Amendment SA2-AB56

AB56-SA2,19,16 e. Denial, in whole or in part, of payment for a service.

AB56-SA2,19,19 f. The failure of a care management organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

AB56-SA2,19,22 g. Denial of an enrollee's request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

AB56-SA2,19,25 h. Denial of an enrollee, who is a resident of a rural area with only one care management organization, to obtain services outside the care management organization's network of contracted providers.

AB56-SA2,20,6 i. Development of a plan of care that is unacceptable to the enrollee because the plan of care requires the enrollee to live in a place that is unacceptable to the enrollee; the plan of care does not provide sufficient care, treatment, or support to meet the enrollee's needs and support the enrollee's identified outcomes; or the plan of care requires the enrollee to accept care, treatment, or support that is unnecessarily restrictive or unwanted by the enrollee.

AB56-SA2,20,7 j. Involuntary disenrollment from the care management organization.

AB56-SA2,480b Section 480b. 46.287 (2) (b) of the statutes is amended to read:

AB56-SA2,20,17 46.287 (2) (b) An enrollee may contest a decision, omission or action of a care management organization other than those specified in par. (a), or may contest the choice of service provider. In these instances, the enrollee shall first send a written request for review by the unit of the department that monitors care management organization contracts. This unit shall review and attempt to resolve the dispute. 1m. by filing a grievance with the care management organization. If the dispute grievance is not resolved to the satisfaction of the enrollee, he or she may request a hearing under the procedures specified in par. (a) 1. (intro.) that the department review the decision of the care management organization.

AB56-SA2,481b Section 481b. 46.288 (2) (intro.) of the statutes is renumbered 46.288 (2) and amended to read:

AB56-SA2,20,25 46.288 (2) Criteria and procedures for determining functional eligibility under s. 46.286 (1) (a), financial eligibility under s. 46.286 (1) (b), and cost sharing under s. 46.286 (2) (a). The rules for determining functional eligibility under s. 46.286 (1) (a) 1m. shall be substantially similar to eligibility criteria for receipt of the long-term support community options program under s. 46.27. Rules under this subsection shall include definitions of the following terms applicable to s. 46.286:

AB56-SA2,482b Section 482b. 46.288 (2) (d) to (j) of the statutes are repealed.

AB56-SA2,483b Section 483b. 46.2896 (1) (a) of the statutes is amended to read:

AB56-SA2,21,6 46.2896 (1) (a) “Long-term care program" means the long-term care program under s. 46.27, 46.275, 46.277, 46.278, or 46.2785; the family care program providing the benefit under s. 46.286; the Family Care Partnership program; or the long-term care program defined in s. 46.2899 (1).”.

AB56-SA2,21,7 67. Page 304, line 10: delete lines 10 to 18 and substitute:

AB56-SA2,21,8 “ Section 484p. 46.536 of the statutes is amended to read:

AB56-SA2,21,16 46.536 Mobile crisis team Crisis program enhancement grants. From the appropriation under s. 20.435 (5) (cf), the department shall award grants in the total amount of $250,000 in each fiscal biennium to counties or regions comprised of multiple counties to establish certified or enhance crisis programs that create mental health mobile crisis teams to serve individuals having mental health crises in rural areas. The department shall award a grant under this section in an amount equal to one-half the amount of money the county or region provides to establish certified or enhance crisis programs that create mobile crisis teams.”.

AB56-SA2,21,17 68. Page 304, line 19: after that line insert:

AB56-SA2,21,18 “ Section 485m. 46.854 of the statutes is created to read:

AB56-SA2,21,21 46.854 Healthy aging grant program. From the appropriation under s. 20.435 (1) (bk), the department shall award in each fiscal year a grant of $250,000 to an entity that conducts programs in healthy aging.

AB56-SA2,485w Section 485w. 46.995 (4) of the statutes is created to read:

AB56-SA2,22,2 46.995 (4) The department shall ensure that any child who is eligible and who applies for the disabled children's long-term support program that is operating under a waiver of federal law receives services under the disabled children's long-term support program that is operating under a waiver of federal law.”.

