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49.45

49.45 Medical assistance; administration.

49.45(1)

(1) Purpose. 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.

49.45(2)

(2) Duties.

49.45(2)(a)

(a) The department shall:

49.45(2)(a)1.

1. Exercise responsibility relating to fiscal matters, the eligibility for benefits under standards set forth in ss. 49.46 to 49.471, and general supervision of the medical assistance program.

49.45(2)(a)2.

2. 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.

49.45(2)(a)3.

3. Determine the eligibility of persons for medical assistance, rehabilitative, and social services under ss. 49.46, 49.468, 49.47, 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, 46.22, or 46.23 or a tribal governing body.

49.45(2)(a)4.

4. 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.

49.45(2)(a)5.

5. Cooperate with the division for learning support, equity and advocacy in the department of public instruction to carry out the provisions of Title XIX.

49.45(2)(a)6.

6. Appoint such advisory committees as are necessary and proper.

49.45(2)(a)7.

7. 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.

49.45(2)(a)8.

8. Periodically report to the joint committee on finance concerning projected expenditures and alternative reimbursement and cost control policies in the medical assistance program.

49.45(2)(a)9.

9. Periodically set forth conditions of participation and reimbursement in a contract with provider of service under this section.

49.45(2)(a)10.

10.

49.45(2)(a)10.a.

a. 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.

49.45(2)(a)10.b.

b. 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% per month or fraction of a month from the date of the overpayment.

49.45(2)(a)10.c.

c. Promulgate rules to implement this subdivision.

49.45(2)(a)11.

11.

49.45(2)(a)11.a.

a. 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. and 8., certify providers who meet the criteria.

49.45(2)(a)11.b.

b. Promulgate rules to implement this subdivision.

49.45(2)(a)12.

12.

49.45(2)(a)12.a.

a. 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.

49.45(2)(a)12.b.

b. Promulgate rules to implement this subdivision.

49.45(2)(a)12r.

12r. 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.

49.45(2)(a)13.

13. Impose additional sanctions for noncompliance with the terms of provider agreements under subd. 9. or certification criteria established under subd. 11.

49.45(2)(a)14.

14. Assure due process in implementing subds. 12. and 13. by providing written notice, a fair hearing and a written decision.

49.45(2)(a)15.

15. Routinely provide notification to persons eligible for medical assistance, or such persons' guardians, of the department's access to provider records.

49.45(2)(a)16.

16. 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.

49.45(2)(a)18.

18. 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.

49.45(2)(a)19.

19. Contract with a county department under s. 46.21, 46.23, 51.42 or 51.437 to perform preadmission screening and resident review under sub. (6c).

49.45(2)(a)20.

20. 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.

49.45(2)(a)22.

22. 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.

49.45(2)(a)23.

23. 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 (1d), for purposes of reimbursement under ss. 46.27 (11) (c) 7. and 46.277 (5) (e).

49.45(2)(a)24.

24. 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.

49.45(2)(a)24m.

24m. 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.

49.45(2)(b)

(b) The department may:

49.45(2)(b)1.

1. Direct a county department under s. 46.215, 46.22 or 46.23 to perform other functions, responsibilities and services, including any functions related to health maintenance organizations, limited service health organizations and preferred provider plans.

49.45(2)(b)2.

2. 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.

49.45(2)(b)3.

3. Audit all claims filed by any contractor making the payment of benefits paid under ss. 49.46 to 49.471 and make proper fiscal adjustments.

49.45(2)(b)4.

4. 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.

49.45(2)(b)5.

5. Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.

49.45(2)(b)6m.

6m. 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.

49.45(2)(b)7.

7. 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 (1) (a), (2) (a) or (b), (3), (3m) (a), (3p), (4) (a), or (4m) (a), 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:

49.45(2)(b)7.a.

a. Services under medical assistance for which providers have demonstrated significant potential to violate s. 49.49 (1) (a), (2) (a) or (b), (3), (3m) (a), (3p), (4) (a), or (4m) (a), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13.

49.45(2)(b)7.b.

b. The amount or amounts of the surety bonds.

