49.45(25)(am)2. 2. Has a serious and persistent mental illness.
49.45(25)(am)3. 3. Has Alzheimer's disease, as defined under s. 46.87 (1) (a).
49.45(25)(am)4. 4. Is an alcoholic, as defined under s. 51.01 (1).
49.45(25)(am)5. 5. Is drug dependent, as defined under s. 51.01 (8b).
49.45(25)(am)6. 6. Is physically disabled, as defined by the department.
49.45(25)(am)7. 7. Is a severely emotionally disturbed child.
49.45(25)(am)8. 8. Is age 65 or over.
49.45(25)(am)9. 9. Is a member of a family that has a child who is at risk of serious physical, mental or emotional dysfunction, as defined by the department.
49.45(25)(am)10. 10. Has HIV infection, as defined in s. 252.01 (2).
49.45(25)(am)11. 11. Is a child who is eligible for early intervention services under s. 51.44.
49.45(25)(am)12. 12. Is infected with tuberculosis.
49.45(25)(am)13. 13. Is a child with asthma.
49.45(25)(am)14. 14. Is a woman who is aged 45 to 64 and who is not a resident of a nursing home or otherwise receiving case management services under this paragraph.
49.45(25)(b) (b) A county, city, village, town or, in a county having a population of 750,000 or more, the department may elect to make case management services under this subsection available in the county, city, village or town to one or more of the categories of beneficiaries under par. (am) through the medical assistance program. A county, city, village, town or, in a county having a population of 750,000 or more, the department that elects to make the services available shall reimburse a case management provider for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government.
49.45(25)(be) (be) A private nonprofit agency that is a certified case management provider may elect to provide case management services to medical assistance beneficiaries who have HIV infection, as defined in s. 252.01 (2). The amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.435 (1) (am).
49.45(25)(bg) (bg) An independent living center, as defined in s. 46.96 (1) (ah), that is a certified case management provider and satisfies the criteria in s. 46.96 (3m) (a) 1. to 3. and (am) may elect to provide case management services to one or more of the categories of medical assistance beneficiaries specified under par. (am). The amount of allowable charges for the services under the medical assistance program that is not provided by the federal government shall be paid from nonfederal, public funds received by the independent living center from a county, city, village or town or from funds distributed as a grant under s. 46.96.
49.45(25)(bj) (bj) The department of corrections may elect to provide case management services under this subsection to persons who are under the supervision of that department under s. 938.183, 938.34 (4h), (4m), or (4n), or 938.357 (3) or (4), who are Medical Assistance beneficiaries, and who meet one or more of the conditions specified in par. (am). The amount of the allowable charges for those services under the Medical Assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.410 (3) (hm), (ho), or (hr).
49.45 Note NOTE: Par. (bj) is amended by 2017 Wis. Act 185 effective on the date specified in the department of corrections notice published in the Wisconsin Administrative Register under 2017 Wis. Act 185, section 110 (2) (b), or 1-1-21, whichever is earlier, to read:
Effective date text (bj) The department of corrections may elect to provide case management services under this subsection to persons who are under the supervision of that department under s. 938.183, 938.34 (4h) or (4n), or 938.357 (3) or (4), who are Medical Assistance beneficiaries, and who meet one or more of the conditions specified in par. (am). The amount of the allowable charges for those services under the Medical Assistance program that is not provided by the federal government shall be paid from the appropriation account under s. 20.410 (3) (hm), (ho), or (hr).
49.45(25)(bm) (bm) Case management services under this subsection may not be provided to a person under par. (am) 7. unless any of the following is true:
49.45(25)(bm)1. 1. A team of mental health experts appointed by the case management provider determines that the person is a severely emotionally disturbed child. The team shall consist of at least 3 members. The case management provider shall appoint at least one member of the team who is a licensed psychologist or a physician specializing in psychiatry. The case management provider shall appoint at least 2 members of the team who are members of the professions of school psychologist, school social worker, registered nurse, social worker, child care worker, occupational therapist or teacher of emotionally disturbed children. The case management provider shall appoint as a member of the team at least one person who personally participated in a psychological evaluation of the child.
