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AB56,535,1210 1. Denial or limited authorization of a requested services, including a
11determination based on the type or level of service, requirement for medical
12necessity, appropriateness, setting, or effectiveness of a covered benefit.
AB56,535,1513 2. Reduction, suspension, or termination of a previously authorized service,
14unless the service was only authorized for a limited amount or duration and that
15amount or duration has been completed.
AB56,535,1616 3. Denial, in whole or in part, of payment for a service.
AB56,535,1717 4. Failure to provide services in a timely manner.
AB56,535,2018 5. Failure of a care management organization or managed care organization
19to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding
20the standard resolution of grievances and appeals.
AB56,535,2321 6. Denial of an enrollee's request to dispute financial liability, including
22copayments, premiums, deductibles, coinsurance, other cost sharing, and other
23member financial liabilities.
AB56,536,3
17. Denial of an enrollee, who is a resident of a rural area with only one care
2management organization or managed care organization, to obtain services outside
3the organization's network of contracted providers.
AB56,662 4Section 662. 49.45 (5) (ar) of the statutes is created to read:
AB56,536,65 49.45 (5) (ar) If a federal regulation specifies a different time limit to request
6a hearing than par. (a) or (ag), the time limit in the federal regulation shall apply.
AB56,663 7Section 663. 49.45 (5) (b) 1. (intro.) of the statutes is amended to read:
AB56,536,218 49.45 (5) (b) 1. (intro.) Upon receipt of a timely petition under par. (a) the
9department shall give the applicant or recipient reasonable notice and opportunity
10for a fair hearing. The department may make such additional investigation as it
11considers necessary. Notice of the hearing shall be given to the applicant or recipient
12and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making
13the medical assistance determination, to the county clerk of the county. The county
14may be represented at such hearing. The department shall render its decision as
15soon as possible after the hearing and shall send a certified copy of its decision to the
16applicant or recipient, to the county clerk, and to any county officer charged with
17administration of the Medical Assistance program. The decision of the department
18shall have the same effect as an order of a county officer charged with the
19administration of the Medical Assistance program. The decision shall be final, but
20may be revoked or modified as altered conditions may require. The department shall
21deny a petition for a hearing or shall refuse to grant relief if:
AB56,664 22Section 664. 49.45 (5) (b) 1. d. of the statutes is created to read:
AB56,537,223 49.45 (5) (b) 1. d. The issue is an adverse benefit determination described in
24par. (ag) 1. to 7. made by a care management organization or managed care

1organization and the person requesting the hearing has not exhausted the internal
2appeal procedure with the organization.
AB56,665 3Section 665. 49.45 (6m) (c) 5. of the statutes is amended to read:
AB56,537,64 49.45 (6m) (c) 5. Admit only patients assessed or who waive or are exempt from
5the requirement of assessment under s. 46.27 (6) (a) or,
if required under s. 50.035
6(4n) or 50.04 (2h), who have been referred to a resource center.
AB56,666 7Section 666. 49.45 (6m) (L) of the statutes is amended to read:
AB56,537,138 49.45 (6m) (L) For purposes of ss. 46.27 (11) (c) 7. and s. 46.277 (5) (e), the
9department shall, by July 1 annually, determine the statewide medical assistance
10daily cost of nursing home care and submit the determination to the department of
11administration for review. The department of administration shall approve the
12determination before payment may be made under s. 46.27 (11) (c) 7. or 46.277 (5)
13(e).
AB56,667 14Section 667. 49.45 (6xm) of the statutes is created to read:
AB56,537,1815 49.45 (6xm) Pediatric inpatient supplement. (a) From the appropriations
16under s. 20.435 (4) (b), (o), and (w), the department shall, using a method determined
17by the department, distribute a total sum of $2,000,000 each state fiscal year to
18hospitals that meet all of the following criteria:
AB56,537,1919 1. The hospital is an acute care hospital located in this state.
AB56,537,2420 2. During the hospital's fiscal year, the inpatient days in the hospital's acute
21care pediatric units and intensive care pediatric units totaled more than 12,000 days,
22not including neonatal intensive care units. For purposes of this subsection, the
23hospital's fiscal year is the hospital's fiscal year that ended in the 2nd calendar year
24preceding the beginning of the state fiscal year.
