Chapter 49

49.45 Note NOTE: The cross-reference to subch. XII of ch. 448 was changed from subch. XI of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. XI of ch. 448.

49.45(9r)(a)7.d. d. A chiropractor licensed under ch. 446.

49.45(9r)(a)7.e. e. A physician assistant who is licensed under subch. IX of ch. 448 or who holds a compact privilege under subch. XIII of ch. 448.

49.45 Note NOTE: The cross-reference to subch. IX of ch. 448 was changed from subch. VIII of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. VIII of ch. 448.

49.45(9r)(b) (b) The department shall promulgate rules and other policies for use of complex rehabilitation technology by recipients of Medical Assistance. The department shall include in the rules all of the following:

49.45(9r)(b)1. 1. Designation of billing codes as complex rehabilitation technology including creation of new billing codes or modification of existing billing codes. The department shall include provisions allowing quarterly updates to the designations under this subdivision.

49.45(9r)(b)2. 2. Establishment of specific supplier standards for companies or entities that provide complex rehabilitation technology and limiting reimbursement only to suppliers that are qualified complex rehabilitation technology suppliers.

49.45(9r)(b)3. 3. A requirement that Medical Assistance recipients who need a complex rehabilitation manual wheelchair, complex rehabilitation power wheelchair, or other complex rehabilitation seating component to be evaluated by all of the following:

49.45(9r)(b)3.a. a. A qualified health care professional who does not have a financial relationship with a qualified complex rehabilitation technology supplier.

49.45(9r)(b)3.b. b. A qualified complex rehabilitation technology professional.

49.45(9r)(b)4. 4. Establishment and maintenance of payment rates for complex rehabilitation technology that are adequate to ensure complex needs patients have access to complex rehabilitation technology, taking into account the significant resources, infrastructure, and staff needed to appropriately provide complex rehabilitation technology to meet the unique needs of complex needs patients.

49.45(9r)(b)5. 5. A requirement for contracts with the department that managed care plans providing services to Medical Assistance recipients comply with this subsection and the rules promulgated under this subsection.

49.45(9r)(b)6. 6. Protection of access to complex rehabilitation technology for complex needs patients.

49.45(9r)(c) (c) This subsection is not intended to affect coverage of speech generating devices, including healthcare common procedure coding system codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, and E2599, under the Medical Assistance program.

49.45(9r)(d) (d) When reviewing prior authorization requests for complex rehabilitation technology items, the department and managed care plans shall act within 10 working days of receiving complete, clinically relevant written documentation necessary to make a determination.

49.45(9r)(dm) (dm) The department may not require a prescription or prior authorization to reimburse a provider for the repair of complex rehabilitation technology if the complex rehabilitation technology has been prescribed and reimbursed as provided in this subsection. This paragraph does not apply to the repair of complex rehabilitation technology if the complex rehabilitation technology is intended for use by an individual who is enrolled in a managed care organization.

49.45(9r)(e) (e) Except as provided in par. (dm), the department shall, consistent with this subsection and without imposing any additional requirements or restrictions under this subsection, reimburse a provider for a complex rehabilitation technology with prior authorization when prescribed by a physician, medically necessary, and used by a recipient of Medical Assistance who is a resident of a nursing home if the complex rehabilitation technology will do any of the following:

49.45(9r)(e)1. 1. Contribute to the recipient’s independent completion of activities of daily living.

49.45(9r)(e)2. 2. Support the recipient’s occupational, vocational, or psychosocial activities.

49.45(9r)(e)3. 3. Provide the recipient the independent ability to move about the facility or to attain or retain self-care.

49.45(9r)(f) (f)

49.45(9r)(f)1. 1. In this paragraph, “KU modifier” means a modifier used in the federal Medicare program related to an exemption from competitive bidding pricing.

49.45(9r)(f)2. 2. For dates of service beginning on March 24, 2024, the department shall, for healthcare common procedure coding system codes relating to complex rehabilitation technology wheelchair repair and accessories, apply a reimbursement rate under the Medical Assistance program equivalent to the maximum fee paid in Wisconsin under the federal Medicare program, including fees under the KU modifier, if applicable.