49.45(25)(bm)2. 2. Individuals who are designated by the coordinating committee have, or a service coordination agency has, determined under s. 46.56 (8) (d) that the person is a child, as defined in s. 46.56 (1) (bm), with emotional and behavioral disabilities.
49.45(25)(c) (c) Except as provided in pars. (b), (be), (bg), and (bj), the department shall reimburse a provider of case management services 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(25)(d) (d) This subsection does not apply to case management services provided under sub. (15) or s. 49.46 (2) (a) 2. or through a community support program under s. 49.46 (2) (b) 6. L.
49.45(25g) (25g)HIV care coordination.
49.45(25g)(a) (a) In this subsection, “care coordination" includes coordination of outpatient medical care, specialty care, inpatient care, dental care, and mental health care and medical case management.
49.45(25g)(b) (b) The department shall develop a proposal to increase medical assistance reimbursement to each provider that receives a grant under s. 252.12 (2) (a) 8. and to which at least one of the following applies:
49.45(25g)(b)1. 1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.
49.45(25g)(b)2. 2. The secretary determines that the provider performs well with respect to all of the following aspects of care:
49.45(25g)(b)2.a. a. Adoption of written standards for patient access and patient communication.
49.45(25g)(b)2.b. b. Use of data to show that standards for patient access and patient communication are satisfied.
49.45(25g)(b)2.c. c. Use of paper or electronic charting tools to organize clinical information.
49.45(25g)(b)2.d. d. Use of data to identify diagnoses and conditions among the provider's patients that have a lasting detrimental effect on health.
49.45(25g)(b)2.e. e. Adoption and implementation of guidelines that are based on evidence for treatment and management of HIV-related conditions.
49.45(25g)(b)2.f. f. Active support of patient self-management.
49.45(25g)(b)2.g. g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.
49.45(25g)(b)2.h. h. Systematic tracking of referrals using a paper or electronic system.
49.45(25g)(b)2.i. i. Measuring the quality of the performance of the provider and of individuals who perform services on behalf of the provider, including with respect to provision of clinical services, patient outcomes, and patient safety.
49.45(25g)(b)2.j. j. Reporting to employees and contractors of the provider and to other persons on the quality of the performance of the provider and of individuals who perform services on behalf of the provider.
49.45(25g)(c) (c) The department's proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (b) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than January 1, 2011.
49.45(25g)(d) (d) The department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal under par. (b) beginning January 1, 2011.
49.45(25g)(e) (e) A provider may not seek medical assistance reimbursement under this subsection and sub. (25) (be) for the same services.
49.45(26) (26)Managed care system. The department shall study alternatives for a system to manage the usage of alcohol and other drug abuse services, including day treatment services, provided under the medical assistance program. On or before September 1, 1988, the department shall submit a plan for a medical assistance alcohol and other drug abuse managed care system to the joint committee on finance. If the cochairpersons of the committee do not notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan within 14 working days after the date of the department's submittal, the department may implement the plan. If within 14 working days after the date of the department's submittal the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan, the department may not implement the plan until it is approved by the committee, as submitted or as modified. If a waiver from the secretary of the federal department of health and human services is necessary to implement the proposed plan, the department of health services may request the waiver, but it may not implement the waiver until it is authorized to implement the plan, as provided in this subsection.
49.45(26g) (26g)Intensive care coordination program.
49.45(26g)(a)(a) Subject to par. (i), the department shall create and implement a program to reimburse participating hospitals and health care systems for intensive care coordination services provided to recipients of Medical Assistance under this subchapter who are not enrolled in coverage under Medicare, 42 USC 1395 et seq.
49.45(26g)(b) (b) To apply to participate in the reimbursement program under this subsection, a hospital or health care system shall submit to the department a description of its intensive care coordination program that includes all of the following:
49.45(26g)(b)1. 1. A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.
