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49.45(26g)(b)1. 1. A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.
49.45(26g)(b)2. 2. The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.
49.45(26g)(b)3. 3. A description of the hospital's or health care system's intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.
49.45(26g)(b)4. 4. A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care:
49.45(26g)(b)4.a. a. Discharge instructions and contacts for following up on care and treatment.
49.45(26g)(b)4.b. b. Referral information.
49.45(26g)(b)4.c. c. Appointment scheduling.
49.45(26g)(b)4.d. d. Medication instructions.
49.45(26g)(b)4.e. e. Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization.
49.45(26g)(b)4.f. f. Information about other health and social resources, such as transportation and housing.
49.45(26g)(b)5. 5. A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization.
49.45(26g)(b)6. 6. The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.
49.45(26g)(c) (c) The department shall do all of the following:
49.45(26g)(c)1. 1. Encourage, but not require, any hospital or health care system that seeks to apply to participate in the reimbursement program under this subsection to collaborate with any managed care organization with which it has an agreement to provide services to Medical Assistance recipients. The department may not limit patient populations eligible to participate in the intensive care coordination program under this subsection to either those individuals enrolled in managed care to receive Medical Assistance services or those individuals currently receiving Medical Assistance services on a fee-for-service basis. The department may not deny a hospital or health care system applicant for the reimbursement program under this subsection solely because the applicant does not have an agreement to implement an intensive care coordination program with a managed care organization.
49.45(26g)(c)2. 2. Respond to the hospital or health care system indicating whether additional information is required to evaluate the application for the reimbursement program under this subsection.
49.45(26g)(c)3. 3. After consulting with hospitals, health care systems, and other providers, develop uniform outcome measures to use in determining the efficacy of the program.
49.45(26g)(c)4. 4. If the hospital or health care system is selected for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement.
49.45(26g)(c)5. 5. If the department does not receive a proposal for the reimbursement program under this subsection, solicit proposals for the reimbursement program under this subsection from other health care providers under s. 146.81 (1).
49.45(26g)(d) (d) The department shall provide as reimbursement for intensive care coordination to participants in the program under this subsection $250 initially for each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the hospital or health care system enrolls in intensive care coordination. The initial enrollment for each recipient lasts for 6 months, and if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population, the participant receives an additional $250 for each enrollee at the end of the 6 months. The program participant may enroll each Medical Assistance recipient in one additional 6-month period for an additional $250 per enrollee initial reimbursement payment and $250 per enrollee at the end of the additional 6-month period if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population. The department shall pay no more than $1,500,000 cumulatively in each fiscal year from all funding sources for reimbursements under this paragraph.
49.45(26g)(e) (e) Annually, each hospital and health care system that is participating in the reimbursement program under this subsection shall submit a report to the department containing all of the following:
49.45(26g)(e)1. 1. The number of Medical Assistance recipients served by intensive care coordination.
49.45(26g)(e)2. 2. For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination.
49.45(26g)(e)3. 3. Any demonstrated outcomes, as specified by the department under par. (c) 3., for Medical Assistance recipients.
49.45(26g)(e)4. 4. Any other information required by the department.
49.45(26g)(f) (f) For each hospital or health care system eligible for the reimbursement program under this subsection, the department shall calculate the costs saved to the Medical Assistance program by avoiding emergency department visits by subtracting the sum of reimbursements made under par. (d) to the participant from the sum of costs of visits to the emergency department as reported under par. (e) 2. that were expected to occur without intensive care coordination but did not because of enrollment in the program under this subsection. If the result of the calculation is positive in the first 6 months of the recipient's enrollment in the program under this subsection, the department shall distribute 25 percent of the amount saved to the hospital, health care system, or managed care organization subject to pars. (g) and (i). If the result of the calculation is positive after 12 months of the recipient's enrollment in the program under this subsection, the department shall distribute a share of the savings to the hospital, health care system, or managed care organization such that the total amount of shared savings payments made equals half of the savings for the entire 12-month period, subject to pars. (g) and (i).
