Amendment ASA1-AB56

AB56-ASA1,350,3 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-ASA1,350,6 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-ASA1,350,7 3. Denial, in whole or in part, of payment for a service.

AB56-ASA1,350,8 4. Failure to provide services in a timely manner.

AB56-ASA1,350,11 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-ASA1,350,14 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-ASA1,350,17 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-ASA1,662 Section 662 . 49.45 (5) (ar) of the statutes is created to read:

AB56-ASA1,350,20 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-ASA1,663 Section 663 . 49.45 (5) (b) 1. (intro.) of the statutes is amended to read:

AB56-ASA1,351,10 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-ASA1,664 Section 664 . 49.45 (5) (b) 1. d. of the statutes is created to read:

AB56-ASA1,351,15 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-ASA1,664r Section 664r. 49.45 (6m) (ar) 1. a. of the statutes is amended to read:

AB56-ASA1,352,11 49.45 (6m) (ar) 1. 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 in the single labor region that is composed of Milwaukee, Ozaukee, Washington, and Waukesha counties include Racine County and shall adjust payment so that the direct care cost targets of facilities in Milwaukee, Ozaukee, Washington, and Waukesha counties are not reduced as a result of including facilities in Racine County in this labor region. The department shall treat as a single labor region the counties of Dane, Dodge, Iowa, Columbia, Richland, 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 Dodge, Richland, and Rock Counties in this labor region. For facilities in Douglas, Dunn, 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.

AB56-ASA1,665 Section 665 . 49.45 (6m) (c) 5. of the statutes is amended to read:

AB56-ASA1,352,15 49.45 (6m) (c) 5. Admit only patients assessed or who waive or are exempt from the requirement of assessment under s. 46.27 (6) (a) or, if required under s. 50.035 (4n) or 50.04 (2h), who have been referred to a resource center.

AB56-ASA1,666 Section 666 . 49.45 (6m) (L) of the statutes is amended to read:

AB56-ASA1,352,22 49.45 (6m) (L) For purposes of ss. 46.27 (11) (c) 7. and s. 46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under s. 46.27 (11) (c) 7. or 46.277 (5) (e).

AB56-ASA1,677 Section 677 . 49.45 (29w) (b) 1. b. of the statutes is amended to read:

AB56-ASA1,353,8 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-ASA1,678 Section 678 . 49.45 (29y) (d) of the statutes is repealed.

AB56-ASA1,680 Section 680 . 49.45 (41) of the statutes is amended to read:

AB56-ASA1,353,16 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-ASA1,353,25 (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-ASA1,681 Section 681. 49.45 (41) (c) of the statutes is created to read:

AB56-ASA1,354,4 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-ASA1,354,9 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 annual average of the county's expenditures for crisis intervention services under this subsection in calendar years 2016, 2017, and 2018, as determined by the department.

AB56-ASA1,354,13 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-ASA1,354,17 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-ASA1,682 Section 682 . 49.45 (47) (b) of the statutes is amended to read:

AB56-ASA1,354,22 49.45 (47) (b) No person may receive reimbursement under s. 46.27 (11) for the provision of services to clients in an adult day care center unless the adult day care center is certified by the department under sub. (2) (a) 11. as a provider of medical assistance.

AB56-ASA1,683 Section 683 . 49.45 (47) (dm) of the statutes is created to read:

AB56-ASA1,355,6 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-ASA1,686 Section 686 . 49.46 (1) (a) 14. of the statutes is amended to read:

AB56-ASA1,355,13 49.46 (1) (a) 14. Any person who would meet the financial and other eligibility requirements for home or community-based services under s. 46.27 (11), 46.277, or 46.2785 but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3), if a waiver under s. 49.45 (38) is in effect or federal law permits federal financial participation for medical assistance coverage of the person and if funding is available for the person under s. 46.27 (11), 46.277, or 46.2785.

