49.46(2)(bm)(bm) Benefits for an individual who is eligible for medical assistance only under sub. (1) (a) 15. are limited to those services related to tuberculosis that are described in 42 USC 1396a (z) (2).

49.46(2)(br)(br) If the federal department of health and human services approves the department’s request to offer a benchmark plan under this paragraph, the department may enroll any child who is receiving services through the early intervention program under s. 51.44 in a benchmark plan under this paragraph. The department may not require a child who is receiving services through the early intervention program under s. 51.44 to enroll in a benchmark plan offered under this paragraph. The department may not charge a copayment to a child who is enrolled in the benchmark plan under this paragraph for services described in par. (b) 19.

49.46(2)(bt)1.1. For the purposes of par. (b) 14m., a “medically monitored treatment service” is a 24-hour, community-based service providing observation, monitoring, and treatment by a multidisciplinary team under supervision of a physician, with a minimum of 12 hours of counseling provided per week for each patient.

49.46(2)(bt)2.2. For the purposes of par. (b) 14m., a “transitional residential treatment service” is a clinically supervised, peer-supported, therapeutic environment with clinical involvement providing substance abuse treatment in the form of counseling for 3 to 11 hours provided per week for each patient.

49.46(2)(bt)3.3. If approval by the federal department of health and human services of a state plan amendment or waiver request is necessary for federal reimbursement of the services under par. (b) 14m., the department is not required to pay for services described in par. (b) 14m. if the department does not receive the necessary approval.

49.46(2)(bt)4.4. The department may not provide reimbursement for services under par. (b) 14m. that are provided before July 1, 2016, or before the date of approval of the state plan amendment or waiver request described under subd. 3., whichever is later.

49.46(2)(c)1.1. In this paragraph and par. (cm):

49.46(2)(c)2.2. For an individual who is entitled to coverage under Part A of Medicare, entitled to coverage under Part B of Medicare, meets the eligibility criteria under sub. (1), and meets the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that are not paid under 42 USC 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums payable under 42 USC 1395v; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under Part A of Medicare. Payment of coinsurance for a service under Part B of Medicare under 42 USC 1395j to 1395w and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)3.3. For an individual who is only entitled to coverage under Part A of Medicare, meets the eligibility criteria under sub. (1), and meets the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that are not paid under 42 USC 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under Part A of Medicare. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)4.4. For an individual who is entitled to coverage under Part A of Medicare, entitled to coverage under Part B of Medicare, and meets the eligibility criteria for Medical Assistance under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that are not paid under 42 USC 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of coinsurance for a service under Part B of Medicare under 42 USC 1395j to 1395w and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)5.5. For an individual who is only entitled to coverage under Part A of Medicare and meets the eligibility criteria for Medical Assistance under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that are not paid under 42 USC 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)5m.5m. For an individual who is only entitled to coverage under Part B of Medicare and meets the eligibility criteria under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395j to 1395w, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of coinsurance for a service under Part B of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)6.6. The income limitation under this paragraph is income that is equal to or less than 100 percent of the poverty line, as established under 42 USC 9902 (2).

49.46(2)(cm)1.1. Beginning on January 1, 1993, for an individual who is entitled to coverage under part A of medicare, is entitled to coverage under part B of medicare, meets the eligibility criteria under sub. (1) and meets the limitation on income under subd. 2., medical assistance shall pay the monthly premiums under 42 USC 1395r.

49.46(2)(cm)2.2. Benefits under subd. 1. are available for an individual whose income is greater than 100 percent of the poverty line but less than 120 percent of the poverty line.

49.46(2)(d)(d) Benefits authorized under this subsection may not include payment for that part of any service payable through 3rd-party liability or any federal, state, county, municipal or private benefit system to which the beneficiary is entitled. “Benefit system” does not include any public assistance program such as, but not limited to, Hill-Burton benefits under 42 USC 291c (e), in effect on April 30, 1980, or relief funded by a relief block grant.

49.46(2)(dc)(dc) For an individual who is eligible for medical assistance and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under par. (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug.

49.46(2)(dm)(dm) Except as provided under s. 49.45 (53m), benefits under this section may not include payment for services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this paragraph, the department shall define “convalescent leave” and “conditional release” by rule.

49.46 AnnotationA categorically needy person applying for assistance under this section was not required to comply with divestment requirements under s. 49.47. Sinclair v. DHSS, 77 Wis. 2d 322, 253 N.W.2d 245 (1977).

49.46 AnnotationSub. (1) (b) and s. 49.47 (6) (d) limit retroactive medical assistance payments to services received not more than three months prior to the date the application is submitted. St. Paul Ramsey Medical Center v. DHSS, 186 Wis. 2d 37, 519 N.W.2d 681 (Ct. App. 1994).