49.45(9r)(f)3. 3. Beginning July 1, 2025, and annually thereafter, the department shall submit to the chief clerk of each house of the legislature for distribution to the legislature under s. 13.172 (2) a report that includes all of the following information:

49.45(9r)(f)3.a. a. The total number of units.

49.45(9r)(f)3.b. b. The total number of claims.

49.45(9r)(f)3.c. c. The total number of claims per provider.

49.45(9r)(f)3.d. d. The average dollar amount of all paid claims.

49.45(9r)(f)3.e. e. The average dollar amount of claims paid per provider.

49.45(9r)(f)3.f. f. The total dollar amount paid per provider.

49.45(9r)(f)3.g. g. A calculation of the amount paid to the provider compared to the amount paid to the provider if the reimbursement were through fee-for-service under the Medical Assistance program under this subchapter.

49.45(9r)(f)3.h. h. The number of repairs done per unit during the last year.

49.45(9s) (9s) Disclosure. Any person who is an employee of, or an owner, partner, member, stockholder or investor in, any legal entity providing services which are reimbursed under this section, shall notify the department, on forms provided by the department for that purpose, if such person is an employee of, or an owner, partner, member, stockholder or investor in, any other legal entity providing services which are reimbursed under this section.

49.45(10) (10) Rule-making powers and duties. The department is authorized to promulgate such rules as are consistent with its duties in administering medical assistance. The department shall promulgate a rule defining the term “part-time intermittent care” for the purpose of s. 49.46.

49.45(11) (11) Penalty. Any person who receives or assists another in receiving assistance under this section, to which the recipient is not entitled, shall be subject to the penalties under ss. 946.91 and 946.93.

49.45(12) (12) Machine-readable medical assistance cards.

49.45(12)(b) (b) If the commissioner of insurance promulgates rules under s. 601.57 (2), 2021 stats., establishing a health insurance identification card system and its computerized support system, the department shall develop a plan to coordinate a system of machine-readable identification cards for medical assistance recipients with the systems established by the commissioner and shall submit the plan to the governor, and to the legislature under s. 13.172 (2), before issuing a request for proposals under par. (c).

49.45(12)(c) (c) The department shall request proposals for a system of machine-readable identification cards for medical assistance recipients and a computerized support system for the cards that will accept and respond to electronically conveyed requests from health care providers for information related to medical assistance recipients, such as eligibility, coverages and authorizations. The request for proposals shall specify that the systems are to be operating by January 1, 1997.

49.45(13) (13) Financial reports.

49.45(13)(a) (a) The department may require service providers to prepare and submit cost reports or financial reports for purposes of rate certification under Title XIX, cost verification, fee schedule determination or research and study purposes. These financial reports may include independently audited financial statements which shall include balance sheets and statements of revenues and expenses. The department may withhold reimbursement or may decrease or not increase reimbursement rates if a provider does not submit the reports required under this paragraph or if the costs on which the reimbursement rates are based cannot be verified from the provider’s cost or financial reports or records from which the reports are derived.

49.45(13)(b) (b) The department may require any provider who fails to submit a cost report or financial report under par. (a) within the period specified by the department to forfeit not less than $10 nor more than $100 for each day the provider fails to submit the report.

49.45(15) (15) Community care organization project guarantee. Upon termination of the community care organization demonstration projects in Barron, La Crosse and Milwaukee counties, any client who was receiving services through any of those projects may continue to receive the full range of community care organization services. The cost of the services shall continue to be paid by medical assistance.