49.45(2)(b)7.c.

c. 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.

49.45(2)(b)8.

8. 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.

49.45(2)(b)9.

9. 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% 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.

49.45(3)

(3) Payment.

49.45(3)(a)

(a) Reimbursement shall be made to each county department under ss. 46.215, 46.22, and 46.23 for any administrative services performed in the Medical Assistance program on the basis of s. 49.78 (8). For purposes of reimbursement under this paragraph, assessments completed under s. 46.27 (6) (a) are administrative services performed in the Medical Assistance program.

49.45(3)(ag)

(ag) Reimbursement shall be made to each entity contracted with under s. 46.283 (2) for functional screenings performed by the entity.

49.45(3)(b)

(b)

49.45(3)(b)1.

1. The contractor, if any, administering benefits or providing prepaid health care under s. 49.46, 49.465, 49.468, 49.47, 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.

49.45(3)(b)2.

2. The contractor, if any, insuring benefits under s. 49.46, 49.465, 49.468, 49.47, 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.

49.45(3)(c)

(c) 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.

49.45(3)(d)

(d) 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.

49.45(3)(dm)

(dm) 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, 49.47, 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.

49.45(3)(e)

(e)

49.45(3)(e)1.

1. 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.

49.45(3)(e)2.

2. 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.

49.45(3)(e)3.

3. 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.

49.45(3)(e)4.

4. 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.

49.45(3)(e)7.

7. 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, treatment 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 where 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 1320c-10, 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.

49.45 - ANNOT.

NOTE: Subd. 7. is amended by 2009 Wis. Act 28 eff. the date stated in the notice provided by the secretary of children and families and published in the Wisconsin Administrative Register under s. 48.62 (9) to read:

49.45 - ANNOT.

7. 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 1320c-10, 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.

49.45(3)(e)7m.

7m. 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.

49.45(3)(e)9.

9. 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.

49.45(3)(e)10.

10. 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.

49.45(3)(e)10m.

10m. All facilities listed in a certificate of approval issued to the University of Wisconsin Hospitals and Clinics Authority under s. 50.35 are a hospital for purposes of reimbursement under this section.

49.45(3)(e)10r.

10r. All facilities listed in a certificate of approval issued to a free-standing pediatric teaching hospital under s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician clinic reimbursement rates to reimburse the facilities under this section for types of services for which, before July 1, 2009, the department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.

49.45(3)(e)11.

11. The department shall use a portion of the moneys collected under s. 50.38 (2) (a) to pay for services provided by eligible hospitals, as defined in s. 50.38 (1), other than critical access hospitals, under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for fiscal year 2008-09 divided by 57.75 percent. For each state fiscal year after state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for the fiscal year divided by 61.68 percent.

49.45(3)(e)12.

12. The department shall use a portion of the moneys collected under s. 50.38 (2) (b) to pay for services provided by critical access hospitals under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For each state fiscal year, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (b) for the fiscal year divided by 61.68 percent.

49.45(3)(f)

(f)

49.45(3)(f)1.

1. Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.

49.45(3)(f)2.

2. The department may deny any provider claim for reimbursement which cannot be verified under subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in s. 49.46 (2) or 49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.

49.45(3)(f)2m.

2m. The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.

49.45(3)(f)3.

3. Contractors under sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.

49.45(3)(fm)

(fm) The department shall seek, on behalf of dentists who are providers, federal reimbursement for the cost of any equipment that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of the cost of the equipment that is reimbursed by the federal government.

49.45(3)(g)

(g)

49.45(3)(g)1.

1. The secretary may authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of statutes, regulations, or rules applicable to the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees authorized by the secretary under this paragraph shall be issued, and shall possess at all times while they are performing their investigatory or audit functions under this section, identification, signed by the secretary, that specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Under the request of a designated person and upon presentation of the person's authorization, providers and medical assistance recipients shall accord the person access to any provider personnel, records, books, or documents or other information needed. Under the written request of a designated person and upon presentation of the person's authorization, providers and recipients shall accord the person access to any needed patient health care records of a recipient. Authorized employees may hold hearings, administer oaths, take testimony, and perform all other duties necessary to bring the matter before the department for final adjudication and determination.