AB56-SA2,22,3 69. Page 346, line 3: delete lines 3 to 5 and substitute:

AB56-SA2,22,6 “(u) Prevention services. For services to prevent child abuse or neglect, $5,289,600 in each fiscal year $6,302,100 in fiscal year 2019-20 and $7,464,600 in fiscal year 2020-21.”.

AB56-SA2,22,7 70. Page 348, line 15: after that line insert:

AB56-SA2,22,8 “ Section 652c. 49.45 (2p) of the statutes is repealed.

AB56-SA2,653t Section 653t. 49.45 (2t) of the statutes is repealed.”.

AB56-SA2,22,10 71. Page 348, line 21: after that line insert:

AB56-SA2,22,11 “ Section 654f. 49.45 (3) (e) 11. of the statutes is amended to read:

AB56-SA2,22,23 49.45 (3) (e) 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 53.69 percent.

AB56-SA2,654h Section 654h. 49.45 (3) (e) 12. of the statutes is amended to read:

AB56-SA2,23,8 49.45 (3) (e) 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 53.69 percent.

AB56-SA2,657b Section 657b. 49.45 (3m) (a) (intro.) of the statutes is amended to read:

AB56-SA2,23,16 49.45 (3m) (a) (intro.) Subject to par. (c) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay to hospitals that serve a disproportionate share of low-income patients an amount equal to the sum of $27,500,000 $56,500,000, as the state share of payments, and the matching federal share of payments. The department may make a payment to a hospital under this subsection under the calculation method described in par. (b) if the hospital meets all of the following criteria:

AB56-SA2,658b Section 658b. 49.45 (3m) (b) 3. a. of the statutes is amended to read:

AB56-SA2,23,21 49.45 (3m) (b) 3. a. No single hospital receives more than $4,600,000 $9,200,000, except that a hospital that is a free-standing pediatric teaching hospital located in Wisconsin that has a percentage calculated under subd. 1. a. greater than 50 percent may receive up to $12,000,000 each fiscal year.”.

AB56-SA2,23,23 72. Page 348, line 23: delete the material beginning with that line and ending with page 349, line 11, and substitute:

AB56-SA2,24,14 “49.45 (3p) (a) Subject to par. (c) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay to hospitals that would are not eligible for payments under sub. (3m) but that meet the criteria under sub. (3m) (a) except that the hospitals do not provide obstetric services 1. and 2. and that, in the most recent year for which information is available, charged at least 6 percent of overall charges for services to the Medical Assistance program for services provided to Medical Assistance recipients an amount equal to the sum of $250,000 $500,000, as the state share of payments, and the matching federal share of payments. The department may make a payment to a hospital under this subsection under a calculation method determined by the department that provides a fee-for-service supplemental payment that increases as the hospital's percentage of inpatient days for Medical Assistance recipients at the hospital the total amount of the hospital's overall charges for services that are charges to the Medical Assistance program increases.”.

AB56-SA2,24,16 73. Page 349, line 12: delete the material beginning with that line and ending with page 351, line 15, and substitute:

AB56-SA2,24,17 “ Section 660b. 49.45 (5) (a) of the statutes is amended to read:

AB56-SA2,24,23 49.45 (5) (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, except as provided in par. (ag) or (ar).

AB56-SA2,661b Section 661b. 49.45 (5) (ag) of the statutes is created to read:

AB56-SA2,25,6 49.45 (5) (ag) A person shall request a hearing within 90 days of the date of receipt of a notice from a care management organization or managed care organization upholding its adverse benefit determination relating to any of the following or within 90 days of the date the care management organization or managed care organization failed to act on the contested matter within the time specified by the department:

AB56-SA2,25,9 1. Denial or limited authorization of a requested services, including a determination based on the type or level of service, requirement for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

AB56-SA2,25,12 2. Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.