49.45(15r) (15r) Emergency medical transportation reimbursement. The department shall submit a state plan amendment to the federal department of health and human services to allow payment of supplemental reimbursements under the Medical Assistance program under this subchapter to public ambulance service providers, as defined in s. 256.01 (3), for ground emergency medical transportation through certified public expenditures. For purposes of this subsection, any ambulance service provider that is owned by any municipality or group of municipalities, regardless of whether or not the ambulance service provider is organized as a nonprofit corporation, is considered a public ambulance service provider. If the state plan amendment under this subsection is approved, the department shall pay to an ambulance service provider that complies with a certified public expenditure arrangement, as established by the department, a supplemental reimbursement equal to the amount of federal financial participation for ground emergency medical transportation services in accordance with state and federal law and regulations, except that the total reimbursement under the Medical Assistance program for the transportation may not exceed the actual cost to the ambulance service provider of providing the transportation. If the federal department of health and human services disapproves the state plan amendment, the department may not pay the supplement under this subsection.

49.45(16) (16) Certification. On or after January 1, 1984, the department may only continue to certify as a medical assistance provider a community-based residential facility that is so certified on December 31, 1983. On or after January 1, 1984, no community-based residential facility may be certified for more beds than the number for which it was certified on December 31, 1983.

49.45(18) (18) Recipient cost sharing.

49.45(18)(ac) (ac) Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.

49.45(18)(ag) (ag) Except as provided in pars. (am), (b), and (c), and subject to par. (d), a recipient specified in par. (ac) shall pay all of the following:

49.45(18)(ag)1. 1. A copayment of $1 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b).

49.45(18)(ag)2. 2. A copayment of $3 for each prescription of a drug that bears a brand name, as defined in s. 450.12 (1) (a).

49.45(18)(am) (am)

49.45(18)(am)1. 1. Except as provided in subd. 2., no person is liable under this subsection for services provided through prepayment contracts.

49.45(18)(am)2. 2. A person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 is liable under this subsection for services provided through a prepayment contract in the amounts and according to the procedures specified by the department.

49.45(18)(b) (b) The following services are not subject to recipient cost sharing under this subsection:

49.45(18)(b)1. 1. Any service provided to a person receiving care as an inpatient in a skilled nursing home or intermediate care facility certified under 42 USC 1396 to 1396k.

49.45(18)(b)2. 2. Any service provided to a person who is less than 18 years old. This subdivision does not apply if the person’s family income exceeds 100 percent of the poverty line and he or she is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.

49.45(18)(b)3. 3. Any service provided under s. 49.46 (2) to a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy.

49.45(18)(b)4. 4. Emergency services.

49.45(18)(b)5. 5. Family planning services, as defined in s. 253.07 (1) (b).

49.45(18)(b)6. 6. Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under s. 46.215 or 46.22.

49.45(18)(b)7. 7. Home health services or, if a home health agency is unavailable, nursing services.

49.45(18)(b)11. 11. Personal care services.

49.45(18)(b)12. 12. Case management services.

49.45(18)(c) (c) The department may limit any medical assistance recipient’s liability under this subsection for services it designates.

49.45(18)(d) (d) No person who designates a pharmacy or pharmacist as his or her sole provider of prescription drugs and who so uses that pharmacy or pharmacist is liable under this subsection for more than $12 per month for prescription drugs received.

49.45(19) (19) Assigning medical support rights.

49.45(19)(a) (a) As a condition of eligibility for medical assistance, a person shall, notwithstanding other provisions of the statutes, be deemed to have assigned to the state, by applying for or receiving medical assistance, any rights to medical support or other payment of medical expenses from any other person, including rights to unpaid amounts accrued at the time of application for medical assistance as well as any rights to support accruing during the time for which medical assistance is paid.

49.45(19)(b) (b) If a person charged with the care and custody of a dependent child or children does not comply with the requirements of this subsection, the person is ineligible for medical assistance. In this case, medical assistance payments shall continue to be made on behalf of the eligible child or children.

49.45(19)(bm) (bm) The department or the county department under s. 46.215 or 46.22 shall notify applicants of the requirements of this subsection at the time of application.

49.45(19)(c) (c) If the mother of a child was enrolled in a health maintenance organization or other prepaid health care plan under medical assistance at the time of the child’s birth, birth expenses that may be recovered by the state under this subsection are the birth expenses incurred by the health maintenance organization or other prepaid health care plan.