49.45(3)(g)2.

2. The department shall promulgate rules to implement this paragraph.

49.45(3)(h)

(h)

49.45(3)(h)1m.

1m. The failure or refusal of a provider to accord department auditors or investigators access as required under par. (g) to any provider personnel, records, books, patient health care records of medical assistance recipients, or documents or other information requested constitutes grounds for decertification or suspension of the provider from participation in the medical assistance program. No payment may be made for services rendered by the provider following decertification, during the period of suspension, or during any period of provider failure or refusal to accord access as required under par. (g).

49.45(3)(h)1n.

1n. The department shall promulgate rules to implement this paragraph.

49.45(3)(j)

(j) Reimbursement for administrative contract costs under this section is limited to the funds available under s. 20.435 (4) (bm).

49.45(3)(k)

(k) If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in s. 448.60 (3), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.

49.45(3)(L)

(L)

49.45(3)(L)1.

1. In this paragraph:

49.45(3)(L)1.a.

a. "Designated health service" has the meaning given in 42 USC 1395nn (h) (6).

49.45(3)(L)1.b.

b. "Medicare" means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395 to 1395ccc.

49.45(3)(L)1.c.

c. "Physician" has the meaning given in s. 448.01 (5).

49.45(3)(L)1.d.

d. "Referral" has the meaning given in 42 USC 1395nn (h) (5).

49.45(3)(L)2.

2. The department may not pay a provider for a designated health service that is authorized under this section or s. 49.46, 49.47, or 49.471, that is provided as the result of a referral made to the provider by a physician and that, under 42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of 42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under 42 USC 1395nn.

49.45(3)(L)3.

3. A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under 42 USC 1395nn (f), as amended to August 10, 1993.

49.45(3)(L)4.

4. Any person who fails to comply with subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.

49.45(3)(L)5.

5. The department shall administer this paragraph consistently with 42 USC 1395nn and 42 USC 1396b (s).

49.45(3)(m)

(m)

49.45(3)(m)1.

1. To be certified under sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in s. 340.01 (23g), that satisfies the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under s. 49.46 (2) (b) 3. or 49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.

49.45(3)(m)2.

2. A person who is certified to provide transportation by specialized medical vehicle under sub. (2) (a) 11. shall ensure that every person who drives or serves as an attendant to passengers on a specialized medical vehicle, before driving or serving as an attendant, has current proficiency in the use of an automated external defibrillator, as defined in s. 256.15 (1) (cr), achieved through instruction provided by an individual, organization, or institution of higher education that is approved under s. 46.03 (38) to provide such instruction.

49.45(4)

(4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.

49.45(5)

(5) Appeal.

49.45(5)(a)

(a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing.

49.45(5)(b)

(b)

49.45(5)(b)1.

1. Upon receipt of a timely petition under par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a certified copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:

49.45(5)(b)1.a.

a. The petitioner withdraws the petition in writing.

49.45(5)(b)1.b.

b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.

49.45(5)(b)1.c.

c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative at a scheduled hearing without good cause, as determined by the department.

49.45(5)(b)2.

2. If a recipient requests a hearing within the timely notice period specified in 42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the county department of the county in which the recipient resides that the recipient has requested a hearing. Medical assistance coverage shall be suspended, reduced, or discontinued if:

49.45(5)(b)2.a.

a. The recipient is contesting a state or federal law or a change in state or federal law and not the determination of the payment made on the recipient's behalf.

49.45(5)(b)2.b.

b. The recipient is notified of a change in his or her medical assistance coverage while the hearing decision is pending but the recipient fails to request a hearing on the change.

49.45(5)(b)3.

3. The recipient shall be promptly informed in writing if medical assistance is to be suspended, reduced or terminated pending the hearing decision.

49.45(5m)

(5m) Supplemental funding for rural hospitals.

49.45(5m)(ag)

(ag) In this subsection, "critical access hospital" has the meaning given in s. 50.33 (1g).