AB56-ASA1,687 Section 687 . 49.46 (1) (em) of the statutes is amended to read:

AB56-ASA1,355,21 49.46 (1) (em) To the extent approved by the federal government, for the purposes of determining financial eligibility and any cost-sharing requirements of an individual under par. (a) 6m., 14., or 14m., (d) 2., or (e), the department or its designee shall exclude any assets accumulated in a person's independence account, as defined in s. 49.472 (1) (c), and any income or assets from retirement benefits earned or accumulated from income or employer contributions while employed and receiving state-funded benefits under s. 46.27 or medical assistance under s. 49.472.

AB56-ASA1,689 Section 689 . 49.46 (2) (b) 8. of the statutes is amended to read:

AB56-ASA1,356,2 49.46 (2) (b) 8. Home or community-based services, if provided under s. 46.27 (11), 46.275, 46.277, 46.278, 46.2785, 46.99, or under the family care benefit if a waiver is in effect under s. 46.281 (1d), or under the disabled children's long-term support program, as defined in s. 46.011 (1g).

AB56-ASA1,691 Section 691 . 49.46 (2) (b) 15. of the statutes is amended to read:

AB56-ASA1,356,5 49.46 (2) (b) 15. Mental health crisis Crisis intervention services under s. 49.45 (41).

AB56-ASA1,696 Section 696 . 49.47 (4) (as) 1. of the statutes is amended to read:

AB56-ASA1,356,11 49.47 (4) (as) 1. The person would meet the financial and other eligibility requirements for home or community-based services under s. 46.27 (11), 46.277, or 46.2785 or under the family care benefit if a waiver is in effect under s. 46.281 (1d) but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3).

AB56-ASA1,697 Section 697 . 49.47 (4) (as) 3. of the statutes is amended to read:

AB56-ASA1,356,14 49.47 (4) (as) 3. Funding is available for the person under s. 46.27 (11), 46.277, or 46.2785 or under the family care benefit if a waiver is in effect under s. 46.281 (1d).

AB56-ASA1,698 Section 698 . 49.47 (4) (b) (intro.) of the statutes is amended to read:

AB56-ASA1,356,23 49.47 (4) (b) (intro.) Eligibility exists if the applicant's property, subject to the exclusion of any amounts under the Long-Term Care Partnership Program established under s. 49.45 (31), any amounts in an independence account, as defined in s. 49.472 (1) (c), or any retirement assets that accrued from employment while the applicant was eligible for the community options program under s. 46.27 (11), 2017 stats., or any other Medical Assistance program, including deferred compensation or the value of retirement accounts in the Wisconsin Retirement System or under the federal Social Security Act, does not exceed the following:

AB56-ASA1,706 Section 706 . 49.472 (3) (b) of the statutes is amended to read:

AB56-ASA1,357,8 49.472 (3) (b) The individual's assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under 42 USC 1382b (a), assets accumulated in an independence account, and, to the extent approved by the federal government, assets from retirement benefits accumulated from income or employer contributions while employed and receiving medical assistance under this section or state-funded benefits under s. 46.27, 2017 stats. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.

AB56-ASA1,707 Section 707 . 49.472 (3) (f) of the statutes is amended to read:

AB56-ASA1,357,13 49.472 (3) (f) The individual maintains premium payments under sub. (4) (am) and, if applicable and to the extent approved by the federal government, premium payments calculated by the department in accordance with sub. (4) (bm), unless the individual is exempted from premium payments under sub. (4) (dm) or (5).

AB56-ASA1,708 Section 708 . 49.472 (4) (am) of the statutes is amended to read:

AB56-ASA1,357,17 49.472 (4) (am) To the extent approved by the federal government and except as provided in pars. (dm) and (em) and sub. (5), an individual who receives medical assistance under this section shall pay a monthly premium of $25 to the department.

AB56-ASA1,709 Section 709 . 49.472 (5) of the statutes is repealed.

AB56-ASA1,722 Section 722 . 49.849 (1) (e) of the statutes is amended to read:

AB56-ASA1,357,23 49.849 (1) (e) “Public assistance" means any services provided as a benefit under a long-term care program, as defined in s. 49.496 (1) (bk), medical assistance under subch. IV, long-term community support services funded under s. 46.27 (7), or aid under s. 49.68, 49.683, 49.685, or 49.785.

