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AB56-SA2,25,97 1. Denial or limited authorization of a requested services, including a
8determination based on the type or level of service, requirement for medical
9necessity, appropriateness, setting, or effectiveness of a covered benefit.
AB56-SA2,25,1210 2. Reduction, suspension, or termination of a previously authorized service,
11unless the service was only authorized for a limited amount or duration and that
12amount or duration has been completed.
AB56-SA2,25,1313 3. Denial, in whole or in part, of payment for a service.
AB56-SA2,25,1414 4. Failure to provide services in a timely manner.
AB56-SA2,25,1715 5. Failure of a care management organization or managed care organization
16to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding
17the standard resolution of grievances and appeals.
AB56-SA2,25,2018 6. Denial of an enrollee's request to dispute financial liability, including
19copayments, premiums, deductibles, coinsurance, other cost sharing, and other
20member financial liabilities.
AB56-SA2,25,2321 7. Denial of an enrollee, who is a resident of a rural area with only one care
22management organization or managed care organization, to obtain services outside
23the organization's network of contracted providers.
AB56-SA2,662b 24Section 662b. 49.45 (5) (ar) of the statutes is created to read:
AB56-SA2,26,2
149.45 (5) (ar) If a federal regulation specifies a different time limit to request
2a hearing than par. (a) or (ag), the time limit in the federal regulation shall apply.
AB56-SA2,663b 3Section 663b. 49.45 (5) (b) 1. (intro.) of the statutes is amended to read:
AB56-SA2,26,174 49.45 (5) (b) 1. (intro.) Upon receipt of a timely petition under par. (a) the
5department shall give the applicant or recipient reasonable notice and opportunity
6for a fair hearing. The department may make such additional investigation as it
7considers necessary. Notice of the hearing shall be given to the applicant or recipient
8and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making
9the medical assistance determination, to the county clerk of the county. The county
10may be represented at such hearing. The department shall render its decision as
11soon as possible after the hearing and shall send a certified copy of its decision to the
12applicant or recipient, to the county clerk, and to any county officer charged with
13administration of the Medical Assistance program. The decision of the department
14shall have the same effect as an order of a county officer charged with the
15administration of the Medical Assistance program. The decision shall be final, but
16may be revoked or modified as altered conditions may require. The department shall
17deny a petition for a hearing or shall refuse to grant relief if:
AB56-SA2,664b 18Section 664b. 49.45 (5) (b) 1. d. of the statutes is created to read:
AB56-SA2,26,2219 49.45 (5) (b) 1. d. The issue is an adverse benefit determination described in
20par. (ag) 1. to 7. made by a care management organization or managed care
21organization and the person requesting the hearing has not exhausted the internal
22appeal procedure with the organization.”.
AB56-SA2,26,23 2374. Page 352, line 22: after that line insert:
AB56-SA2,26,24 24 Section 667b. 49.45 (6xm) of the statutes is created to read:
AB56-SA2,27,4
149.45 (6xm) Pediatric inpatient supplement. (a) From the appropriations
2under s. 20.435 (4) (b), (o), and (w), the department shall, using a method determined
3by the department, distribute a total sum of $2,000,000 each state fiscal year to
4hospitals that meet all of the following criteria:
AB56-SA2,27,55 1. The hospital is an acute care hospital located in this state.
AB56-SA2,27,106 2. During the hospital's fiscal year, the inpatient days in the hospital's acute
7care pediatric units and intensive care pediatric units totaled more than 12,000 days,
8not including neonatal intensive care units. For purposes of this subsection, the
9hospital's fiscal year is the hospital's fiscal year that ended in the 2nd calendar year
10preceding the beginning of the state fiscal year.
AB56-SA2,27,1511 (b) Notwithstanding par. (a), from the appropriations under s. 20.435 (4) (b),
12(o), and (w), the department may, using a method determined by the department,
13distribute an additional total sum of $10,000,000 in each state fiscal year to hospitals
14that are free-standing pediatric teaching hospitals located in Wisconsin that have
15a percentage calculated under s. 49.45 (3m) (b) 1. a. greater than 45 percent.
AB56-SA2,668h 16Section 668h. 49.45 (19) (title) of the statutes is amended to read:
AB56-SA2,27,1817 49.45 (19) (title) Assigning Establishing paternity and assigning medical
18support rights.