49.45(5m)(am)

(am) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (o), (w) and (xc), the department shall distribute not more than $5,000,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under 42 USC 1396b (i) (3).

49.45(5m)(b)

(b) The supplemental funding for rural hospitals under par. (am) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation to that utilization in other rural hospitals.

49.45(5r)

(5r) Supplemental funding for uncompensated care. Notwithstanding sub. (3) (e), from the appropriation account under s. 20.435 (4) (w), the department shall distribute $3,000,000 in each fiscal year to the University of Wisconsin Hospital and Clinics for care that is not otherwise compensated, except that the department may not make payments that exceed limitations based on customary charges under 42 USC 1396b (i) (3).

49.45(6b)

(6b) Centers for the developmentally disabled. From the appropriation under s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Beginning in fiscal year 2009-10, following each placement made under s. 46.275 that involves a relocation from a center for the developmentally disabled, the department shall reduce the reimbursement to the center by an amount, as determined by the department for each placement, that is equal to the nonfederal share of the costs for the placement under s. 46.275.

49.45(6c)

(6c) Preadmission screening and resident review.

49.45(6c)(a)

(a) Definitions. In this subsection:

49.45(6c)(a)1.

1. "Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. "Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.

49.45(6c)(a)2.

2. "Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.

49.45(6c)(a)3.

3. "County department" means a department under s. 46.21, 46.23, 51.42 or 51.437.

49.45(6c)(a)4.

4. "Developmental disability" means any of the following:

49.45(6c)(a)4.a.

a. Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.

49.45(6c)(a)4.b.

b. A severe, chronic disability that meets all of the conditions for individuals with related conditions as specified in 42 CFR 435.1009.

49.45(6c)(a)5.

5. "Facility" has the meaning given under 42 USC 1396r (a).

49.45(6c)(a)6.

6. "Facility care" means services provided in a facility that are in conformity with 42 USC 1396r and that are payable under sub. (6m).

49.45(6c)(a)6m.

6m. "Intermediate facility" has the meaning given in s. 46.279 (1) (b).

49.45(6c)(a)7.

7. "Mental illness" has the meaning given in 42 USC 1396r (e).

49.45(6c)(b)

(b) Preadmission screening. Except as provided in par. (e), every individual who applies for admission to a facility or to an institution for mental diseases shall be screened to determine if the individual has developmental disability or mental illness. The department or an entity to which the department has delegated authority shall screen every individual who has been identified as having a developmental disability or mental illness to determine if the individual needs facility care. If the individual is determined to need facility care, the department or an entity to which the department has delegated authority shall also assess the individual to determine if he or she requires active treatment for developmental disability or active treatment for mental illness. If the department or entity determines that the individual requires active treatment for developmental disability, the department or entity shall determine whether the level of care required by the individual that is provided by a facility could be provided safely in an intermediate facility or under a plan that is developed under s. 46.279 (4).

49.45(6c)(c)

(c) Resident review. Except as provided in par. (e), the department or an entity to which the department has delegated authority shall review every resident of a facility or institution for mental diseases who has a developmental disability or mental illness and who has experienced a significant change in his or her physical or mental condition to determine all of the following:

49.45(6c)(c)1.

1. Whether the resident needs facility care.

49.45(6c)(c)2.

2. Whether the resident requires active treatment for developmental disability or active treatment for mental illness.

49.45(6c)(c)3.

3. If the department or entity determines under subd. 1. that the resident needs facility care and under subd. 2. that the resident requires active treatment for developmental disability, whether the level of care required by the resident that is provided by a facility could be provided safely in an intermediate facility or under a plan that is developed under s. 46.279 (4).

49.45(6c)(d)

(d) Payment for facility care.

49.45(6c)(d)1.

1. No payment may be made under sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46, 49.47, or 49.471, who has developmental disability or mental illness and for whom under par. (b) or (c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.

49.45(6c)(d)2.

2. Payment may be made under sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under s. 49.46, 49.47, or 49.471 and who has developmental disability or mental illness and is determined under par. (b) or (c) to need facility care, regardless of whether it is determined under par. (b) or (c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.

