duties and exercise any of the powers of the department under this subsection.

49.45(49r) (49r) Value-based purchasing.

49.45(49r)(a) (a) In this subsection, “manufacturer” has the meaning given in s. 450.01 (12).

49.45(49r)(b) (b) Subject to par. (e), the department may enter into a value-based purchasing arrangement for the Medical Assistance program by written agreement with a manufacturer based on agreed upon metrics to which the department and the manufacturer agree in writing. A value-based purchasing arrangement under this paragraph may include any of the following:

49.45(49r)(b)1. 1. Rebates.

49.45(49r)(b)2. 2. Discounts.

49.45(49r)(b)3. 3. Price reductions.

49.45(49r)(b)4. 4. Risk sharing.

49.45(49r)(b)5. 5. Reimbursements.

49.45(49r)(b)6. 6. Payment deferrals or installment payments.

49.45(49r)(b)7. 7. Guarantees.

49.45(49r)(b)8. 8. Shared savings payments.

49.45(49r)(b)9. 9. Withholds.

49.45(49r)(b)10. 10. Bonuses.

49.45(49r)(b)11. 11. Any other thing of value.

49.45(49r)(c) (c) Nothing in this subsection may be interpreted to require a manufacturer or the department to enter into an arrangement described under par. (b).

49.45(49r)(d) (d) Nothing in this subsection may be construed to alter or modify coverage requirements under the Medical Assistance program.

49.45(49r)(e) (e) If the department determines it is unable to implement this subsection without a waiver of federal law, state plan amendment, or other federal approval, the department shall request from the secretary of the federal department of health and human services any waiver of federal law, state plan amendment, or other federal approval necessary to implement this subsection. If the federal department of health and human services does not approve a waiver of federal law, state plan amendment, or other federal approval under this paragraph, the department is not required to implement this subsection.

49.45(50) (50) Disease management.

49.45(50)(a) (a) In this subsection, “disease management” means an integrated and systematic approach for managing the health care needs of patients who are at risk of or are diagnosed with a specific disease, using all of the following:

49.45(50)(a)1. 1. Best practices.

49.45(50)(a)2. 2. Prevention strategies.

49.45(50)(a)3. 3. Clinical practice improvement.

49.45(50)(a)4. 4. Clinical interventions and protocols.

49.45(50)(a)5. 5. Outcomes research, information, and technology.

49.45(50)(a)6. 6. Other tools and resources to reduce overall costs and improve measurable outcomes.

49.45(50)(b) (b) The department may contract with an entity, under the department’s request-for-proposal procedures, to engage in disease management activities on behalf of recipients of medical assistance.

49.45(52) (52) Payment adjustments; federal funding for certain services.

49.45(52)(a) (a)

49.45(52)(a)1. 1. If the department provides the notice under par. (c) selecting the payment procedure in this paragraph, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payment adjustments to county departments under s. 46.215, 46.22, 46.23, 51.42, or 51.437 or to local health departments, as defined in s. 250.01 (4), as appropriate, for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16., except for services specified under s. 49.46 (2) (b) 6. b. and c. provided to children participating in the early intervention program under s. 51.44. Payment adjustments under this paragraph shall include the state share of the payments. The total of any payment adjustments under this paragraph and Medical Assistance payments made from appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), may not exceed applicable limitations on payments under 42 USC 1396a (a) (30) (A).

49.45(52)(a)2. 2. The department may require a county department or local health department to submit a certified cost report that meets the requirements of the federal department of health and human services for covered services described in subd. 1.

49.45(52)(b) (b) If the department provides the notice under par. (c) selecting the payment procedure in this paragraph, all of the following apply:

49.45(52)(b)1. 1. Annually, a county department under s. 46.215, 46.22, 46.23, 51.42, or 51.437 shall submit a certified cost report that meets the requirements of the federal department of health and human services for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16., except for services specified under s. 49.46 (2) (b) 6. b. and c. provided to children participating in the early intervention program under s. 51.44.

49.45(52)(b)2. 2. For services described under subd. 1., the department shall base the amount of a claim for federal medical assistance funds on certified cost reports submitted by county departments under subd. 1. to the extent the reports comply with federal requirements.

49.45(52)(b)3. 3. The department shall pay county departments a percentage of the federal funds claimed under subd. 2. for services described under subd. 1., which percentage is established in the most recent biennial budget.

49.45(52)(b)4. 4. The department may pay a local health department, as defined in s. 250.01 (4), that submits certified cost reports for services described under subd. 1. a percentage of the federal funds claimed for those services, which percentage is established in the most recent biennial budget.

49.45(52)(c) (c) The department shall select a payment procedure under either par. (a) or (b) and may change which procedure under par. (a) or (b) is selected. The department shall notify each county department and local health department, as applicable, of the selected payment procedure before the date on which payment for services is made under that selected or newly selected procedure.

49.45(53) (53) Payments for certain services. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under ss. 49.46 (2) (a) 4. d. and (b) 6. j. and m. and 49.471 (11) (f) that are provided before January 1, 2012.

49.45(53m) (53m) Coverage program for institutions for mental disease. Subject to any necessary waiver or other approval from the federal department of health and human services, or as otherwise permitted under federal law, the department shall, if federal funding participation is available, provide Medical Assistance coverage of services provided in an institution for mental disease to persons ages 21 to 64.