AB56-ASA1,723 Section 723 . 49.849 (2) (a) (intro.) of the statutes is amended to read:

AB56-ASA1,358,8 49.849 (2) (a) (intro.) Subject to par. (b), the department may collect from the property of a decedent by affidavit under sub. (3) (b) or by lien under sub. (4) (a) an amount equal to the medical assistance that is recoverable under s. 49.496 (3) (a), the long-term community support services under s. 46.27, 2017 stats., that is recoverable under s. 46.27 (7g) (c) 1., 2017 stats., or the aid under s. 49.68, 49.683, 49.685, or 49.785 that is recoverable under s. 49.682 (2) (a) or (am), and that was paid on behalf of the decedent or the decedent's spouse, if all of the following conditions are satisfied:

AB56-ASA1,724 Section 724 . 49.849 (6) (a) of the statutes is renumbered 49.849 (6).

AB56-ASA1,725 Section 725 . 49.849 (6) (b) of the statutes is repealed.

AB56-ASA1,728 Section 728 . 50.03 (3) (b) (intro.) of the statutes is amended to read:

AB56-ASA1,358,16 50.03 (3) (b) (intro.) The application for a license and, except as otherwise provided in this subchapter, the report of a licensee shall be in writing upon forms provided by the department and shall contain such information as the department requires, including the name, address and type and extent of interest of each of the following persons:

AB56-ASA1,729 Section 729 . 50.03 (4) (c) 1. of the statutes is amended to read:

AB56-ASA1,359,2 50.03 (4) (c) 1. A community-based residential facility license is valid until it is revoked or suspended under this section. Every 24 months, on a schedule determined by the department, a community-based residential facility licensee shall submit through an online system prescribed by the department a biennial report in the form and containing the information that the department requires, including payment of the fees required any fee due under s. 50.037 (2) (a). If a complete biennial report is not timely filed, the department shall issue a warning to the licensee. The department may revoke a community-based residential facility license for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department.

AB56-ASA1,730 Section 730 . 50.033 (2m) of the statutes is amended to read:

AB56-ASA1,359,11 50.033 (2m) Reporting. Every 24 months, on a schedule determined by the department, a licensed adult family home shall submit through an online system prescribed by the department a biennial report in the form and containing the information that the department requires, including payment of the any fee required due under sub. (2). If a complete biennial report is not timely filed, the department shall issue a warning to the licensee. The department may revoke the license for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department.

AB56-ASA1,731 Section 731 . 50.034 (1) (a) of the statutes is amended to read:

AB56-ASA1,359,21 50.034 (1) (a) No person may operate a residential care apartment complex that provides living space for residents who are clients under s. 46.27 (11) or 46.277 and publicly funded services as a home health agency or under contract with a county department under s. 46.215, 46.22, 46.23, 51.42 or 51.437 that is a home health agency unless the residential care apartment complex is certified by the department under this section. The department may charge a fee, in an amount determined by the department, for certification under this paragraph. The amount of any fee charged by the department for certification of a residential care apartment complex need not be promulgated as a rule under ch. 227.

AB56-ASA1,732 Section 732 . 50.034 (2m) of the statutes is created to read:

AB56-ASA1,360,9 50.034 (2m) Reporting. Every 24 months, on a schedule determined by the department, a residential care apartment complex 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 required under sub. (1). If a complete report is not timely filed, the department shall issue a warning to the operator of the residential care apartment complex. The department may revoke a residential care apartment complex's certification or registration for failure to timely and completely report within 60 days after the report date established under the schedule determined by the department. Notwithstanding the reporting schedule under this subsection, a certified residential care apartment complex shall continue to pay required fees on the schedule established in rules promulgated by the department.

AB56-ASA1,733 Section 733 . 50.034 (3) (a) 1. of the statutes is repealed.