49.45(6c)(e)

(e)

49.45(6c)(e)1.

1. Payment under sub. (6m) may be made to a facility and no screening under par. (b) or review under par. (c) is required for an individual who is medically diagnosed as having developmental disability or mental illness, and who is not a danger to himself or herself or to others, if, immediately after release from a hospital, the individual enters the facility, as part of a medically prescribed period of recovery, for a period not to exceed 30 days and the admission is approved by the department or an entity to which the department has delegated authority.

49.45(6c)(e)2.

2. Payment under sub. (6m) may be made to a facility or institution for mental diseases for an individual who is 65 years of age or older, is medically diagnosed as having developmental disability or mental illness, is not a danger to himself or herself or to others and is competent to make an independent decision, if, following screening under par. (b) or review under par. (c), all of the following apply:

49.45(6c)(e)2.a.

a. It is determined that the individual needs facility care and requires active treatment for developmental disability or active treatment for mental illness.

49.45(6c)(e)2.b.

b. The individual chooses not to participate in active treatment.

49.45(6c)(f)

(f) Hearing. An individual for whom admission to a facility or institution for mental diseases is denied under par. (b) or for whom a determination under par. (c) results in prohibition of payment to a facility or institution for mental diseases under par. (d) and relocation from the facility to a facility or institution for mental diseases may request a hearing from the department.

49.45(6c)(g)

(g) Rule making. The department shall promulgate all of the following rules:

49.45(6c)(g)1.

1. Establishing criteria and procedures for a determination by the department under par. (d) that a resident be relocated from a facility after March 31, 1990, and before December 31, 1993.

49.45(6c)(g)2.

2. Establishing standards for the conduct of hearings under par. (f).

49.45(6h)

(6h) Liability for disallowances. If the department or the federal health care financing administration finds a skilled nursing facility or intermediate care facility in this state that provides care to medical assistance recipients for which the facility receives reimbursement under sub. (6m) to be an institution for mental diseases, the facility shall be liable for any retroactive federal medicaid disallowances for services provided after the date of the finding.

49.45(6j)

(6j) Limitation on certain facility coverage. The department shall determine, under a method devised by the department, the average population during the period from January 1, 1987, to June 30, 1988, of persons in each skilled nursing facility or an intermediate care facility who are mentally ill and are aged 21 to 64, except persons under 22 years of age who were receiving medical assistance services in the facility prior to reaching age 21 and continuously thereafter. Beginning July 1, 1988, the payment under sub. (6m) for services provided by a facility to persons who are mentally ill and are within the age limitations specified in this subsection may not exceed the payment for the average population of these persons in that facility, as determined by the department.

49.45(6m)

(6m) Payment to facilities.

49.45(6m)(a)

(a) In this subsection:

49.45(6m)(a)1.

1. "Active treatment" has the meaning specified in 42 USC 1396r (e) (7) (G) (iii).

49.45(6m)(a)2.

2. "Cost center" means a group of similar facility expenses.

49.45(6m)(a)3.

3. "Facility" means a nursing home or a community-based residential facility that is licensed under s. 50.03 and that is certified by the department as a provider of medical assistance.

49.45(6m)(a)5.

5. "Nursing home" has the meaning given under s. 50.01 (3).

49.45(6m)(a)6.

6. "Resource Utilization Groupings III" means a comparative resource utilization grouping that classifies each facility resident based on information obtained from performing, for the resident, a minimum data set assessment developed by the federal Centers for Medicare and Medicaid Services.

49.45(6m)(ag)

(ag) Payment for care provided in a facility under this subsection made under s. 20.435 (4) (b), (o), (pa), or (w) shall, except as provided in pars. (bg), (bm), and (br), be determined according to a prospective payment system updated annually by the department. The payment system shall implement standards that are necessary and proper for providing patient care and that meet quality and safety standards established under subch. II of ch. 50 and ch. 150. The payment system shall reflect all of the following:

49.45(6m)(ag)1.

