Chapter 49

49.46(1)(cr) (cr) To the extent approved by the federal department of health and human services, an individual or family described in par. (c) or (cg) is not eligible for Medical Assistance if the federal department of health and human services approves a request from the department to deny all or some transitional Medical Assistance benefits to that individual or family, if approval is required. The department shall allow individuals who are receiving transitional Medical Assistance benefits on December 31, 2013, to continue to receive those benefits until their 12-month period ends, if required under federal law. If the federal department of health and human services approves the department’s request to charge a premium to recipients of continued transitional Medical Assistance benefits, the department may charge a premium to any recipient of continued transitional Medical Assistance benefits whose income exceeds 100 percent of the poverty line.

49.46(1)(d) (d) For the purposes of this section:

49.46(1)(d)1. 1. Children who are placed in licensed foster homes by the department and who would be eligible for payment of aid to families with dependent children in foster homes except that their placement is not made by a county department under s. 46.215, 46.22, or 46.23 will be considered as recipients of aid to families with dependent children.

49.46(1)(d)2. 2. Any accommodated person or any patient in a public medical institution shall be considered a recipient for purposes of this section if such person or patient would have inadequate means to meet his or her need for care and services if living in his or her usual living arrangement.

49.46(1)(d)3. 3. Any child adopted under s. 48.48 (12) shall be considered a recipient for any medical condition which exists at the time of the adoption or develops subsequent to the adoption.

49.46(1)(d)4. 4. A child who meets the conditions under 42 USC 1396a (e) (3) shall be considered a recipient of benefits under s. 49.77 or federal Title XVI.

49.46(1)(e) (e) If an application under s. 49.47 (3) shows that the individual meets the income limits under s. 49.19 or meets the income and resource requirements under federal Title XVI or s. 49.77, or that the individual is an essential person, an accommodated person, or a patient in a public medical institution, the individual shall be granted the benefits enumerated under sub. (2) whether or not the individual requests or receives a grant of any of such aids.

49.46(1)(em) (em) To the extent approved by the federal government, for the purposes of determining financial eligibility and any cost-sharing requirements of an individual under par. (a) 6m., 14., or 14m., (d) 2., or (e), the department or its designee shall exclude any assets accumulated in a person’s independence account, as defined in s. 49.472 (1) (c), and any income or assets from retirement benefits earned or accumulated from income or employer contributions while employed and receiving medical assistance under s. 49.472.

49.46(1)(j) (j) An individual determined to be eligible for benefits under par. (a) 9. remains eligible for benefits under par. (a) 9. for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 90th day after the last day of the pregnancy falls without regard to any change in the individual’s family income.

49.46(1)(k) (k)

49.46(1)(k)1. 1. If a child eligible for benefits under par. (a) 10. is receiving inpatient services covered under sub. (2) on the day before the birthday on which the child attains the age of 6 and, but for attaining that age, the child would remain eligible for benefits under par. (a) 10., the child remains eligible for benefits until the end of the stay for which the inpatient services are furnished.

49.46(1)(k)2. 2. If a child eligible for benefits under par. (a) 11. is receiving inpatient services covered under sub. (2) on the day before the birthday on which the child attains the age of 19 and, but for attaining that age, the child would remain eligible for benefits under par. (a) 11., the child remains eligible for benefits until the end of the stay for which the inpatient services are furnished.

49.46(1)(L) (L) For the purposes of par. (a) 9. to 12., “income” includes income that would be used in determining eligibility for aid to families with dependent children under s. 49.19, except to the extent that that determination is inconsistent with 42 USC 1396a (a) 17., and excludes income that would be excluded in determining eligibility for aid to families with dependent children under s. 49.19. For the purposes of par. (am), “income” shall be determined in accordance with the approved state plan for services under 42 USC 1396.

49.46(1)(m) (m)

49.46(1)(m)1. 1. Except as provided in subd. 2., any individual who is otherwise eligible under this subsection and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for medical assistance and if the department determines it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor’s behalf.

49.46(1)(m)2. 2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with subd. 1., the failure does not affect the minor’s eligibility under this subsection.

49.46(1m) (1m) Pilot project for working recipients of supplemental security income or social security disability income. The department shall request that the secretary of the federal department of health and human services and the commissioner of the federal social security administration waive the income and asset requirements for recipients of benefits under federal Title II or XVI to allow the department to conduct a pilot project to allow those recipients to work without losing eligibility for benefits under federal Title II or XVI or for medical assistance or medicare, as defined in s. 49.45 (3) (L) 1. b. If the request is approved, the department may implement the program and may require participants in the program to pay, on a sliding scale, a copayment for the cost of the program.

49.46(1p) (1p) Demonstration project for persons with HIV. The department shall request a waiver from the secretary of the federal department of health and human services to allow the department to provide under this section coverage of services specified under sub. (2) for persons who have HIV infection, as defined in s. 252.01 (2). If a waiver is granted and in effect, the department shall provide coverage for the services specified under sub. (2) for persons who qualify under the terms of the waiver.

