Amendment SA2-AB56

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:

AB56-SA2,31,14 “49.45 (41) Mental health crisis Crisis intervention services. (a) In this subsection, “mental health crisis intervention services" means crisis intervention services for the treatment of mental illness, intellectual disability, substance abuse, and dementia that are provided by a mental health crisis intervention program operated by, or under contract with, a county, if the county is certified as a medical assistance provider.

AB56-SA2,31,23 (b) If a county elects to become certified as a provider of mental health crisis intervention services, the county may provide mental health crisis intervention services under this subsection in the county to medical assistance recipients through the medical assistance program. A county that elects to provide the services shall pay the amount of the allowable charges for the services under the medical assistance program that is not provided by the federal government. The department shall reimburse the county under this subsection only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.

AB56-SA2,681b Section 681b. 49.45 (41) (c) of the statutes is created to read:

AB56-SA2,32,3 49.45 (41) (c) Notwithstanding par. (b), if a county elects to deliver crisis intervention services under the Medical Assistance program on a regional basis according to criteria established by the department, all of the following apply:

AB56-SA2,32,7 1. After January 1, 2020, the department shall require the county to annually contribute for the crisis intervention services an amount equal to 75 percent of the county's expenditures for crisis intervention services under this subsection in calendar year 2017, as determined by the department.

AB56-SA2,32,11 2. The department shall reimburse the provider of crisis intervention services in the county the amount of allowable charges for those services under the Medical Assistance program, including both the federal share and nonfederal share of those charges, that exceeds the amount of the county contribution required under subd. 1.

AB56-SA2,32,15 3. If a county submits a certified cost report under s. 49.45 (52) (b) to claim federal medical assistance funds, the claim based on certified costs made by a county for amounts under subd. 2. may not include any part of the nonfederal share of the amount under subd. 2.”.

AB56-SA2,32,17 78. Page 354, line 23: delete the material beginning with that line and ending with page 355, line 6, and substitute:

AB56-SA2,32,18 “ Section 683b. 49.45 (47) (dm) of the statutes is created to read:

AB56-SA2,33,2 49.45 (47) (dm) Every 24 months, on a schedule determined by the department, an adult day care center shall submit through an online system prescribed by the department a report in the form and containing the information that the department requires, including payment of any fee due under par. (c). If a complete report is not timely filed, the department shall issue a warning to the operator of the adult day care center. The department may revoke an adult day care center's certification for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department.”.

AB56-SA2,33,3 79. Page 355, line 6: after that line insert:

AB56-SA2,33,4 “ Section 685b. 49.46 (1) (a) 1m. of the statutes is amended to read:

AB56-SA2,33,8 49.46 (1) (a) 1m. Any pregnant woman whose income does not exceed the standard of need under s. 49.19 (11) and whose pregnancy is medically verified. Eligibility continues to the last day of the month in which the 60th day or, if approved by the federal government, the 365th day after the last day of the pregnancy falls.”.

AB56-SA2,33,9 80. Page 355, line 21: after that line insert:

AB56-SA2,33,10 “ Section 688b. 49.46 (1) (j) of the statutes is amended to read:

AB56-SA2,33,15 49.46 (1) (j) An individual determined to be eligible for benefits under par. (a) 9. remains eligible for benefits under par. (a) 9. for the balance of the pregnancy and to the last day of the month in which the 60th day or, if approved by the federal government, the 365th day after the last day of the pregnancy falls without regard to any change in the individual's family income.”.

AB56-SA2,33,16 81. Page 356, line 2: after that line insert:

AB56-SA2,33,17 “ Section 690p. 49.46 (2) (b) 12p. of the statutes is created to read:

AB56-SA2,33,19 49.46 (2) (b) 12p. Subject to the limitations under s. 49.45 (30y), services provided by a certified doula.”.

AB56-SA2,33,20 82. Page 356, line 4: delete lines 4 and 5 and substitute:

AB56-SA2,33,22 “49.46 (2) (b) 15. Mental health crisis Crisis intervention services under s. 49.45 (41).”.

AB56-SA2,33,23 83. Page 356, line 5: after that line insert:

AB56-SA2,33,24 “ Section 691d. 49.46 (2) (b) 21. of the statutes is created to read:

AB56-SA2,34,2 49.46 (2) (b) 21. Subject to par. (bv), nonmedical services that contribute to the determinants of health.

AB56-SA2,691g Section 691g. 49.46 (2) (bv) of the statutes is created to read:

AB56-SA2,34,10 49.46 (2) (bv) The department shall determine those services under par. (b) 21. that contribute to the determinants of health. The department shall seek any necessary state plan amendment or request any waiver of federal Medicaid law to implement this paragraph. The department is not required to provided the services under this paragraph as a benefit under the Medical Assistance program if the federal department of health and human services does not provide federal financial participation for the services under this paragraph.

AB56-SA2,694h Section 694h. 49.463 of the statutes is repealed.

AB56-SA2,695b Section 695b. 49.47 (4) (ag) 2. of the statutes is amended to read:

AB56-SA2,34,15 49.47 (4) (ag) 2. Pregnant and the woman's pregnancy is medically verified Eligibility continues to the last day of the month in which the 60th day or, if approved by the federal government, the 365th day after the last day of the pregnancy falls.”.

AB56-SA2,34,16 84. Page 356, line 23: after that line insert:

AB56-SA2,34,17 “ Section 699c. 49.471 (1) (cr) of the statutes is created to read:

AB56-SA2,34,19 49.471 (1) (cr) “Enhanced federal medical assistance percentage" means a federal medical assistance percentage described under 42 USC 1396d (y) or (z).

AB56-SA2,700c Section 700c. 49.471 (4) (a) 4. b. of the statutes is amended to read:

AB56-SA2,34,23 49.471 (4) (a) 4. b. The individual's family income does not exceed 100 133 percent of the poverty line before application of the 5 percent income disregard under 42 CFR 435.603 (d).

AB56-SA2,701c Section 701c. 49.471 (4) (a) 8. of the statutes is created to read:

AB56-SA2,35,1 49.471 (4) (a) 8. An individual who meets all of the following criteria:

AB56-SA2,35,2 a. The individual is an adult under the age of 65.

AB56-SA2,35,4 b. The adult has a family income that does not exceed 133 percent of the poverty line, except as provided in sub. (4g).

AB56-SA2,35,6 c. The adult is not otherwise eligible for the Medical Assistance program under this subchapter or the Medicare program under 42 USC 1395 et seq.

AB56-SA2,702c Section 702c. 49.471 (4g) of the statutes is created to read:

AB56-SA2,35,15 49.471 (4g) Medicaid expansion; federal medical assistance percentage. For services provided to individuals described under sub. (4) (a) 8., the department shall comply with all federal requirements to qualify for the highest available enhanced federal medical assistance percentage. The department shall submit any amendment to the state medical assistance plan, request for a waiver of federal Medicaid law, or other approval request required by the federal government to provide services to the individuals described under sub. (4) (a) 8. and qualify for the highest available enhanced federal medical assistance percentage.

AB56-SA2,703b Section 703b. 49.471 (6) (b) of the statutes is amended to read: