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 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)(dm) (dm) Every 24 months, on a schedule determined by the department, an adult day care center shall submit through an online system prescribed by the department a report in the form and containing the information that the department requires, including payment of any fee due under par. (c). If a complete report is not timely filed, the department shall issue a warning to the operator of the adult day care center. The department may revoke an adult day care center's certification for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department.
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(47m) (47m)Family Care funding.
49.45(47m)(a) (a) In this subsection, “care management organization” means a care management organization under contract with the department of health services as described under s. 46.284.
49.45(47m)(b) (b) The department shall collaborate with care management organizations and the federal centers for Medicare and Medicaid services to develop an allowable payment mechanism to increase the direct care and services portion of the capitation rates to address the direct caregiver workforce challenges in the state.
49.45(47m)(d) (d) The department may not implement the plan developed under this subsection unless the department receives federal approval. The department may supplement the appropriation under s. 20.435 (4) (b) from the appropriation under s. 20.865 (4) (a) for implementation of the payment mechanism under par. (b). The department may only use moneys for the payment mechanism under par. (b). Notwithstanding s. 13.101, the joint committee on finance is not required before making a supplementation under this paragraph.
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(49g) (49g)Billing for prescription drugs.
49.45(49g)(a)(a) In this subsection:
49.45(49g)(a)1d. 1d. “Abortion" has the meaning given in s. 253.10 (2) (a).
49.45(49g)(a)1g. 1g. “Abortion provider" means a person that provides abortion services or is an affiliate of a person that provides abortion services.
49.45(49g)(a)1m. 1m. “Covered entity" has the meaning given in 42 USC 256b (a) (4) (C) and (K).
49.45(49g)(a)2. 2. “Prescription drug" has the meaning given in s. 450.01 (20).
49.45(49g)(b) (b) When billing the Medical Assistance program under this subchapter for reimbursement for a prescription drug, a covered entity that is an abortion provider shall bill the actual acquisition cost of the prescription drug for which coverage is provided under s. 49.46 (2) (b) 6. h. and a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h.
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(53m) (53m)Coverage program for institutions for mental disease. Subject to any necessary waiver approval of the federal department of health and human services, or as otherwise permitted under federal law, the department may, if federal funding participation is available, provide Medical Assistance coverage of services provided in an institution for mental disease to persons ages 21 to 64.
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)(c) (c) Special services. From the appropriations under s. 20.435 (4) (b) and (o) and (7) (bt), the department may pay the costs of services provided under the early intervention program under s. 51.44 that are included in program participant's individualized family service plan and that were not authorized for payment under the state Medicaid plan or a department policy before July 1, 2017, including any services under the early intervention program under s. 51.44 that are delivered by a type of provider that becomes certified to provide Medical Assistance service on July 1, 2017, or after.
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.
49.45(59)(e)1.1. If the department determines that a health maintenance organization has not complied with a requirement under pars. (b) to (d), the department shall order the health maintenance organization to comply with the requirement within 15 days after the department's determination of noncompliance.
49.45(59)(e)2. 2. The department may terminate a contract with a health maintenance organization to provide medical assistance if the health maintenance organization fails to comply with a requirement under pars. (b) to (d).
49.45(59)(e)3. 3. The department may audit a health maintenance organization to determine whether the health maintenance organization has complied with the requirements under pars. (b) to (d).
49.45(59)(f) (f) The department shall specify in contracts with health maintenance organizations to provide medical assistance the method for adjusting payments under par. (b) to correct a health maintenance organization's inaccurate counting of inpatient discharges or outpatient visits in calculating a monthly payment to a hospital under par. (b).
49.45(59)(g) (g) If a health maintenance organization and hospital do not agree on the amount of a monthly payment that the health maintenance organization is required to pay the hospital under par. (b), either the health maintenance organization or the hospital, within 6 months after the first day of the month in which the payment is due, may request that the department determine the amount of the payment. The department shall determine the amount of the payment within 60 days after the request for a determination is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under ch. 227 on the department's determination.
49.45(60) (60)Savings account program. The department shall submit to the federal department of health and human services a request for a waiver of federal Medicaid law to establish and implement a savings account program that is similar in function and operation to health savings accounts in the Medical Assistance program under this subchapter. The department shall exclude from any requirement to have a Medical Assistance savings account under the waiver request under this subsection any individual who is elderly, blind, or disabled and any child.
49.45 History History: 1971 c. 40 s. 93; 1971 c. 42, 125; 1971 c. 213 s. 5; 1971 c. 215, 217, 307; 1973 c. 62, 90, 147; 1973 c. 333 ss. 106g, 106h, 106j, 201w; 1975 c. 39; 1975 c. 223 s. 28; 1975 c. 224 ss. 54h, 56 to 59m; 1975 c. 383 s. 4; 1975 c. 411; 1977 c. 29, 418; 1979 c. 34 ss. 837f to 838, 2102 (20) (a); 1979 c. 102, 177, 221, 355; 1981 c. 20 ss. 839 to 854, 2202 (20) (r); 1981 c. 93, 317; 1983 a. 27 ss. 1046 to 1062m, 2200 (42); 1983 a. 245, 447, 527; 1985 a. 29 ss. 1026m to 1031d, 3200 (23), (56), 3202 (27); 1985 a. 120, 176, 269; 1985 a. 332 ss. 91, 251 (5), 253; 1985 a. 340; 1987 a. 27 ss. 989r to 1000s, 2247, 3202 (24); 1987 a. 186, 307, 339, 399; 1987 a. 403 s. 256; 1987 a. 413; 1989 a. 6; 1989 a. 31 ss. 1402 to 1452g, 2909g, 2909i; 1989 a. 107, 173, 310, 336, 351, 359; 1991 a. 22, 39, 80, 250, 269, 315, 316; 1993 a. 16 ss. 1362g to 1403, 3883; 1993 a. 27, 107, 112, 183, 212, 246, 269, 335, 356, 437, 446, 469; 1995 a. 20; 1995 a. 27 ss. 2947 to 3002r, 7299, 9126 (19), 9130 (4), 9145 (1); 1995 a. 191, 216, 225, 289, 303, 398, 417, 457; 1997 a. 3, 13, 27, 114, 175, 191, 237, 252, 293; 1999 a. 9, 63, 103, 180, 185; 2001 a. 13, 16, 35, 38, 57, 67, 104, 109; 2003 a. 33, 318, 321; 2005 a. 22; 2005 a. 25 ss. 1120 to 1149f, 2503 to 2510; 2005 a. 107, 165, 253, 254, 264, 301, 340, 386, 441; 2007 a. 20 ss. 1513 to 1559h, 9121 (6) (a); 2007 a. 90, 97, 104, 141, 153; 2009 a. 2, 28, 113, 177, 180, 190, 221, 334, 342; 2011 a. 10, 32, 120, 126, 158, 192, 209, 258; 2011 a. 260 s. 81; 2013 a. 20, 92; 2013 a. 116 ss. 2, 3, 29, 30; 2013 a. 117 ss. 2, 4; 2013 a. 130; 2013 a. 165 s. 114; 2013 a. 226; 2015 a. 55, 152, 153, 172, 294; 2017 a. 34, 59, 138, 185, 262, 268, 271, 279, 306, 344, 370; 2019 a. 8 ss. 15, 71; 2019 a. 9; s. 13.92 (1) (bm) 2.
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2017-18 Wisconsin Statutes updated through 2019 Wis. Act 20 and through all Supreme Court and Controlled Substances Board Orders filed before and in effect on November 11, 2019. Published and certified under s. 35.18. Changes effective after November 11, 2019, are designated by NOTES. (Published 11-11-19)