49.45(26g)(b)2. 2. The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.
49.45(26g)(b)3. 3. A description of the hospital's or health care system's intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.
49.45(26g)(b)4. 4. A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care:
49.45(26g)(b)4.a. a. Discharge instructions and contacts for following up on care and treatment.
49.45(26g)(b)4.b. b. Referral information.
49.45(26g)(b)4.c. c. Appointment scheduling.
49.45(26g)(b)4.d. d. Medication instructions.
49.45(26g)(b)4.e. e. Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization.
49.45(26g)(b)4.f. f. Information about other health and social resources, such as transportation and housing.
49.45(26g)(b)5. 5. A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization.
49.45(26g)(b)6. 6. The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.
49.45(26g)(c) (c) The department shall do all of the following:
49.45(26g)(c)1. 1. Encourage, but not require, any hospital or health care system that seeks to apply to participate in the reimbursement program under this subsection to collaborate with any managed care organization with which it has an agreement to provide services to Medical Assistance recipients. The department may not limit patient populations eligible to participate in the intensive care coordination program under this subsection to either those individuals enrolled in managed care to receive Medical Assistance services or those individuals currently receiving Medical Assistance services on a fee-for-service basis. The department may not deny a hospital or health care system applicant for the reimbursement program under this subsection solely because the applicant does not have an agreement to implement an intensive care coordination program with a managed care organization.
49.45(26g)(c)2. 2. Respond to the hospital or health care system indicating whether additional information is required to evaluate the application for the reimbursement program under this subsection.
49.45(26g)(c)3. 3. After consulting with hospitals, health care systems, and other providers, develop uniform outcome measures to use in determining the efficacy of the program.
49.45(26g)(c)4. 4. If the hospital or health care system is selected for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement.
49.45(26g)(c)5. 5. If the department does not receive a proposal for the reimbursement program under this subsection, solicit proposals for the reimbursement program under this subsection from other health care providers under s. 146.81 (1).
49.45(26g)(d) (d) The department shall provide as reimbursement for intensive care coordination to participants in the program under this subsection $250 initially for each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the hospital or health care system enrolls in intensive care coordination. The initial enrollment for each recipient lasts for 6 months, and if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population, the participant receives an additional $250 for each enrollee at the end of the 6 months. The program participant may enroll each Medical Assistance recipient in one additional 6-month period for an additional $250 per enrollee initial reimbursement payment and $250 per enrollee at the end of the additional 6-month period if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population. The department shall pay no more than $1,500,000 cumulatively in each fiscal year from all funding sources for reimbursements under this paragraph.
49.45(26g)(e) (e) Annually, each hospital and health care system that is participating in the reimbursement program under this subsection shall submit a report to the department containing all of the following:
49.45(26g)(e)1. 1. The number of Medical Assistance recipients served by intensive care coordination.
49.45(26g)(e)2. 2. For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination.
49.45(26g)(e)3. 3. Any demonstrated outcomes, as specified by the department under par. (c) 3., for Medical Assistance recipients.
49.45(26g)(e)4. 4. Any other information required by the department.
49.45(26g)(f) (f) For each hospital or health care system eligible for the reimbursement program under this subsection, the department shall calculate the costs saved to the Medical Assistance program by avoiding emergency department visits by subtracting the sum of reimbursements made under par. (d) to the participant from the sum of costs of visits to the emergency department as reported under par. (e) 2. that were expected to occur without intensive care coordination but did not because of enrollment in the program under this subsection. If the result of the calculation is positive in the first 6 months of the recipient's enrollment in the program under this subsection, the department shall distribute 25 percent of the amount saved to the hospital, health care system, or managed care organization subject to pars. (g) and (i). If the result of the calculation is positive after 12 months of the recipient's enrollment in the program under this subsection, the department shall distribute a share of the savings to the hospital, health care system, or managed care organization such that the total amount of shared savings payments made equals half of the savings for the entire 12-month period, subject to pars. (g) and (i).