AB56-SA2,669m 19Section 669m. 49.45 (19) (a) of the statutes is amended to read:
AB56-SA2,28,220 49.45 (19) (a) As Except as provided in par. (c), as a condition of eligibility for
21medical assistance, a person shall, notwithstanding other provisions of the statutes,
22be deemed to have assigned to the state, by applying for or receiving medical
23assistance, any rights to medical support or other payment of medical expenses from
24any other person, including rights to unpaid amounts accrued at the time of

1application for medical assistance as well as any rights to support accruing during
2the time for which medical assistance is paid.
AB56-SA2,670h 3Section 670h. 49.45 (19) (am) of the statutes is created to read:
AB56-SA2,28,114 49.45 (19) (am) As a condition of eligibility for medical assistance, a person
5shall cooperate in good faith with efforts directed at establishing the paternity of a
6nonmarital child and obtaining support payments or any other payments or property
7to which the person and the dependent child or children may have rights. This
8cooperation shall be in accordance with federal law and regulations applying to
9paternity establishment and collection of support payments and may not be required
10if the person has good cause for refusing to cooperate, as determined by the
11department in accordance with federal law and regulations.
AB56-SA2,671m 12Section 671m. 49.45 (19) (c) of the statutes is amended to read:
AB56-SA2,28,1713 49.45 (19) (c) If the mother of a child was enrolled in a health maintenance
14organization or other prepaid health care plan under medical assistance at the time
15of the child's birth,
The state may not seek recovery of birth expenses that may be
16recovered by the state under this subsection are the birth expenses incurred by the
17health maintenance organization or other prepaid health care plan
.
AB56-SA2,672c 18Section 672c. 49.45 (23) of the statutes is repealed.
AB56-SA2,673g 19Section 673g. 49.45 (23) (g) of the statutes is repealed.
AB56-SA2,674g 20Section 674g. 49.45 (23b) of the statutes is repealed.
AB56-SA2,676m 21Section 676m. 49.45 (24L) of the statutes is created to read:
AB56-SA2,28,2522 49.45 (24L) Critical access reimbursement payments to dental providers. (a)
23Based on the criteria in pars. (b) and (c), the department shall increase
24reimbursements to dental providers that meet quality of care standards, as
25established by the department.
AB56-SA2,29,2
1(b) In order to be eligible for enhanced reimbursement under this subsection,
2the provider must meet one of the following qualifications:
AB56-SA2,29,53 1. For a nonprofit or public provider, 50 percent or more of the individuals
4served by the provider are individuals who are without dental insurance or are
5enrolled in the Medical Assistance program.
AB56-SA2,29,76 2. For a for-profit provider, 5 percent or more of the individuals served by the
7provider are enrolled in the Medical Assistance program.
AB56-SA2,29,188 (c) For dental services rendered on or after January 1, 2020, by a qualified
9nonprofit critical access dental provider, the department shall increase
10reimbursement by 50 percent above the reimbursement rate that would otherwise
11be paid to that provider. For dental services rendered on or after January 1, 2020,
12by a qualified for-profit critical access dental provider, the department shall increase
13reimbursement by 30 percent above the reimbursement rate that would otherwise
14be paid to that provider. For dental providers rendering services to individuals in
15managed care under the Medical Assistance program, for services rendered on or
16after January 1, 2020, the department shall increase reimbursement to pay an
17additional amount on the basis of the rate that would have been paid to the dental
18provider had the individual not been enrolled in managed care.
AB56-SA2,29,2119 (d) If a provider has more than one service location, the thresholds described
20under par. (b) apply to each location, and payment for each service location would be
21determined separately.”.
AB56-SA2,29,23 2275. Page 352, line 24: delete the material beginning with that line and ending
23with page 353, line 8, and substitute:
AB56-SA2,30,10
1“49.45 (29w) (b) 1. b. “Telehealth" is means a service provided from a remote
2location using a combination of interactive video, audio, and externally acquired
3images through a networking environment between an individual or a provider at
4an originating site and a provider at a remote location with the service being of
5sufficient audio and visual fidelity and clarity as to be functionally equivalent to
6face-to-face contact; or, in circumstances determined by the department, an
7asynchronous transmission of digital clinical information through a secure
8electronic communications system from one provider to another provider
.
9“Telehealth" does not include telephone conversations or Internet-based
10communications between providers or between providers and individuals.”.
AB56-SA2,30,11 1176. Page 353, line 9: delete that line and substitute:
AB56-SA2,30,12 12 Section 678b. 49.45 (29y) (d) of the statutes is repealed.