AB56,538,5
1(b) Notwithstanding par. (a), from the appropriations under s. 20.435 (4) (b),
2(o), and (w), the department may, using a method determined by the department,
3distribute an additional total sum of $10,000,000 in each state fiscal year to hospitals
4that are free-standing pediatric teaching hospitals located in Wisconsin that have
5a percentage calculated under s. 49.45 (3m) (b) 1. a. greater than 45 percent.
AB56,668 6Section 668. 49.45 (19) (title) of the statutes is amended to read:
AB56,538,87 49.45 (19) (title) Assigning Establishing paternity and assigning medical
8support rights.
AB56,669 9Section 669 . 49.45 (19) (a) of the statutes is amended to read:
AB56,538,1610 49.45 (19) (a) As Except as provided in par. (c), as a condition of eligibility for
11medical assistance, a person shall, notwithstanding other provisions of the statutes,
12be deemed to have assigned to the state, by applying for or receiving medical
13assistance, any rights to medical support or other payment of medical expenses from
14any other person, including rights to unpaid amounts accrued at the time of
15application for medical assistance as well as any rights to support accruing during
16the time for which medical assistance is paid.
AB56,670 17Section 670. 49.45 (19) (am) of the statutes is created to read:
AB56,538,2518 49.45 (19) (am) As a condition of eligibility for medical assistance, a person
19shall cooperate in good faith with efforts directed at establishing the paternity of a
20nonmarital child and obtaining support payments or any other payments or property
21to which the person and the dependent child or children may have rights. This
22cooperation shall be in accordance with federal law and regulations applying to
23paternity establishment and collection of support payments and may not be required
24if the person has good cause for refusing to cooperate, as determined by the
25department in accordance with federal law and regulations.
AB56,671
1Section 671. 49.45 (19) (c) of the statutes is amended to read:
AB56,539,62 49.45 (19) (c) If the mother of a child was enrolled in a health maintenance
3organization or other prepaid health care plan under medical assistance at the time
4of the child's birth,
The state may not seek recovery of birth expenses that may be
5recovered by the state under this subsection are the birth expenses incurred by the
6health maintenance organization or other prepaid health care plan
.
AB56,672 7Section 672 . 49.45 (23) of the statutes, as affected by 2019 Wisconsin Act ....
8(this act), is repealed.
AB56,673 9Section 673 . 49.45 (23) (g) of the statutes is repealed.
AB56,674 10Section 674 . 49.45 (23b) of the statutes is repealed.
AB56,675 11Section 675. 49.45 (24k) of the statutes is repealed.
AB56,676 12Section 676. 49.45 (24L) of the statutes is created to read:
AB56,539,1613 49.45 (24L) Critical access reimbursement payments to dental providers. (a)
14Based on the criteria in pars. (b) and (c), the department shall increase
15reimbursements to dental providers that meet quality of care standards, as
16established by the department.
AB56,539,1817 (b) In order to be eligible for enhanced reimbursement under this subsection,
18the provider must meet one of the following qualifications:
AB56,539,2119 1. For a nonprofit or public provider, 50 percent or more of the individuals
20served by the provider are individuals who are without dental insurance or are
21enrolled in the Medical Assistance program.
AB56,539,2322 2. For a for-profit provider, 5 percent or more of the individuals served by the
23provider are enrolled in the Medical Assistance program.
AB56,540,924 (c) For dental services rendered on or after January 1, 2020, by a qualified
25nonprofit critical access dental provider, the department shall increase

1reimbursement by 50 percent above the reimbursement rate that would otherwise
2be paid to that provider. For dental services rendered on or after January 1, 2020,
3by a qualified for-profit critical access dental provider, the department shall increase
4reimbursement by 30 percent above the reimbursement rate that would otherwise
5be paid to that provider. For dental providers rendering services to individuals in
6managed care under the Medical Assistance program, for services rendered on or
7after January 1, 2020, the department shall increase reimbursement to pay an
8additional amount on the basis of the rate that would have been paid to the dental
9provider had the individual not been enrolled in managed care.
AB56,540,1210 (d) If a provider has more than one service location, the thresholds described
11under par. (b) apply to each location, and payment for each service location would be
12determined separately.
AB56,677 13Section 677. 49.45 (29w) (b) 1. b. of the statutes is amended to read:
AB56,540,2314 49.45 (29w) (b) 1. b. “Telehealth" is means a service provided from a remote
15location using a combination of interactive video, audio, and externally acquired
16images through a networking environment between an individual or a provider at
17an originating site and a provider at a remote location with the service being of
18sufficient audio and visual fidelity and clarity as to be functionally equivalent to
19face-to-face contact; or, in circumstances determined by the department, an
20asynchronous transmission of digital clinical information through a secure
21electronic communications system from one provider to another provider
.