49.45(26g)(g) (g) If a hospital or health care system participating in the program under this subsection provides services to Medical Assistance recipients enrolled in managed care, the department shall make any payment under the program under this subsection under par. (d) or (f) to the managed care organization with which the hospital or health care system has an agreement to provide services to Medical Assistance recipients. The managed care organization shall pass the payments made under pars. (d) and (f) on to the hospital or health care system no later than 30 days after receiving the payment from the department. The department shall make payments under pars. (d) and (f) to a hospital or health care system that provides services to Medical Assistance recipients who are not enrolled in managed care directly to the hospital or health care system.
49.45(26g)(h) (h) No later than 24 months after the date on which the first hospital or health care system is able to enroll individuals in the intensive care coordination program under this subsection, the department shall submit a report to the joint committee on finance summarizing the information reported under par. (e) including the costs saved by avoiding emergency department visits as calculated under par. (f).
49.45(26g)(i) (i) The department shall seek any necessary approval from the federal department of health and human services to implement the program under this subsection. If the federal department of health and human services disapproves the request for approval, the department may implement the reimbursement under par. (d), the savings distribution under par. (f), or both or any part of the program under this subsection.
49.45(26g)(j) (j) If the federal department of health and human services does not disapprove a request for approval under par. (i) or if federal approval is not required, the department shall implement at least 2 pilot programs under this subsection by the later of September 1, 2018, or the date that is 30 days after the date of federal approval, if approval is needed.
49.45(27) (27)Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v).
49.45(29) (29)Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46, 49.47, and 49.471.
49.45(29r) (29r)Behavioral health care coordination pilot projects.
49.45(29r)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29r)(b) (b) Subject to par. (c), the department shall develop and award at least 2 pilot projects lasting no more than 3 years each to test alternative, coordinated care delivery and Medical Assistance payment models designed to reduce costs of recipients of Medical Assistance under this subchapter who have significant or chronic mental illness. A health care provider that is awarded a pilot project shall target a Medical Assistance population of high volume or high intensity users of non-behavioral health medical services, such as individuals with more than 5 emergency department visits in a year or individuals who have frequent or longer than average inpatient hospital stays, who also have significant or chronic mental illness. The department may not limit eligibility for the pilot project or awards under this subsection on the basis that the health care provider that is awarded the pilot project serves a target population that includes individuals enrolled in a Medical Assistance health maintenance organization. Each pilot project under this subsection shall include either a Medical Assistance payment on a per member per month basis for a specified pilot project population that is in addition to existing payment for services provided under the Medical Assistance program, including services reimbursed on a fee-for-service basis and services provided under managed care, or shall include an alternative Medical Assistance payment for a specified pilot project. The department shall require health care providers that are awarded a pilot project to submit to the department interim and final reports analyzing differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports. The department shall award the pilot projects and allocate funding only to health care providers that meet all of the following criteria:
49.45(29r)(b)1. 1. The health care provider provides all of the following services directly or through an affiliated entity:
49.45(29r)(b)1.a. a. Emergency department services.
49.45(29r)(b)1.b. b. Outpatient psychiatric services.
49.45(29r)(b)1.c. c. Outpatient primary care services.
49.45(29r)(b)1.d. d. Inpatient psychiatric services.
49.45(29r)(b)1.e. e. General inpatient hospital services.
49.45(29r)(b)1.f. f. Services of a care coordinator or navigator for each individual in the pilot project.
49.45(29r)(b)2. 2. The health care provider provides, directly or through an affiliated entity or contracted entity, the coordination of social services fostering the individual's recovery following an inpatient psychiatric discharge.
49.45(29r)(c) (c) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot projects under par. (b) beginning no earlier than January 1, 2016.
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2015-16 Wisconsin Statutes updated through 2017 Wis. Act 367 and all Supreme Court and Controlled Substances Board Orders effective on or before June 13, 2018. Published and certified under s. 35.18. Changes effective after June 13, 2018 are designated by NOTES. (Published 6-13-18)