“Physician" means a person licensed to practice medicine and surgery, and includes graduates of osteopathic colleges holding an unlimited license to practice medicine and surgery.
“Provider" means a person, corporation, limited liability company, partnership, unincorporated business or professional association and any agent or employee thereof who provides medical assistance.
“Public medical institution" has the meaning designated in Title XIX of the federal social security act.
“Secretary" means the secretary of health services.
“Skilled nursing home" means a facility or distinct part thereof, which:
Is licensed or approved under state law for the accommodation of convalescents or other persons who are not acutely ill and not in need of hospital care;
Employs sufficient registered nursing practitioners for supervision of those giving nursing care to patients; and
Qualifies as a “skilled nursing facility" within the meaning of Title XIX of the social security act.
“Spouse" means the legal husband or wife of the beneficiary, whether or not eligible for medical assistance.
Medical assistance; administration. 49.45(1)(1)
To provide appropriate health care for eligible persons and obtain the most benefits available under Title XIX of the federal social security act, the department shall administer medical assistance, rehabilitative and other services to help eligible individuals and families attain or retain capability for independence or self-care as hereinafter provided.
Exercise responsibility relating to fiscal matters, the eligibility for benefits under standards set forth in ss. 49.46
, and general supervision of the medical assistance program.
Employ necessary personnel under the classified service for the efficient and economical performance of the program and shall supply residents of this state with information concerning the program and procedures.
Determine the eligibility of persons for medical assistance, rehabilitative, and social services under ss. 49.46
, and 49.471
and rules and policies adopted by the department and may, under a contract under s. 49.78 (2)
, delegate all, or any portion, of this function to the county department under s. 46.215
, or 46.23
or a tribal governing body.
To the extent funds are available under s. 20.435 (4) (bm)
, certify all proper charges and claims for administrative services to the department of administration for payment and the department of administration shall draw its warrant forthwith.
Cooperate with the division for learning support in the department of public instruction to carry out the provisions of Title XIX.
Appoint such advisory committees as are necessary and proper.
Cooperate with the federal authorities for the purpose of providing the assistance and services available under Title XIX to obtain the best financial reimbursement available to the state from federal funds.
Periodically report to the joint committee on finance concerning projected expenditures and alternative reimbursement and cost control policies in the medical assistance program.
Periodically set forth conditions of participation and reimbursement in a contract with provider of service under this section.
After reasonable notice and opportunity for hearing, recover money improperly or erroneously paid or overpayments to a provider by offsetting or adjusting amounts owed the provider under the program, crediting against a provider's future claims for reimbursement for other services or items furnished by the provider under the program, or requiring the provider to make direct payment to the department or its fiscal intermediary.
Establish a deadline for payment of a recovery imposed under this subdivision and, if a provider fails to pay all of the amount to be recovered by the deadline, require payment, by the provider, of interest on any delinquent amount at the rate of 1 percent per month or fraction of a month from the date of the overpayment.
Establish criteria for certification of providers of medical assistance and, except as provided in par. (b) 6m.
and s. 49.48
, and subject to par. (b) 7.
, certify providers who meet the criteria.
The department shall accept relevant education, training, instruction, or other experience that an applicant obtained in connection with military service, as defined in s. 111.32 (12g)
, to count toward the education, training, instruction, or other experience that is required to certify providers of medical assistance if the applicant demonstrates to the satisfaction of the department that the education, training, instruction, or other experience that the applicant obtained in connection with his or her military service is substantially equivalent to the education, training, instruction, or other experience required for the certification.
Decertify a provider from or restrict a provider's participation in the medical assistance program, if after giving reasonable notice and opportunity for hearing the department finds that the provider has violated a federal statute or regulation or a state statute or administrative rule and the violation is, by statute, regulation, or rule, grounds for decertification or restriction. The department shall suspend the provider pending the hearing under this subdivision if the department includes in its decertification notice findings that the provider's continued participation in the medical assistance program pending hearing is likely to lead to the irretrievable loss of public funds and is unnecessary to provide adequate access to services to medical assistance recipients. As soon as practicable after the hearing, the department shall issue a written decision. No payment may be made under the medical assistance program with respect to any service or item furnished by the provider subsequent to decertification or during the period of suspension.
Notify the medical examining board, or any affiliated credentialing board attached to the medical examining board, of any decertification or suspension of a person holding a license granted by the board or the affiliated credentialing board if the grounds for the decertification or suspension include fraud or a quality of care issue.
Impose additional sanctions for noncompliance with the terms of provider agreements under subd. 9.
or certification criteria established under subd. 11.
Assure due process in implementing subds. 12.
by providing written notice, a fair hearing and a written decision.
Routinely provide notification to persons eligible for medical assistance, or such persons' guardians, of the department's access to provider records.
Notify the joint committee on finance and appropriate standing committees in each house of the legislature prior to renewing, extending or amending the claims processing contract under the medical assistance program.
Conduct outreach for the early and periodic screening, diagnosis and treatment program as required under 42 CFR 441
. This activity is limited to persons under 21 years of age who have been determined to be eligible for medical assistance.