22“Telehealth" does not include telephone conversations or Internet-based
23communications between providers or between providers and individuals.
AB56,678 24Section 678. 49.45 (29y) (d) of the statutes is repealed.
AB56,679 25Section 679. 49.45 (30y) of the statutes is created to read:
AB56,541,3
149.45 (30y) Certified doula services; pilot project. (a) In this subsection,
2“certified doula" means an individual who has received certification from a doula
3certifying organization recognized by the department.
AB56,541,64 (b) For purposes of this subsection, services provided by certified doulas include
5continuous emotional and physical support during labor and birth of a child and
6intermittent services during the prenatal and postpartum periods.
AB56,541,117 (c) Subject to par. (d), the department shall reimburse under the Medical
8Assistance program benefits as provided under this subsection for pregnant women
9enrolled in the Medical Assistance program who reside in the counties of Brown,
10Dane, Milwaukee, Rock, or Sheboygan, or another county as determined by the
11department.
AB56,541,1712 (d) The department shall request from the secretary of the federal department
13of health and human services any approval necessary to allow reimbursement under
14the Medical Assistance program for services provided by a certified doula. The
15department may not pay reimbursement unless federal approval is not required or
16any required federal approval allowing reimbursement under s. 49.46 (2) (b) 12p. is
17approved and in effect.
AB56,680 18Section 680. 49.45 (41) of the statutes is amended to read:
AB56,541,2419 49.45 (41) Mental health crisis Crisis intervention services. (a) In this
20subsection, “mental health crisis intervention services" means crisis intervention
21services for the treatment of mental illness, intellectual disability, substance abuse,
22and dementia
that are provided by a mental health crisis intervention program
23operated by, or under contract with, a county, if the county is certified as a medical
24assistance provider.
AB56,542,9
1(b) If a county elects to become certified as a provider of mental health crisis
2intervention services, the county may provide mental health crisis intervention
3services under this subsection in the county to medical assistance recipients through
4the medical assistance program. A county that elects to provide the services shall
5pay the amount of the allowable charges for the services under the medical
6assistance program that is not provided by the federal government. The department
7shall reimburse the county under this subsection only for the amount of the allowable
8charges for those services under the medical assistance program that is provided by
9the federal government.
AB56,681 10Section 681. 49.45 (41) (c) of the statutes is created to read:
AB56,542,1311 49.45 (41) (c) Notwithstanding par. (b), if a county elects to deliver crisis
12intervention services under the Medical Assistance program on a regional basis
13according to criteria established by the department, all of the following apply:
AB56,542,1714 1. After January 1, 2020, the department shall require the county to annually
15contribute for the crisis intervention services an amount equal to 75 percent of the
16county's expenditures for crisis intervention services under this subsection in
17calendar year 2017, as determined by the department.
AB56,542,2118 2. The department shall reimburse the provider of crisis intervention services
19in the county the amount of allowable charges for those services under the Medical
20Assistance program, including both the federal share and nonfederal share of those
21charges, that exceeds the amount of the county contribution required under subd. 1.
AB56,542,2522 3. If a county submits a certified cost report under s. 49.45 (52) (b) to claim
23federal medical assistance funds, the claim based on certified costs made by a county
24for amounts under subd. 2. may not include any part of the nonfederal share of the
25amount under subd. 2.
AB56,682
1Section 682. 49.45 (47) (b) of the statutes is amended to read:
AB56,543,52 49.45 (47) (b) No person may receive reimbursement under s. 46.27 (11) for the
3provision of services to clients in an adult day care center unless the adult day care
4center is certified by the department under sub. (2) (a) 11. as a provider of medical
5assistance.
AB56,683 6Section 683 . 49.45 (47) (dm) of the statutes is created to read:
AB56,543,147 49.45 (47) (dm) Every 24 months, on a schedule determined by the department,
8an adult day care center shall submit through an online system prescribed by the
9department a report in the form and containing the information that the department
10requires, including payment of any fee due under par. (c). If a complete report is not
11timely filed, the department shall issue a warning to the operator of the adult day
12care center. The department may revoke an adult day care center's certification for
13failure to timely and completely report within 60 days after the report date
14established under the schedule determined by the department.
AB56,684 15Section 684. 49.45 (60) of the statutes is repealed.