49.45(26g)(g) (g) If a hospital or health care system participating in the program under this subsection provides services to Medical Assistance recipients enrolled in managed care, the department shall make any payment under the program under this subsection under par. (d) or (f) to the managed care organization with which the hospital or health care system has an agreement to provide services to Medical Assistance recipients. The managed care organization shall pass the payments made under pars. (d) and (f) on to the hospital or health care system no later than 30 days after receiving the payment from the department. The department shall make payments under pars. (d) and (f) to a hospital or health care system that provides services to Medical Assistance recipients who are not enrolled in managed care directly to the hospital or health care system.
49.45(26g)(h) (h) No later than 24 months after the date on which the first hospital or health care system is able to enroll individuals in the intensive care coordination program under this subsection, the department shall submit a report to the joint committee on finance summarizing the information reported under par. (e) including the costs saved by avoiding emergency department visits as calculated under par. (f).
49.45(26g)(i) (i) The department shall seek any necessary approval from the federal department of health and human services to implement the program under this subsection. If the federal department of health and human services disapproves the request for approval, the department may implement the reimbursement under par. (d), the savings distribution under par. (f), or both or any part of the program under this subsection.
49.45(26g)(j) (j) If the federal department of health and human services does not disapprove a request for approval under par. (i) or if federal approval is not required, the department shall implement at least 2 pilot programs under this subsection by the later of September 1, 2018, or the date that is 30 days after the date of federal approval, if approval is needed.
49.45(27) (27)Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v).
49.45(29) (29)Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46, 49.47, and 49.471.
49.45(29r) (29r)Behavioral health care coordination pilot projects.
49.45(29r)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29r)(b) (b) Subject to par. (c), the department shall develop and award at least 2 pilot projects lasting no more than 3 years each to test alternative, coordinated care delivery and Medical Assistance payment models designed to reduce costs of recipients of Medical Assistance under this subchapter who have significant or chronic mental illness. A health care provider that is awarded a pilot project shall target a Medical Assistance population of high volume or high intensity users of non-behavioral health medical services, such as individuals with more than 5 emergency department visits in a year or individuals who have frequent or longer than average inpatient hospital stays, who also have significant or chronic mental illness. The department may not limit eligibility for the pilot project or awards under this subsection on the basis that the health care provider that is awarded the pilot project serves a target population that includes individuals enrolled in a Medical Assistance health maintenance organization. Each pilot project under this subsection shall include either a Medical Assistance payment on a per member per month basis for a specified pilot project population that is in addition to existing payment for services provided under the Medical Assistance program, including services reimbursed on a fee-for-service basis and services provided under managed care, or shall include an alternative Medical Assistance payment for a specified pilot project. The department shall require health care providers that are awarded a pilot project to submit to the department interim and final reports analyzing differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports. The department shall award the pilot projects and allocate funding only to health care providers that meet all of the following criteria:
49.45(29r)(b)1. 1. The health care provider provides all of the following services directly or through an affiliated entity:
49.45(29r)(b)1.a. a. Emergency department services.
49.45(29r)(b)1.b. b. Outpatient psychiatric services.
49.45(29r)(b)1.c. c. Outpatient primary care services.
49.45(29r)(b)1.d. d. Inpatient psychiatric services.
49.45(29r)(b)1.e. e. General inpatient hospital services.
49.45(29r)(b)1.f. f. Services of a care coordinator or navigator for each individual in the pilot project.
49.45(29r)(b)2. 2. The health care provider provides, directly or through an affiliated entity or contracted entity, the coordination of social services fostering the individual's recovery following an inpatient psychiatric discharge.
49.45(29r)(c) (c) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot projects under par. (b) beginning no earlier than January 1, 2016.
49.45(29r)(d) (d) Subject to par. (c), the department shall allocate a total state share amount of $600,000 plus any federal matching moneys as funding for all 3-year pilot projects under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot projects under this subsection.
49.45(29u) (29u)Psychiatric consultation reimbursement pilot project.
49.45(29u)(a)(a) In this subsection, “health care provider" does not include a health maintenance organization.