AB56-SA2,679p 13Section 679p. 49.45 (30y) of the statutes is created to read:
AB56-SA2,30,1614 49.45 (30y) Certified doula services; pilot project. (a) In this subsection,
15“certified doula" means an individual who has received certification from a doula
16certifying organization recognized by the department.
AB56-SA2,30,1917 (b) For purposes of this subsection, services provided by certified doulas include
18continuous emotional and physical support during labor and birth of a child and
19intermittent services during the prenatal and postpartum periods.
AB56-SA2,30,2420 (c) Subject to par. (d), the department shall reimburse under the Medical
21Assistance program benefits as provided under this subsection for pregnant women
22enrolled in the Medical Assistance program who reside in the counties of Brown,
23Dane, Milwaukee, Rock, or Sheboygan, or another county as determined by the
24department.
AB56-SA2,31,6
1(d) The department shall request from the secretary of the federal department
2of health and human services any approval necessary to allow reimbursement under
3the Medical Assistance program for services provided by a certified doula. The
4department may not pay reimbursement unless federal approval is not required or
5any required federal approval allowing reimbursement under s. 49.46 (2) (b) 12p. is
6approved and in effect.”.
AB56-SA2,31,8 777. Page 353, line 11: delete the material beginning with that line and ending
8with page 354, line 17, and substitute:
AB56-SA2,31,14 9“49.45 (41) Mental health crisis Crisis intervention services. (a) In this
10subsection, “mental health crisis intervention services" means crisis intervention
11services for the treatment of mental illness, intellectual disability, substance abuse,
12and dementia
that are provided by a mental health crisis intervention program
13operated by, or under contract with, a county, if the county is certified as a medical
14assistance provider.
AB56-SA2,31,2315 (b) If a county elects to become certified as a provider of mental health crisis
16intervention services, the county may provide mental health crisis intervention
17services under this subsection in the county to medical assistance recipients through
18the medical assistance program. A county that elects to provide the services shall
19pay the amount of the allowable charges for the services under the medical
20assistance program that is not provided by the federal government. The department
21shall reimburse the county under this subsection only for the amount of the allowable
22charges for those services under the medical assistance program that is provided by
23the federal government.
AB56-SA2,681b 24Section 681b. 49.45 (41) (c) of the statutes is created to read:
AB56-SA2,32,3
149.45 (41) (c) Notwithstanding par. (b), if a county elects to deliver crisis
2intervention services under the Medical Assistance program on a regional basis
3according to criteria established by the department, all of the following apply:
AB56-SA2,32,74 1. After January 1, 2020, the department shall require the county to annually
5contribute for the crisis intervention services an amount equal to 75 percent of the
6county's expenditures for crisis intervention services under this subsection in
7calendar year 2017, as determined by the department.
AB56-SA2,32,118 2. The department shall reimburse the provider of crisis intervention services
9in the county the amount of allowable charges for those services under the Medical
10Assistance program, including both the federal share and nonfederal share of those
11charges, that exceeds the amount of the county contribution required under subd. 1.
AB56-SA2,32,1512 3. If a county submits a certified cost report under s. 49.45 (52) (b) to claim
13federal medical assistance funds, the claim based on certified costs made by a county
14for amounts under subd. 2. may not include any part of the nonfederal share of the
15amount under subd. 2.”.
AB56-SA2,32,17 1678. Page 354, line 23: delete the material beginning with that line and ending
17with page 355, line 6, and substitute:
AB56-SA2,32,18 18 Section 683b. 49.45 (47) (dm) of the statutes is created to read:
AB56-SA2,33,219 49.45 (47) (dm) Every 24 months, on a schedule determined by the department,
20an adult day care center shall submit through an online system prescribed by the
21department a report in the form and containing the information that the department
22requires, including payment of any fee due under par. (c). If a complete report is not
23timely filed, the department shall issue a warning to the operator of the adult day
24care center. The department may revoke an adult day care center's certification for

1failure to timely and completely report within 60 days after the report date
2established under the schedule determined by the department.”.
AB56-SA2,33,3 379. Page 355, line 6: after that line insert:
AB56-SA2,33,4 4 Section 685b. 49.46 (1) (a) 1m. of the statutes is amended to read:
AB56-SA2,33,85 49.46 (1) (a) 1m. Any pregnant woman whose income does not exceed the
6standard of need under s. 49.19 (11) and whose pregnancy is medically verified.
7Eligibility continues to the last day of the month in which the 60th day or, if approved
8by the federal government, the 365th day
after the last day of the pregnancy falls.”.
