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49.45(42) (42)Personal care services.
49.45(42)(c)(c) The department may charge a fee to certify a provider of personal care services described under par. (d) 3. e., except that no fee may be imposed on an individual who is eligible for the veterans fee waiver program under s. 45.44. Fees collected under this paragraph shall be credited to the appropriation account under s. 20.435 (6) (jm).
49.45(42)(d) (d) Personal care services under s. 49.46 (2) (b) 6. j. provided to an individual are reimbursable under medical assistance only if all of the following conditions are met:
49.45(42)(d)1. 1. The provider of the personal care services receives prior authorization from the department for all personal care services that are provided to the individual in excess of 50 hours in a calendar year.
49.45(42)(d)2. 2. The individual is not eligible to receive home health services under medicare, as defined in sub. (3) (L) 1. b.
49.45(42)(d)3. 3. The provider of the personal care services is one of the following:
49.45(42)(d)3.a. a. An independent living center meeting the criteria to receive a grant under s. 46.96.
49.45(42)(d)3.b. b. A county department under s. 46.215, 46.22, 46.23, 51.42, or 51.437.
49.45(42)(d)3.c. c. A federally recognized American Indian tribe or band certified to provide services to medical assistance beneficiaries.
49.45(42)(d)3.d. d. A home health agency licensed under s. 50.49.
49.45(42)(d)3.e. e. Any other entity certified under sub. (2) (a) 11. to provide personal care services under s. 49.46 (2) (b) 6. j.
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 under s. 46.27 (11) 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)(e) (e) If the department takes enforcement action against an adult day care center for violating a certification requirement established under s. 49.45 (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(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(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(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(51) (51)Medical care transportation services.
49.45(51)(a)(a) By November 1 annually, the department shall provide to the department of revenue information concerning the estimated amounts of supplements payable from the appropriation accounts under s. 20.435 (4) (b) and (gm) to specific local governmental units for the provision of transportation for medical care, as specified under s. 49.46 (2) (b) 3., during the fiscal year. Beginning November 1, 2004, the information that the department provides under this paragraph shall include any adjustments necessary to reflect actual claims submitted by service providers in the previous fiscal year.
49.45(51)(b) (b) On the date that is the 3rd Monday in November, the department shall annually pay to specific local governmental units the estimated net amounts specified in par. (a).
49.45(52) (52)Payment adjustments; federal funding for certain services.
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(54) (54)Therapy for children participating in the birth to 3 program.
49.45(54)(a)(a) Federal share for county expenditures. If a county certifies to the department that the amount the county expended to provide services specified under s. 49.46 (2) (b) 6. b. and c. to children participating in the early intervention program under s. 51.44 exceeds the amount the county received as reimbursement under this section, based on reimbursement rates established by the department for those services, and the federal government pays the state the federal share of Medical Assistance for the amount by which the county expenditures exceed the reimbursement, the department may disburse the federal share to the county. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under s. 51.44 or for services under the disabled children's long-term support program, as defined in s. 46.011 (1g).
49.45(54)(b) (b) Services provided by special educators. If a county provides services to assess and promote skill acquisition to children who are participating in the early intervention program under s. 51.44 and the services are provided by a special educator who is a certified provider of medical assistance, the department shall reimburse the county the federal share of medical assistance for the county's allowable charges for providing the services. The county shall pay the remaining expenses for the services. The department shall promulgate rules establishing certification requirements for special educators who provide service under this paragraph, and requirements for county reporting of expenditures for services under this paragraph. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under s. 51.44 or for services under the disabled children's long-term support program, as defined in s. 46.011 (1g).
49.45(56) (56)Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57), the department shall develop and implement, for Medical Assistance recipients, disease management programs. These programs shall have at least the following characteristics:
49.45(56)(a) (a) The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
49.45(56)(b) (b) Educating health care providers on health care process improvement by developing best practice models.
49.45(56)(c) (c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
49.45(56)(d) (d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
49.45(56)(e) (e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
49.45(57) (57)Physical health risk assessment. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.
49.45(58) (58)Program for all-inclusive care for the elderly. The department may administer the program of all-inclusive care for the elderly under 42 USC 1396u-4.
49.45(59) (59)Health maintenance organization payments to hospitals.
49.45(59)(a)(a) The department shall, from the appropriation accounts under s. 20.435 (4) (xc) and (xe), pay each health maintenance organization with which it contracts to provide medical assistance a monthly amount that the health maintenance organization shall use to make payments to hospitals under par. (b).
49.45(59)(b) (b) Health maintenance organizations shall pay all of the moneys they receive under par. (a) to eligible hospitals, as defined in s. 50.38 (1), within 15 days after receiving the moneys. The department shall specify in contracts with health maintenance organizations to provide medical assistance a method that health maintenance organizations shall use to allocate the amounts received under par. (a) among eligible hospitals based on the number of discharges from inpatient stays and the number of outpatient visits for which the health maintenance organization paid such a hospital in the previous month for enrollees who are recipients of medical assistance. Payments under this paragraph shall be in addition to any amount that a health maintenance organization is required by agreement between the health maintenance organization and a hospital to pay the hospital for providing services to the health maintenance organization's enrollees.
49.45(59)(c) (c) Each health maintenance organization that provides medical assistance shall report to the department each month the amount it paid each hospital under par. (b) and the percentage of the total payments it made under par. (b) that it paid to each hospital.
49.45(59)(d) (d) Each health maintenance organization that provides medical assistance shall report monthly to each hospital to which the health maintenance organization makes payments under par. (b) such information regarding the payments that the department specifies in its contract with the health maintenance organization to provide medical assistance.
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2011-12 Wisconsin Statutes updated though 2013 Wis. Act 200 and all Supreme Court Orders entered before April 11, 2014. Published and certified under s. 35.18. Changes effective after April 11, 2014 are designated by NOTES. (Published 4-11-14)