49.45(29u)(b) (b) Subject to par. (e), the department shall develop and award a pilot project lasting up to 3 years to test a new Medical Assistance payment model for adult recipients of Medical Assistance that is designed to encourage the provision of psychiatric consultations by psychiatrists to health care providers treating primary care issues and to selected specialty health care providers to help those providers manage and treat adults with mild to moderate mental illness and physical health needs. An applicant for the pilot project under this subsection shall submit a strategy to use the pilot project funding to improve mental health access in the applicant's service area and to reduce overall Medical Assistance costs. The department shall require the health care provider that is awarded the pilot project to submit to the department interim and final reports analyzing the differences in utilization of services and Medical Assistance expenditures between individuals in the pilot project population and individuals in a control group that is agreed upon by the health care provider awarded the pilot project and the department. A health care provider that is awarded a pilot project shall submit the interim report by January 1, 2017, and shall submit a final report by January 1, 2019, and at the conclusion of the pilot project if the project concludes later than January 1, 2019. The department shall provide to a health care provider that is awarded a pilot project the Medical Assistance utilization and expenditure data necessary for the health care provider to create the reports.
49.45(29u)(c) (c) The department shall award a pilot project only to a health care provider that is an organization that provides outpatient psychiatric services and primary and specialty care outpatient services for physical health conditions. The department shall allocate funding to the health care provider that is awarded a pilot project or to individual psychiatrists providing care within the organization of the health care provider that is awarded a pilot project. The department shall allocate a total state share amount of $200,000 plus any federal matching moneys as funding for the 3-year pilot project under this subsection. The department shall seek federal Medicaid moneys to match the state share allocated for the pilot project under this subsection.
49.45(29u)(d) (d) The department may limit a pilot project awarded to a health care provider described under par. (c) to specific providers or clinics within the multispecialty outpatient clinic organization.
49.45(29u)(e) (e) Subject to approval by the federal department of health and human services of any required waiver of federal Medicaid law or any required amendment to the state Medical Assistance plan, the department shall implement the pilot project under par. (b) beginning no earlier than January 1, 2016.
49.45(29w) (29w)Mental health services.
49.45(29w)(a) (a) In providing mental health benefits under this subchapter, the department shall do all of the following:
49.45(29w)(a)1. 1. Allow a severely emotionally disturbed child, as defined in sub. (25) (a), to access in-home therapy without having to show a failure to succeed in outpatient therapy.
49.45(29w)(a)2. 2. Allow qualifying families to participate in in-home therapy even if a child in that family is enrolled in a day treatment program.
49.45(29w)(b)1.1. In this paragraph:
49.45(29w)(b)1.a. a. “Mental health service" means a service that is covered under one of the Medical Assistance mental health or substance abuse benefits under s. 49.46 (2) of outpatient mental health, outpatient substance abuse, pharmacologic management, mental health day treatment, substance abuse day treatment, crisis intervention, service provided by a community support program or community based-psychosocial service program, community recovery services, psychotherapy and alcohol and other drug abuse services, child or adolescent day treatment services, or any other mental health or substance abuse benefit described in s. 49.46 (2).
49.45(29w)(b)1.b. b. “Telehealth" means a service provided from a remote location using a combination of interactive video, audio, and externally acquired images through a networking environment between an individual or a provider at an originating site and a provider at a remote location with the service being of sufficient audio and visual fidelity and clarity as to be functionally equivalent to face-to-face contact; or, in circumstances determined by the department, an asynchronous transmission of digital clinical information through a secure electronic communications system from one provider to another provider. “Telehealth" does not include telephone conversations or Internet-based communications between providers or between providers and individuals.
49.45(29w)(b)2. 2. Mental health services provided through telehealth are reimbursable by the Medical Assistance program under this subchapter if the provider of the service through telehealth satisfies all of the following criteria:
49.45(29w)(b)2.a. a. The provider is a certified provider of mental health services under Medical Assistance in this state and is an agency that is certified by the department as an emergency mental health service program, a comprehensive community services program, a mental health day treatment services program for children, a program organized under s. 46.23, 51.42, or 51.437, an outpatient psychotherapy clinic, or a community support program or that is certified by the department to perform a community substance abuse prevention and treatment service, except for narcotic treatment service for opiate addiction.
49.45(29w)(b)2.ag. ag. The provider and the individual providing the service comply with all Medical Assistance coverage policies and standards established by the department, rules, and federal statutes and regulations for each particular mental health service provided.
49.45(29w)(b)2.ar. ar. The provider is certified for telehealth by the department.