AB56,685 16Section 685. 49.46 (1) (a) 1m. of the statutes is amended to read:
AB56,543,2017 49.46 (1) (a) 1m. Any pregnant woman whose income does not exceed the
18standard of need under s. 49.19 (11) and whose pregnancy is medically verified.
19Eligibility continues to the last day of the month in which the 60th day or, if approved
20by the federal government, the 365th day
after the last day of the pregnancy falls.
AB56,686 21Section 686. 49.46 (1) (a) 14. of the statutes is amended to read:
AB56,544,222 49.46 (1) (a) 14. Any person who would meet the financial and other eligibility
23requirements for home or community-based services under s. 46.27 (11), 46.277, or
2446.2785 but for the fact that the person engages in substantial gainful activity under
2542 USC 1382c (a) (3), if a waiver under s. 49.45 (38) is in effect or federal law permits

1federal financial participation for medical assistance coverage of the person and if
2funding is available for the person under s. 46.27 (11), 46.277, or 46.2785.
AB56,687 3Section 687. 49.46 (1) (em) of the statutes is amended to read:
AB56,544,104 49.46 (1) (em) To the extent approved by the federal government, for the
5purposes of determining financial eligibility and any cost-sharing requirements of
6an individual under par. (a) 6m., 14., or 14m., (d) 2., or (e), the department or its
7designee shall exclude any assets accumulated in a person's independence account,
8as defined in s. 49.472 (1) (c), and any income or assets from retirement benefits
9earned or accumulated from income or employer contributions while employed and
10receiving state-funded benefits under s. 46.27 or medical assistance under s. 49.472.
AB56,688 11Section 688. 49.46 (1) (j) of the statutes is amended to read:
AB56,544,1612 49.46 (1) (j) An individual determined to be eligible for benefits under par. (a)
139. remains eligible for benefits under par. (a) 9. for the balance of the pregnancy and
14to the last day of the month in which the 60th day or, if approved by the federal
15government, the 365th day
after the last day of the pregnancy falls without regard
16to any change in the individual's family income.
AB56,689 17Section 689. 49.46 (2) (b) 8. of the statutes is amended to read:
AB56,544,2118 49.46 (2) (b) 8. Home or community-based services, if provided under s. 46.27
19(11),
46.275, 46.277, 46.278, 46.2785, 46.99, or under the family care benefit if a
20waiver is in effect under s. 46.281 (1d), or under the disabled children's long-term
21support program, as defined in s. 46.011 (1g).
AB56,690 22Section 690 . 49.46 (2) (b) 12p. of the statutes is created to read:
AB56,544,2423 49.46 (2) (b) 12p. Subject to the limitations under s. 49.45 (30y), services
24provided by a certified doula.
AB56,691 25Section 691. 49.46 (2) (b) 15. of the statutes is amended to read:
AB56,545,2
149.46 (2) (b) 15. Mental health crisis Crisis intervention services under s. 49.45
2(41).
AB56,692 3Section 692. 49.46 (2) (b) 21. of the statutes is created to read:
AB56,545,54 49.46 (2) (b) 21. Subject to par. (bv), nonmedical services that contribute to the
5determinants of health.
AB56,693 6Section 693. 49.46 (2) (bv) of the statutes is created to read:
AB56,545,137 49.46 (2) (bv) The department shall determine those services under par. (b) 21.
8that contribute to the determinants of health. The department shall seek any
9necessary state plan amendment or request any waiver of federal Medicaid law to
10implement this paragraph. The department is not required to provided the services
11under this paragraph as a benefit under the Medical Assistance program if the
12federal department of health and human services does not provide federal financial
13participation for the services under this paragraph.
AB56,694 14Section 694. 49.463 of the statutes is repealed.
AB56,695 15Section 695. 49.47 (4) (ag) 2. of the statutes is amended to read:
AB56,545,1816 49.47 (4) (ag) 2. Pregnant and the woman's pregnancy is medically verified
17Eligibility continues to the last day of the month in which the 60th day or, if approved
18by the federal government, the 365th day
after the last day of the pregnancy falls.
AB56,696 19Section 696. 49.47 (4) (as) 1. of the statutes is amended to read:
AB56,545,2420 49.47 (4) (as) 1. The person would meet the financial and other eligibility
21requirements for home or community-based services under s. 46.27 (11), 46.277, or
2246.2785 or under the family care benefit if a waiver is in effect under s. 46.281 (1d)
23but for the fact that the person engages in substantial gainful activity under 42 USC
241382c
(a) (3).
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