49.46(2) (2) Benefits.

49.46(2)(a) (a) Except as provided in par. (be), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits:

49.46(2)(a)1. 1. Physicians’ services, excluding services provided under par. (b) 6. f.

49.46(2)(a)2. 2. Early and periodic screening and diagnosis, including case management services, of persons under 21 years of age and all medical treatment and dentists’ services found necessary by this screening and diagnosis.

49.46(2)(a)3. 3. Rural health clinic services.

49.46(2)(a)4. 4. The following medical services if prescribed or ordered by a provider acting within the scope of the provider’s practice under statutes, rules, or regulations that govern the provider’s practice:

49.46(2)(a)4.a. a. Inpatient hospital services other than services in an institution for mental diseases, including psychiatric and alcohol or other drug abuse treatment services.

49.46(2)(a)4.b. b. Services specified in this paragraph, provided by any hospital on an outpatient basis.

49.46(2)(a)4.c. c. Skilled nursing home services other than in an institution for mental diseases, except as limited under s. 49.45 (6c) and (30m) (b) and (c).

49.46(2)(a)4.d. d. Home health services, subject to the limitation under s. 49.45 (8), or, if a home health agency is unavailable, nursing services.

49.46(2)(a)4.e. e. Laboratory and X-ray services.

49.46(2)(a)4.f. f. Services and supplies for family planning, as defined in s. 253.07 (1) (a).

49.46(2)(a)4m. 4m. Nurse-midwifery services.

49.46(2)(a)6. 6. Premiums, deductibles and coinsurance and other cost-sharing obligations for items and services otherwise paid under this subsection that are required for enrollment in a group health plan, as specified in sub. (1) (m), except that, if enrollment in the group health plan requires enrollment of family members who are not eligible under this subsection, the department shall pay, if it is cost-effective, for an ineligible family member only the premium that is required for enrollment in the group health plan.

49.46(2)(b) (b) Except as provided in pars. (be) and (dc), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services:

49.46(2)(b)1. 1. Dentists’ services, limited to basic services within each of the following categories:

49.46(2)(b)1.a. a. Diagnostic services.

49.46(2)(b)1.b. b. Preventive services.

49.46(2)(b)1.c. c. Restorative services.

49.46(2)(b)1.d. d. Endodontic services.

49.46(2)(b)1.e. e. Periodontic services.

49.46(2)(b)1.f. f. Oral and maxillofacial surgery services.

49.46(2)(b)1.g. g. Emergency treatment of dental pain.

49.46(2)(b)1.hm. hm. Removable prosthodontic services.

49.46(2)(b)1.im. im. Fixed prosthodontic services.

49.46(2)(b)2. 2. Optometrists’ or opticians’ services.

49.46(2)(b)3. 3. Transportation by emergency medical vehicle to obtain emergency medical care, transportation by specialized medical vehicle to obtain medical care including the unloaded travel of the specialized medical vehicle necessary to provide that transportation, or transportation by common carrier or private motor vehicle to obtain medical care.

49.46(2)(b)4. 4. Chiropractors’ services.

49.46(2)(b)5. 5. Eyeglasses.

49.46(2)(b)6. 6. The following services that, other than under subd. 6. f., fm., k., and Lr., are prescribed or ordered by a provider acting within the scope of the provider’s practice under statutes, rules, or regulations that govern the provider’s practice:

49.46(2)(b)6.a. a. Intermediate care facility services other than in an institution for mental diseases, except as limited under s. 49.45 (30m) (b) and (c).

49.46(2)(b)6.b. b. Physical and occupational therapy.

49.46(2)(b)6.c. c. Speech, hearing and language disorder services.

49.46(2)(b)6.d. d. Medical supplies and equipment.

49.46(2)(b)6.dm. dm. Subject to the requirements under s. 49.45 (9r), durable medical equipment that is considered complex rehabilitation technology, excluding speech generating devices.

49.46(2)(b)6.e. e. Subject to the limitation under s. 49.45 (30r), inpatient hospital, skilled nursing facility and intermediate care facility services for patients of any institution for mental diseases who are under 21 years of age, are under 22 years of age and who were receiving these services immediately prior to reaching age 21, are 65 years of age or older, or are otherwise permitted under s. 49.45 (53m).

49.46(2)(b)6.f. f. Medical day treatment services, mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist.

49.46(2)(b)6.fm. fm. Subject to the limitations under s. 49.45 (45), mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist, to an individual who is 21 years of age or older in the individual’s home or in the community.

49.46(2)(b)6.g. g. Nursing services as defined in rules that the department shall promulgate.

49.46(2)(b)6.h. h. Legend drugs, as listed in the Wisconsin medical assistance drug index.