49.45(20) (20) Exemption from continuation requirements. An insurer, as defined in s. 632.897 (1) (d), with which the department contracts under sub. (2) (b) 2. for the provision of health care to medical assistance recipients is exempt from the continuation of group coverage requirements of s. 632.897 with regard to those recipients, their spouses and dependents.

49.45(21) (21) Taking over provider’s operation; repayments required.

49.45(21)(ag) (ag) In this subsection, “take over the operation” means obtain, with respect to an aspect of a provider’s business for which the provider has filed claims for medical assistance reimbursement, any of the following:

49.45(21)(ag)1. 1. Ownership of the provider’s business or all or substantially all of the assets of the business.

49.45(21)(ag)2. 2. Majority control over decisions.

49.45(21)(ag)3. 3. The right to any profits or income.

49.45(21)(ag)4. 4. The right to contact and offer services to patients, clients, or residents served by the provider.

49.45(21)(ag)5. 5. An agreement that the provider will not compete with the person at all or with respect to a patient, client, resident, service, geographical area, or other part of the provider’s business.

49.45(21)(ag)6. 6. The right to perform services that are substantially similar to services performed by the provider at the same location as those performed by the provider.

49.45(21)(ag)7. 7. The right to use any distinctive name or symbol by which the provider is known in connection with services to be provided by the person.

49.45(21)(ar) (ar) Before a person may take over the operation of a provider that is liable for repayment of improper or erroneous payments or overpayments under ss. 49.43 to 49.497, full repayment shall be made. Upon request, the department shall notify the provider or the person that intends to take over the operation of the provider as to whether the provider is liable.

49.45(21)(b) (b) If, notwithstanding the prohibition under par. (ar), a person takes over the operation of a provider and the applicable amount under par. (ar) has not been repaid, the department may, in addition to withholding certification as authorized under sub. (2) (b) 8., proceed against the provider or the person. Within 30 days after the certified provider receives notice from the department, the amount shall be repaid in full. If the amount is not repaid in full, the department may bring an action to compel payment, may proceed under sub. (2) (a) 12., or may do both.

49.45(21)(c) (c) The department may enforce this subsection within 4 years following a transfer.

49.45(21)(d) (d) This subsection supersedes any provision of chs. 180, 181, 185, and 193.

49.45(21)(e) (e) The department shall promulgate rules to implement this subsection.

49.45(22) (22) Medical assistance services provided by health maintenance organizations. If the department contracts with health maintenance organizations for the provision of medical assistance it shall give special consideration to health maintenance organizations that provide or that contract to provide comprehensive, specialized health care services to pregnant teenagers. If the department contracts with health maintenance organizations for the provision of medical assistance, the department shall determine which medical assistance recipients who have attained the age of 2 but have not attained the age of 6 and who are at risk for lead poisoning have not received lead screening from those health maintenance organizations. The department shall report annually to the appropriate standing committees of the legislature under s. 13.172 (3) on the percentage of medical assistance recipients under the age of 2 who received a lead screening test in that year provided by a health maintenance organization compared with the percentage that the department set as a goal for that year.

49.45(23) (23) Assistance for childless adults demonstration project.

49.45(23)(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 conduct a demonstration project to provide health care coverage to adults who are under the age of 65, who have family incomes not to exceed 100 percent of the poverty line before application of the 5 percent income disregard under 42 CFR 435.603 (d), and who are not otherwise eligible for medical assistance under this subchapter, the Badger Care health care program under s. 49.665, or Medicare under 42 USC 1395 et seq.

49.45(23)(b) (b) If the waiver is granted and in effect, the department may promulgate rules defining the health care benefit plan, including more specific eligibility requirements and cost-sharing requirements. Cost sharing may include an annual enrollment fee, which may not exceed $75 per year. Notwithstanding s. 227.24 (3), the plan details under this subsection may be promulgated as an emergency rule under s. 227.24 without a finding of emergency. If the waiver is granted and in effect, the demonstration project under this subsection shall begin on the effective date of the waiver.

49.45(23)(d) (d) In determining income for purposes of eligibility under this subsection, the department shall apply s. 49.471 (7) (d) to the individual to the extent the federal department of health and human services approves, if approval is required.