AB56-ASA1,734 Section 734 . 50.034 (5m) of the statutes is amended to read:

AB56-ASA1,360,19 50.034 (5m) Provision of information required. Subject to sub. (5p), when When a residential care apartment complex first provides written material regarding the residential care apartment complex to a prospective resident, the residential care apartment complex shall also provide the prospective resident information specified by the department concerning the services of a resource center under s. 46.283, the family care benefit under s. 46.286, and the availability of a functional screening and a financial and cost-sharing screening to determine the prospective resident's eligibility for the family care benefit under s. 46.286 (1).

AB56-ASA1,735 Section 735 . 50.034 (5n) (intro.) of the statutes is amended to read:

AB56-ASA1,361,2 50.034 (5n) Required referral. (intro.) Subject to sub. (5p), when When a residential care apartment complex first provides written material regarding the residential care apartment complex to a prospective resident who is at least 65 years of age or has developmental disability or a physical disability and whose disability or condition is expected to last at least 90 days, the residential care apartment complex shall refer the prospective resident to a resource center under s. 46.283, unless any of the following applies:

AB56-ASA1,736 Section 736 . 50.034 (5p) of the statutes is repealed.

AB56-ASA1,737 Section 737 . 50.034 (6) of the statutes is amended to read:

AB56-ASA1,361,10 50.034 (6) Funding. Funding for supportive, personal or nursing services that a person who resides in a residential care apartment complex receives, other than private or 3rd-party funding, may be provided only under s. 46.27 (11) (c) 7. or 46.277 (5) (e), except if the provider of the services is a certified medical assistance provider under s. 49.45 or if the funding is provided as a family care benefit under ss. 46.2805 to 46.2895.

AB56-ASA1,738 Section 738 . 50.035 (4m) of the statutes is amended to read:

AB56-ASA1,361,19 50.035 (4m) Provision of information required. Subject to sub. (4p), when When a community-based residential facility first provides written material regarding the community-based residential facility to a prospective resident, the community-based residential facility shall also provide the prospective resident information specified by the department concerning the services of a resource center under s. 46.283, the family care benefit under s. 46.286, and the availability of a functional screening and a financial and cost-sharing screening to determine the prospective resident's eligibility for the family care benefit under s. 46.286 (1).

AB56-ASA1,739 Section 739 . 50.035 (4n) (intro.) of the statutes is amended to read:

AB56-ASA1,362,5 50.035 (4n) Required referral. (intro.) When a community-based residential facility first provides written information regarding the community-based residential facility to a prospective resident who is at least 65 years of age or has developmental disability or a physical disability and whose disability or condition is expected to last at least 90 days, the community-based residential facility shall refer the individual to a resource center under s. 46.283 or, if the secretary has not certified under s. 46.281 (3) that a resource center is available in the area of the community-based residential facility to serve individuals in an eligibility group to which the prospective resident belongs, to the county department that administers a program under ss. 46.27 or 46.277, unless any of the following applies:

AB56-ASA1,740 Section 740 . 50.035 (4p) of the statutes is repealed.

AB56-ASA1,741 Section 741 . 50.04 (2g) (a) of the statutes is amended to read:

AB56-ASA1,362,13 50.04 (2g) (a) Subject to sub. (2i), a A nursing home shall, within the time period after inquiry by a prospective resident that is prescribed by the department by rule, inform the prospective resident of the services of a resource center under s. 46.283, the family care benefit under s. 46.286, and the availability of a functional screening and a financial and cost-sharing screening to determine the prospective resident's eligibility for the family care benefit under s. 46.286 (1).

AB56-ASA1,742 Section 742 . 50.04 (2h) (a) (intro.) of the statutes is amended to read:

AB56-ASA1,362,19 50.04 (2h) (a) (intro.) Subject to sub. (2i), a A nursing home shall, within the time period prescribed by the department by rule, refer to a resource center under s. 46.283 a person who is seeking admission, who is at least 65 years of age or has developmental disability or physical disability and whose disability or condition is expected to last at least 90 days, unless any of the following applies:

AB56-ASA1,743 Section 743 . 50.04 (2i) of the statutes is repealed.