Submit a report, by May 1, 1991, and annually thereafter, to the joint committee on finance on the participation rates of children in the early and periodic screening and diagnosis program.
After consulting with counties, independent living centers, consumer organizations and home health agencies, periodically identify those barriers to the provision of personal care services under s. 49.46 (2) (b) 6. j.
which lead to a failure to respond to the needs and preferences of individuals who are eligible for these services and act to remove the barriers to the extent possible.
Promulgate rules that define “supportive services", “personal services" and “nursing services" provided in a certified residential care apartment complex, as defined under s. 50.01 (6d)
, for purposes of reimbursement under s. 46.277 (5) (e)
In consultation with hospitals, health maintenance organizations, county departments of social services and of human services and other interested parties, develop and, not later than January 1, 1999, implement a process for expediting medical assistance eligibility determinations for persons in urgent medical situations. The department shall promulgate any rules necessary for the implementation of that process.
Promulgate rules that require that the written plan of care for persons receiving personal care services under medical assistance be reviewed by a registered nurse at least every 60 days. The rules shall provide that the written plan of care shall designate intervals for visits to the recipient's home by a registered nurse as part of the review of the plan of care. The designated intervals for visits shall be based on the individual recipient's needs, and each recipient shall be visited in his or her home by a registered nurse at least once in every 12-month period. The rules shall also provide that a visit to the recipient is also required if, in the course of the nurse's review of the plan of care, there is evidence that a change in the recipient's condition has occurred that may warrant a change in the plan of care.
Direct a county department under s. 46.215
to perform other functions, responsibilities and services, including any functions related to health maintenance organizations, limited service health organizations and preferred provider plans.
Contract with any organization whether or not organized for profit to administer, in full or in part, the benefits under the medical assistance program including prepaid health care. The department shall accept bids on contracts for administrative services and services evaluating the medical assistance program as provided in ch. 16
, but may accept the contract deemed most advantageous for claims processing services; or contract with any insurer authorized under the insurance code of this state to insure the program in full or in part and on behalf of the department. The department shall submit a report each December 31 to the governor, the joint committee on finance and the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under s. 13.172 (3)
, regarding the effectiveness of the management information system for monitoring and analyzing medical assistance expenditures.
Audit all claims filed by any contractor making the payment of benefits paid under ss. 49.46
and make proper fiscal adjustments.
Audit claims filed by any provider of medical assistance, and as part of that audit, request of any such provider, and review, medical records of individuals who have received benefits under the medical assistance program.
Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.
Limit the number of providers of particular services that may be certified under par. (a) 11.
or the amount of resources, including employees and equipment, that a certified provider may use to provide particular services to medical assistance recipients, if the department finds that existing certified providers and resources provide services that are adequate in quality and amount to meet the need of medical assistance recipients for the particular services; and if the department finds that the potential for medical assistance fraud or abuse exists if additional providers are certified or additional resources are used by certified providers. The department shall promulgate rules to implement this subdivision.
Require, as a condition of certification under par. (a) 11.
, all providers of a specific service that is among those enumerated under s. 49.46 (2)
, 49.47 (6) (a)
, or 49.471 (11)
, as specified in this subdivision, to file with the department a surety bond issued by a surety company licensed to do business in this state. Providers subject to this subdivision provide those services specified under s. 49.46 (2)
, 49.47 (6) (a)
, or 49.471 (11)
for which providers have demonstrated significant potential to violate s. 49.49 (3p)
or (4m) (a)
or 946.91 (2)
, (3) (a)
, or (6)
, to require recovery under par. (a) 10.
, or to need additional sanctions under par. (a) 13.
The surety bond shall be payable to the department in an amount that the department determines is reasonable in view of amounts of former recoveries against providers of the specific service and the department's costs to pursue those recoveries. The department shall promulgate rules to implement this subdivision that specify all of the following:
Terms of the surety bond, including amounts, if any, without interest to be refunded to the provider upon withdrawal or decertification from the medical assistance program.
Require a person who takes over the operation, as defined in sub. (21) (ag)
, of a provider, to first obtain certification under par. (a) 11.
for the operation of the provider, regardless of whether the person is currently certified. The department may withhold the certification required under this subdivision until any outstanding repayment under sub. (21)
is made. The department shall promulgate rules to implement this subdivision.
After providing reasonable notice and opportunity for a hearing, charge an assessment to a provider that repeatedly has been subject to recoveries under par. (a) 10. a.
because of the provider's failure to follow identical or similar billing procedures or to follow other identical or similar program requirements. The assessment shall be used to defray in part the costs of audits and investigations by the department under sub. (3) (g)
and may not exceed $1,000 or 200 percent of the amount of any such repeated recovery made, whichever is greater. The provider shall pay the assessment to the department within 10 days after receipt of notice of the assessment or the final decision after administrative hearing, whichever is later. The department may recover any part of an assessment not timely paid by offsetting the assessment against any medical assistance payment owed to the provider and may refer any unpaid assessments not collected in this manner to the attorney general, who may proceed with collection under this subdivision. Failure to timely pay in any manner an assessment charged under this subdivision, other than an assessment that is offset against any medical assistance payment owed to the provider, is grounds for decertification under par. (a) 12.