1. A prudent buyer approach to payment for services, under which a reasonable price recognizing selected factors that influence costs is paid for service that is of acceptable quality.

49.45(6m)(ag)2.

2. Except as provided in subd. 3r., standards established by the department that shall be based upon allowable costs incurred by facilities in the state as available from information submitted under par. (c) 3. and compiled by the department.

49.45(6m)(ag)3m.

3m. For each state fiscal year, rates that shall be set by the department based on information from cost reports for costs specified under par. (am) 1. bm., 4., 5m., and 6. for the most recently completed fiscal year of the facility.

49.45(6m)(ag)3p.

3p. For all costs specified under par. (am) 1. bm., an acuity-based payment rate system to which all of the following applies:

49.45(6m)(ag)3p.a.

a. The system shall incorporate acuity measurements under the most recent Resource Utilization Groupings III methodology to determine factors for case-mix adjustment.

49.45(6m)(ag)3p.b.

b. Four times annually, for each facility resident who is a Medical Assistance recipient on March 31, June 30, September 30, or December 31, as applicable, the system shall determine the average case-mix index by use of the factors specified under subd. 3p. a.

49.45(6m)(ag)3p.c.

c. The system shall incorporate payment adjustments for dementia, behavioral needs, or other complex medical conditions.

49.45(6m)(ag)3p.d.

d. The system may include incentives for providing high quality of care.

49.45(6m)(ag)3r.

3r. Flat-rate payment for all costs specified under par. (am) 1. a. and 2.

49.45(6m)(ag)5.

5. Consideration for special needs of facility residents.

49.45(6m)(ag)6.

6. Standards for capital payment that will be based upon replacement value of a facility as determined by a commercial estimator with which the department contracts and criteria and limitations as determined by the department.

49.45(6m)(ag)7.

7. Assurance of an acceptable quality of care for all medical assistance recipients provided nursing home care.

49.45(6m)(am)

(am) In determining payments for a facility under the payment system in par. (ag), the department shall consider all of the following cost centers:

49.45(6m)(am)1.

1. Allowable direct care costs, including, if provided, any of the following:

49.45(6m)(am)1.a.

a. Personal comfort supplies; medical supplies; over-the-counter drugs; and nonbillable services of a ward clerk, activity person, recreation person, social worker, volunteer coordinator, teacher for residents aged 22 and older, vocational counselor for residents aged 22 and older, religious person, therapy aide, therapy assistant, and counselor on resident living.

49.45(6m)(am)1.bm.

bm. Nonbillable services of a registered nurse, licensed practical nurse, and nurse aide.

49.45(6m)(am)2.

2. Allowable support service costs, including the following allowable facility expenses:

49.45(6m)(am)2.a.

a. Dietary service for the provision of meals to facility residents.

49.45(6m)(am)2.b.

b. Environmental service for the provision of maintenance, housekeeping, laundry and security service.

49.45(6m)(am)2.c.

c. Allowable fuel and utility costs, including the facility expenses that the department determines are allowable for the provision of electrical service, water and sewer services, and heat.

49.45(6m)(am)2.d.

d. Allowable administrative and general costs, including costs related to the facility's overall management and administration and allowable expenses that are not recognized or reimbursed in other cost centers and including the costs of commercial estimators approved by the department under par. (ar) 6.

49.45(6m)(am)4.

4. Property tax or municipal service costs paid by the owner of the facility for the facility.

49.45(6m)(am)5m.

5m. Allowable interest expense of the facility, less interest income of the facility and less interest income of affiliated entities, to the extent required under the approved state plan for services under 42 USC 1396.

49.45(6m)(am)6.

6. Capital payment necessary for the provision of service over time, including allowable facility expenses for suitable space, furnishings, property insurance and movable equipment for patient care.

49.45(6m)(ap)

(ap) If the bed occupancy of a nursing home is below the minimum patient day occupancy standards that are established by the department under par. (ar) (intro.), the department may approve a request by the nursing home to delicense any of the nursing home's licensed beds. If the department approves the nursing home's request, all of the following apply:

49.45(6m)(ap)1.