AB56-SA2,33,9 980. Page 355, line 21: after that line insert:
AB56-SA2,33,10 10 Section 688b. 49.46 (1) (j) of the statutes is amended to read:
AB56-SA2,33,1511 49.46 (1) (j) An individual determined to be eligible for benefits under par. (a)
129. remains eligible for benefits under par. (a) 9. for the balance of the pregnancy and
13to the last day of the month in which the 60th day or, if approved by the federal
14government, the 365th day
after the last day of the pregnancy falls without regard
15to any change in the individual's family income.”.
AB56-SA2,33,16 1681. Page 356, line 2: after that line insert:
AB56-SA2,33,17 17 Section 690p. 49.46 (2) (b) 12p. of the statutes is created to read:
AB56-SA2,33,1918 49.46 (2) (b) 12p. Subject to the limitations under s. 49.45 (30y), services
19provided by a certified doula.”.
AB56-SA2,33,20 2082. Page 356, line 4: delete lines 4 and 5 and substitute:
AB56-SA2,33,22 21“49.46 (2) (b) 15. Mental health crisis Crisis intervention services under s.
2249.45 (41).”.
AB56-SA2,33,23 2383. Page 356, line 5: after that line insert:
AB56-SA2,33,24 24 Section 691d. 49.46 (2) (b) 21. of the statutes is created to read:
AB56-SA2,34,2
149.46 (2) (b) 21. Subject to par. (bv), nonmedical services that contribute to the
2determinants of health.
AB56-SA2,691g 3Section 691g. 49.46 (2) (bv) of the statutes is created to read:
AB56-SA2,34,104 49.46 (2) (bv) The department shall determine those services under par. (b) 21.
5that contribute to the determinants of health. The department shall seek any
6necessary state plan amendment or request any waiver of federal Medicaid law to
7implement this paragraph. The department is not required to provided the services
8under this paragraph as a benefit under the Medical Assistance program if the
9federal department of health and human services does not provide federal financial
10participation for the services under this paragraph.
AB56-SA2,694h 11Section 694h. 49.463 of the statutes is repealed.
AB56-SA2,695b 12Section 695b. 49.47 (4) (ag) 2. of the statutes is amended to read:
AB56-SA2,34,1513 49.47 (4) (ag) 2. Pregnant and the woman's pregnancy is medically verified
14Eligibility continues to the last day of the month in which the 60th day or, if approved
15by the federal government, the 365th day
after the last day of the pregnancy falls.”.
AB56-SA2,34,16 1684. Page 356, line 23: after that line insert:
AB56-SA2,34,17 17 Section 699c. 49.471 (1) (cr) of the statutes is created to read:
AB56-SA2,34,1918 49.471 (1) (cr) “Enhanced federal medical assistance percentage" means a
19federal medical assistance percentage described under 42 USC 1396d (y) or (z).
AB56-SA2,700c 20Section 700c. 49.471 (4) (a) 4. b. of the statutes is amended to read:
AB56-SA2,34,2321 49.471 (4) (a) 4. b. The individual's family income does not exceed 100 133
22percent of the poverty line before application of the 5 percent income disregard under
2342 CFR 435.603 (d)
.
AB56-SA2,701c 24Section 701c. 49.471 (4) (a) 8. of the statutes is created to read:
AB56-SA2,35,1
149.471 (4) (a) 8. An individual who meets all of the following criteria:
AB56-SA2,35,22 a. The individual is an adult under the age of 65.
AB56-SA2,35,43 b. The adult has a family income that does not exceed 133 percent of the poverty
4line, except as provided in sub. (4g).
AB56-SA2,35,65 c. The adult is not otherwise eligible for the Medical Assistance program under
6this subchapter or the Medicare program under 42 USC 1395 et seq.
AB56-SA2,702c 7Section 702c. 49.471 (4g) of the statutes is created to read:
AB56-SA2,35,158 49.471 (4g) Medicaid expansion; federal medical assistance percentage. For
9services provided to individuals described under sub. (4) (a) 8., the department shall
10comply with all federal requirements to qualify for the highest available enhanced
11federal medical assistance percentage. The department shall submit any
12amendment to the state medical assistance plan, request for a waiver of federal
13Medicaid law, or other approval request required by the federal government to
14provide services to the individuals described under sub. (4) (a) 8. and qualify for the
15highest available enhanced federal medical assistance percentage.
AB56-SA2,703b 16Section 703b. 49.471 (6) (b) of the statutes is amended to read:
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