A provider's payment of an assessment does not relieve the provider of any other legal liability incurred in connection with the recovery for which the assessment is charged, but is not evidence of violation of a statute or rule. The department shall credit all assessments received under this subdivision to the appropriation account under s. 20.435 (4) (iL)
. The department shall promulgate rules to implement this subdivision.
Report on Medical Assistance program changes and finances. 49.45(2n)(a)(a)
In this subsection, “Medical Assistance program" includes any program operated under this subchapter, demonstration program operated under 42 USC 1315
, and program operated under a waiver of federal law relating to medical assistance that is granted by the federal department of health and human services.
Before January 1, 2015, and every 90 days thereafter, the department shall submit to the joint committee on finance a report that contains all of the following information:
An updated description of any Medical Assistance program changes implemented by the department, including any amendments to the Medical Assistance state plan.
An updated estimate of the projected savings associated with any changes described under subd. 1.
An updated projection of the total Medical Assistance program benefit expenditures during the fiscal biennium and an analysis of how these projected expenditures compare to the funding provided in the most recent biennial budget act.
Approval of Medical Assistance program changes.
After March 1, 2018, the department may not expand eligibility under section 2001 (a) (1) (C) of the Patient Protection and Affordable Care Act, P.L. 111-148
, for the Medical Assistance program under this subchapter unless the state legislature has passed legislation to allow the expansion and that legislation is in effect.
Submission of state plan amendments and provider payments. 49.45(2t)(a)(a)
The department may not submit a Medical Assistance state plan amendment to the federal department of health and human services or implement a change to the reimbursement rate for or make a supplemental payment to a provider under the Medical Assistance program under this subchapter when the amendment, rate change, or payment has an expected fiscal effect of $7,500,000 or more from all revenue sources over a 12-month period following the implementation date of the amendment, rate change, or payment without submitting the proposed state plan amendment, rate change, or payment to the joint committee on finance for review. If the cochairpersons of the joint committee on finance do not notify the department within 14 working days after the date of the submittal under this paragraph that the committee has scheduled a meeting for the purpose of reviewing the proposed state plan amendment, rate change, or payment, the department may submit the state plan amendment, implement the rate change, or make the payment. If, within 14 working days after the date of the submittal under this paragraph by the department, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed state plan amendment, rate change, or payment, the department may submit the state plan amendment, implement the rate change, or make the payment only upon approval by the committee.
Notwithstanding par. (a)
, the department is not required to submit a proposed change to a reimbursement rate for or supplemental payment to a provider under the Medical Assistance program under this subchapter to the joint committee on finance under par. (a)
if explicit expenditure authority or funding for the specific change or supplemental payment is included in enacted legislation.
Reimbursement shall be made to each county department under ss. 46.215
, and 46.23
for any administrative services performed in the Medical Assistance program on the basis of s. 49.78 (8)
Reimbursement shall be made to each entity contracted with under s. 46.283 (2)
for functional screenings performed by the entity.
The contractor, if any, administering benefits or providing prepaid health care under s. 49.46
, or 49.471
shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in sub. (2) (a) 4.
, but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
The contractor, if any, insuring benefits under s. 49.46
, or 49.471
shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the persons eligible to receive them and for its services as insurer.
Payment for services provided under this section shall be made directly to the hospital, skilled and intermediate nursing homes, prepaid health care group, other organization or individual providing such services or to an organization which provides such services or arranges for their availability on a prepayment basis.
No payment may be made for inpatient hospital services, skilled nursing home services, intermediate care facility services, tuberculosis institution services or inpatient mental institution services, unless the facility providing such services has in operation a utilization review program and meets federal regulations governing such utilization review program.
After distribution of computer software has been made under 1993 Wisconsin Act 16
, section 9126 (13h)
, no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under s. 49.46
, or 49.471
unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under 42 USC 1395
The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital's total reimbursement or payment to that which would be provided to an economically and efficiently operated facility.
A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented under subd. 1.
shall annually prepare a report of cost and other data in the manner prescribed by the department.
The department may adopt a prospective payment system under subd. 1.
which may include consideration of an average rate per diem, diagnosis-related groups or a hospital-specific prospective rate per discharge.
If the department maintains a retrospective reimbursement system under subd. 1.
for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital's fiscal year may not exceed the lower of the hospital's charges for the services or the actual and reasonable allowable costs to the hospital of providing the services, plus any disproportionate share funding that the hospital is qualified to receive under 42 USC 1396r-4
The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under sub. (6m)
. This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under 42 USC 1320c
, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
Notwithstanding subd. 7.
, the daily reimbursement or payment rate for services at a hospital established under s. 45.50 (10)
provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50
Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital's reimbursement or payment rate under subd. 1.
Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.