AB56-SA2,25,13 3. Denial, in whole or in part, of payment for a service.

AB56-SA2,25,14 4. Failure to provide services in a timely manner.

AB56-SA2,25,17 5. Failure of a care management organization or managed care organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

AB56-SA2,25,20 6. Denial of an enrollee's request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

AB56-SA2,25,23 7. Denial of an enrollee, who is a resident of a rural area with only one care management organization or managed care organization, to obtain services outside the organization's network of contracted providers.

AB56-SA2,662b Section 662b. 49.45 (5) (ar) of the statutes is created to read:

AB56-SA2,26,2 49.45 (5) (ar) If a federal regulation specifies a different time limit to request a hearing than par. (a) or (ag), the time limit in the federal regulation shall apply.

AB56-SA2,663b Section 663b. 49.45 (5) (b) 1. (intro.) of the statutes is amended to read:

AB56-SA2,26,17 49.45 (5) (b) 1. (intro.) 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:

AB56-SA2,664b Section 664b. 49.45 (5) (b) 1. d. of the statutes is created to read:

AB56-SA2,26,22 49.45 (5) (b) 1. d. The issue is an adverse benefit determination described in par. (ag) 1. to 7. made by a care management organization or managed care organization and the person requesting the hearing has not exhausted the internal appeal procedure with the organization.”.

AB56-SA2,26,23 74. Page 352, line 22: after that line insert:

AB56-SA2,26,24 “ Section 667b. 49.45 (6xm) of the statutes is created to read:

AB56-SA2,27,4 49.45 (6xm) Pediatric inpatient supplement. (a) From the appropriations under s. 20.435 (4) (b), (o), and (w), the department shall, using a method determined by the department, distribute a total sum of $2,000,000 each state fiscal year to hospitals that meet all of the following criteria:

AB56-SA2,27,5 1. The hospital is an acute care hospital located in this state.

AB56-SA2,27,10 2. During the hospital's fiscal year, the inpatient days in the hospital's acute care pediatric units and intensive care pediatric units totaled more than 12,000 days, not including neonatal intensive care units. For purposes of this subsection, the hospital's fiscal year is the hospital's fiscal year that ended in the 2nd calendar year preceding the beginning of the state fiscal year.

AB56-SA2,27,15 (b) Notwithstanding par. (a), from the appropriations under s. 20.435 (4) (b), (o), and (w), the department may, using a method determined by the department, distribute an additional total sum of $10,000,000 in each state fiscal year to hospitals that are free-standing pediatric teaching hospitals located in Wisconsin that have a percentage calculated under s. 49.45 (3m) (b) 1. a. greater than 45 percent.

AB56-SA2,668h Section 668h. 49.45 (19) (title) of the statutes is amended to read:

AB56-SA2,27,18 49.45 (19) (title) Assigning Establishing paternity and assigning medical support rights.

AB56-SA2,669m Section 669m. 49.45 (19) (a) of the statutes is amended to read:

AB56-SA2,28,2 49.45 (19) (a) As Except as provided in par. (c), as a condition of eligibility for medical assistance, a person shall, notwithstanding other provisions of the statutes, be deemed to have assigned to the state, by applying for or receiving medical assistance, any rights to medical support or other payment of medical expenses from any other person, including rights to unpaid amounts accrued at the time of application for medical assistance as well as any rights to support accruing during the time for which medical assistance is paid.

AB56-SA2,670h Section 670h. 49.45 (19) (am) of the statutes is created to read:

AB56-SA2,28,11 49.45 (19) (am) As a condition of eligibility for medical assistance, a person shall cooperate in good faith with efforts directed at establishing the paternity of a nonmarital child and obtaining support payments or any other payments or property to which the person and the dependent child or children may have rights. This cooperation shall be in accordance with federal law and regulations applying to paternity establishment and collection of support payments and may not be required if the person has good cause for refusing to cooperate, as determined by the department in accordance with federal law and regulations.