49.45(29w)(b)2.b. b. The individual who is providing the service is currently licensed, certified, or registered in his or her profession in this state and is in good standing with the applicable examining board in this state for that individual's profession.
49.45(29w)(b)2.c. c. The provider is located in the United States. The provider is not required to be located in this state.
49.45(29y) (29y)Mental health consultation reimbursement.
49.45(29y)(a)(a) In this subsection, “clinical consultation" means, for a student up to age 21, communication from a mental health professional or a qualified treatment trainee working under the supervision of a mental health professional to another individual who is working with the client to inform, inquire, and instruct regarding all of the following and to direct and coordinate clinical service components:
49.45(29y)(a)1. 1. The client's symptoms.
49.45(29y)(a)2. 2. Strategies for effective engagement, care, and intervention for the client.
49.45(29y)(a)3. 3. Treatment expectations for the client across service settings.
49.45(29y)(b) (b) The department shall, subject to any approval necessary from the federal department of health and human services, reimburse clinical consultation from the Medical Assistance program under this subchapter.
49.45(29z) (29z)Buprenorphine prior authorization review. The department shall review its prior authorization policy on buprenorphine-containing products provided to Medical Assistance program recipients. On November 1, 2018, and every 6 months thereafter, the department shall submit to the standing committees of the legislature with jurisdiction over health under s. 13.172 (3) a report describing the department's findings on the prior authorization policy on buprenorphine-containing products and its progress on eliminating prior authorization requirements for buprenorphine-containing products in populations where removal of prior authorization is appropriate. The department is not required to submit the report under this subsection after the date the prior authorization requirement for use of buprenorphine-containing products by Medical Assistance program recipients is eliminated for all appropriate populations.
49.45(30) (30)Services provided by community support programs.
49.45(30)(a)(a) A county shall provide the portion of the cost of services under s. 49.46 (2) (b) 6. L. that is not provided by the federal government.
49.45(30)(b) (b) The department shall reimburse a provider of services under s. 49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.
49.45(30c) (30c)Licensed treatment professionals. To the extent allowable by the federal department of health and human services, the department shall certify and reimburse under the Medical Assistance program under this subchapter licensed treatment professionals, as defined in s. 51.03 (6) (a), for mental health services provided at a school regardless of whether the school site is designated as a clinic office and regardless of whether the licensed treatment professional is employed by, a contractor of, or affiliated with a clinic. The department shall seek any approval necessary from the federal department of health and human services to provide reimbursement to licensed treatment professionals under this subsection.
49.45(30e) (30e)Community-based psychosocial service programs.
49.45(30e)(a)(a) When services are reimbursable. Services under s. 49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:
49.45(30e)(a)1. 1. Reimbursement for the services under s. 49.46 (2) (b) 6. Lm. 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(30e)(a)2. 2. The county in which the individual resides elects to make the services under s. 49.46 (2) (b) 6. Lm. available in the county through the medical assistance program.
49.45(30e)(a)3. 3. The individual's psychosocial health needs require more than outpatient counseling, but less than the services provided by a community support program under s. 51.421.
49.45(30e)(a)4. 4. The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under par. (b) 3.
49.45(30e)(a)5. 5. Any other condition required by rule under par. (b) 4. is satisfied.
49.45(30e)(b) (b) Rules. The department shall promulgate rules regarding all of the following:
49.45(30e)(b)1. 1. Standards for determining whether an individual is eligible under par. (a) 3.
49.45(30e)(b)2. 2. The scope of psychosocial services that may be provided under s. 49.46 (2) (b) 6. Lm.
49.45(30e)(b)3. 3. Requirements for certification of community-based psychosocial service programs.
49.45(30e)(b)4. 4. Any other conditions for coverage of community-based psychosocial services under the Medical Assistance Program.
49.45(30e)(c) (c) Provider reimbursement. A county that elects to make the services under s. 49.46 (2) (b) 6. Lm. 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 Cross-reference Cross-reference: See also ch. DHS 36, Wis. adm. code.
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2017-18 Wisconsin Statutes updated through 2019 Wis. Act 18 and through all Supreme Court and Controlled Substances Board Orders filed before and in effect on October 1, 2019. Published and certified under s. 35.18. Changes effective after October 1, 2019, are designated by NOTES. (Published 10-1-19)