49.46(2)(b)6.i. i. Over-the-counter drugs listed by the department in the Wisconsin medical assistance drug index.

49.46(2)(b)6.j. j. Personal care services, subject to the limitation under s. 49.45 (42).

49.46(2)(b)6.k. k. Alcohol and other drug abuse day treatment services.

49.46(2)(b)6.L. L. Mental health and psychosocial rehabilitative services, including case management services, provided by the staff of a community support program certified under s. 49.45 (2) (a) 11.

49.46(2)(b)6.Lm. Lm. Subject to the limitations under s. 49.45 (30e), psychosocial services, including case management services, provided by the staff of a community-based psychosocial service program.

49.46(2)(b)6.Lo. Lo. Subject to the limitations under s. 49.45 (30g), community recovery services.

49.46(2)(b)6.Lr. Lr. Psychotherapy and alcohol and other drug abuse services, as specified under s. 49.45 (30f).

49.46(2)(b)6.m. m. Respiratory care services for ventilator-dependent individuals.

49.46(2)(b)8. 8. Home or community-based services, if provided under s. 46.275, 46.277, 46.278, 46.2785, 46.99, or under the family care benefit if a waiver is in effect under s. 46.281 (1d), or under the disabled children’s long-term support program, as defined in s. 46.011 (1g).

49.46(2)(b)9. 9. Case management services, as specified under s. 49.45 (24) or (25).

49.46(2)(b)10. 10. Hospice care as defined in 42 USC 1396d (o) (1).

49.46(2)(b)11. 11. Podiatrists’ services.

49.46(2)(b)12. 12. Care coordination for women with high-risk pregnancies.

49.46(2)(b)12m. 12m. Prenatal, postpartum and young child care coordination services under s. 49.45 (44).

49.46(2)(b)12t. 12t. Subject to the limitations under s. 49.45 (30x), licensed midwife services provided by a certified professional midwife licensed under s. 440.982.

49.46(2)(b)13. 13. Care coordination and follow-up, including lead investigations, as defined in s. 254.11 (8s), of persons having lead poisoning or lead exposure, as defined in s. 254.11 (9).

49.46(2)(b)14. 14. School medical services under s. 49.45 (39).

49.46(2)(b)14m. 14m. Subject to par. (bt), substance abuse treatment services provided by a medically monitored treatment service or a transitional residential treatment service.

49.46(2)(b)14p. 14p. Subject to s. 49.45 (30j), services provided by a peer recovery coach.

49.46(2)(b)15. 15. Crisis intervention services under s. 49.45 (41).

49.46(2)(b)16. 16. Case management services for recipients with high-cost chronic health conditions or high-cost catastrophic health conditions, if the department operates a program under s. 49.45 (43).

49.46(2)(b)17. 17. Services under s. 49.45 (54) (c) for children participating in the early intervention program under s. 51.44.

49.46(2)(b)18. 18. Care coordination, as specified under s. 49.45 (25g).

49.46(2)(b)19. 19. Subject to par. (br), services provided by early intervention teachers, home trainers, parent-to-parent mentors, and developmental specialists to children in the benchmark plan under par. (br).

49.46(2)(b)20. 20. Subject to s. 49.45 (24j), any additional services, as determined by the department, that are targeted to a population enrolled in a medical home initiative under s. 49.45 (24j).

49.46(2)(b)21. 21. Subject to s. 49.45 (61), consultations between providers conducted through interactive telehealth described under s. 49.45 (61) (c) 1.

49.46(2)(b)22. 22. Subject to s. 49.45 (61), asynchronous telehealth services and remote patient monitoring described under s. 49.45 (61) (c) 2.

49.46(2)(b)23. 23. Subject to s. 49.45 (61), services described under s. 49.45 (61) (c) 3. that are provided through communication technology and that are covered under the federal Medicare program and any telehealth services that the department specifies by rule under s. 49.45 (61) (d).

49.46(2)(bc) (bc) Subject to s. 49.45 (24j), the department may provide any of the services described in par. (a) or (b) through a medical home initiative under s. 49.45 (24j).

49.46(2)(be) (be) Benefits for an individual eligible under sub. (1) (a) 9. are limited to those services under par. (a) or (b) that are related to pregnancy, including postpartum services and family planning services, as defined in s. 253.07 (1) (b), or related to other conditions which may complicate pregnancy.

49.46(2)(bh) (bh) The department shall provide reimbursement for services that are reimbursable under this section and that are provided by a licensed pharmacist within the scope of his or her license or are services performed under s. 450.033. If the department determines it is unable to implement this paragraph without a state plan amendment or waiver of federal law, the department shall submit to the federal department of health and human services any necessary state plan amendment or waiver of federal law necessary to implement this paragraph. If the federal government disapproves the amendment or waiver request, the department is not required to implement this paragraph.