1. The department shall delicense the number of beds in accordance with the nursing home's request.

49.45(6m)(ap)2.

2. The department may not include the number of beds of the nursing home that the department delicenses under this paragraph in determining the costs per patient day under the minimum patient day occupancy standards under par. (ar).

49.45(6m)(ap)3.

3. The nursing home may not use or sell a bed that is delicensed under this paragraph.

49.45(6m)(ap)4.

4.

49.45(6m)(ap)4.a.

a. Every 12 months following the delicensure of a bed under this paragraph, for which a nursing home has not resumed licensure under subd. 5., the department shall reduce the licensed bed capacity of the nursing home by 10% of all of the nursing home's beds that remain delicensed under this paragraph or by 25% of one bed, whichever is greater. The department shall reduce the statewide maximum number of licensed nursing home beds under s. 150.31 (1) (intro.) by the number or portion of a number of beds by which the nursing home's licensed bed capacity is reduced under this subdivision.

49.45(6m)(ap)4.b.

b. Subdivision 4. a. does not apply with respect to the delicensure of beds between October 14, 1997, and the date that is 60 days after October 14, 1997, during the period of any contract entered into by a nursing home prior to January 1, 1997, if the contract requires the nursing home to maintain its current licensed bed capacity.

49.45(6m)(ap)5.

5. A nursing home retains the right to resume licensure of a bed of the nursing home that was delicensed under this paragraph unless the licensed bed capacity of the nursing home has been reduced by that bed under subd. 4. The nursing home may not resume licensure of a fraction of a bed. The nursing home may resume licensure 18 months after the nursing home notifies the department in writing that the nursing home intends to resume the licensure. If a nursing home resumes licensure of a bed under this subdivision, subd. 2. does not apply with respect to that bed.

49.45(6m)(ap)6.

6. If subd. 4. b. applies and the nursing home later resumes licensure of a bed that was delicensed between October 14, 1997, and the date that is 60 days after October 14, 1997, the department shall calculate the costs per patient day using the methodology specified in the state plan that is in place at the time that the delicensed beds are resumed.

49.45(6m)(ar)

(ar) In determining payments for a facility under par. (ag), the department may establish minimum patient day occupancy standards for determining costs per patient day and shall apply the following methods to calculate amounts payable for the rate year for the cost centers described under par. (am):

49.45(6m)(ar)1.

1. For direct care costs:

49.45(6m)(ar)1.a.

a. The department shall establish standards for payment of allowable direct care costs under par. (am) 1. bm., for facilities that do not primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state and separate standards for payment of allowable direct care costs, for facilities that primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state. The standards shall be adjusted by the department for regional labor cost variations. The department shall treat as a single labor region the counties of Dane, Iowa, Columbia, Sauk, and Rock and shall adjust payment so that the direct care cost targets of facilities in Dane, Iowa, Columbia, and Sauk counties are not reduced as a result of including facilities in Rock County in this labor region. For facilities in Douglas, Pierce, and St. Croix counties, the department shall perform the adjustment by use of the wage index that is used by the federal department of health and human services for hospital reimbursement under 42 USC 1395 to 1395ggg.

49.45(6m)(ar)1.b.

b. The department shall establish the direct care component of the facility rate for each facility by comparing actual allowable direct care cost information of that facility adjusted for inflation to the standards established under subd. 1. a.

49.45(6m)(ar)1.c.

c. If a facility has an approved program for provision of service to mentally retarded residents, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under subd. 1. b. may be made to that facility according to a method developed by the department.

49.45(6m)(ar)1.cm.

cm. Funding distributed to facilities for the provision of active treatment to residents with a diagnosis of developmental disability shall be distributed in accordance with a method developed by the department which is consistent with a prudent buyer approach to payment for services.

49.45(6m)(ar)2.

2. For support service costs, the department shall establish one or more standards for the payment of support service costs that take into account support service costs for a sample of all facilities within the state.

49.45(6m)(ar)4.

4. For net property taxes or municipal services, payment shall be made for the amount of