AB56-SA2,671m Section 671m. 49.45 (19) (c) of the statutes is amended to read:

AB56-SA2,28,17 49.45 (19) (c) If the mother of a child was enrolled in a health maintenance organization or other prepaid health care plan under medical assistance at the time of the child's birth, The state may not seek recovery of birth expenses that may be recovered by the state under this subsection are the birth expenses incurred by the health maintenance organization or other prepaid health care plan.

AB56-SA2,672c Section 672c. 49.45 (23) of the statutes is repealed.

AB56-SA2,673g Section 673g. 49.45 (23) (g) of the statutes is repealed.

AB56-SA2,674g Section 674g. 49.45 (23b) of the statutes is repealed.

AB56-SA2,676m Section 676m. 49.45 (24L) of the statutes is created to read:

AB56-SA2,28,25 49.45 (24L) Critical access reimbursement payments to dental providers. (a) Based on the criteria in pars. (b) and (c), the department shall increase reimbursements to dental providers that meet quality of care standards, as established by the department.

AB56-SA2,29,2 (b) In order to be eligible for enhanced reimbursement under this subsection, the provider must meet one of the following qualifications:

AB56-SA2,29,5 1. For a nonprofit or public provider, 50 percent or more of the individuals served by the provider are individuals who are without dental insurance or are enrolled in the Medical Assistance program.

AB56-SA2,29,7 2. For a for-profit provider, 5 percent or more of the individuals served by the provider are enrolled in the Medical Assistance program.

AB56-SA2,29,18 (c) For dental services rendered on or after January 1, 2020, by a qualified nonprofit critical access dental provider, the department shall increase reimbursement by 50 percent above the reimbursement rate that would otherwise be paid to that provider. For dental services rendered on or after January 1, 2020, by a qualified for-profit critical access dental provider, the department shall increase reimbursement by 30 percent above the reimbursement rate that would otherwise be paid to that provider. For dental providers rendering services to individuals in managed care under the Medical Assistance program, for services rendered on or after January 1, 2020, the department shall increase reimbursement to pay an additional amount on the basis of the rate that would have been paid to the dental provider had the individual not been enrolled in managed care.

AB56-SA2,29,21 (d) If a provider has more than one service location, the thresholds described under par. (b) apply to each location, and payment for each service location would be determined separately.”.

AB56-SA2,29,23 75. Page 352, line 24: delete the material beginning with that line and ending with page 353, line 8, and substitute:

AB56-SA2,30,10 “49.45 (29w) (b) 1. b. “Telehealth" is 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.”.

AB56-SA2,30,11 76. Page 353, line 9: delete that line and substitute:

AB56-SA2,30,12 “ Section 678b. 49.45 (29y) (d) of the statutes is repealed.

AB56-SA2,679p Section 679p. 49.45 (30y) of the statutes is created to read:

AB56-SA2,30,16 49.45 (30y) Certified doula services; pilot project. (a) In this subsection, “certified doula" means an individual who has received certification from a doula certifying organization recognized by the department.

AB56-SA2,30,19 (b) For purposes of this subsection, services provided by certified doulas include continuous emotional and physical support during labor and birth of a child and intermittent services during the prenatal and postpartum periods.

AB56-SA2,30,24 (c) Subject to par. (d), the department shall reimburse under the Medical Assistance program benefits as provided under this subsection for pregnant women enrolled in the Medical Assistance program who reside in the counties of Brown, Dane, Milwaukee, Rock, or Sheboygan, or another county as determined by the department.

AB56-SA2,31,6 (d) The department shall request from the secretary of the federal department of health and human services any approval necessary to allow reimbursement under the Medical Assistance program for services provided by a certified doula. The department may not pay reimbursement unless federal approval is not required or any required federal approval allowing reimbursement under s. 49.46 (2) (b) 12p. is approved and in effect.”.

AB56-SA2,31,8 77. Page 353, line 11: delete the material beginning with that line and ending with page 354, line 17, and substitute: