AB56: Bill Text

AB56,535,12 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.

AB56,535,15 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.

AB56,535,16 3. Denial, in whole or in part, of payment for a service.

AB56,535,17 4. Failure to provide services in a timely manner.

AB56,535,20 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.

AB56,535,23 6. Denial of an enrollee's request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

AB56,536,3 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.

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

AB56,536,6 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.

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

AB56,536,21 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:

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

AB56,537,2 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.

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

AB56,537,6 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.

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

AB56,537,13 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).

AB56,667 Section 667. 49.45 (6xm) of the statutes is created to read:

AB56,537,18 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:

AB56,537,19 1. The hospital is an acute care hospital located in this state.

AB56,537,24 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.

AB56,538,5 (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.

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

AB56,538,8 49.45 (19) (title) Assigning Establishing paternity and assigning medical support rights.

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

AB56,538,16 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.

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

AB56,538,25 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.

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

AB56,539,6 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.

AB56,672 Section 672 . 49.45 (23) of the statutes, as affected by 2019 Wisconsin Act .... (this act), is repealed.

AB56,673 Section 673 . 49.45 (23) (g) of the statutes is repealed.

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

AB56,675 Section 675. 49.45 (24k) of the statutes is repealed.

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

AB56,539,16 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.

AB56,539,18 (b) In order to be eligible for enhanced reimbursement under this subsection, the provider must meet one of the following qualifications:

AB56,539,21 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.

AB56,539,23 2. For a for-profit provider, 5 percent or more of the individuals served by the provider are enrolled in the Medical Assistance program.

AB56,540,9 (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.

AB56,540,12 (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.

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

AB56,540,23 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.

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

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

AB56,541,3 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.

AB56,541,6 (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.

AB56,541,11 (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.

AB56,541,17 (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.

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

AB56,541,24 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.

AB56,542,9 (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.

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

AB56,542,13 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:

AB56,542,17 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.

AB56,542,21 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.

AB56,542,25 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.

AB56,682 Section 682. 49.45 (47) (b) of the statutes is amended to read:

AB56,543,5 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.

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

AB56,543,14 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.

AB56,684 Section 684. 49.45 (60) of the statutes is repealed.

AB56,685 Section 685. 49.46 (1) (a) 1m. of the statutes is amended to read:

AB56,543,20 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.

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

AB56,544,2 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.

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

AB56,544,10 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.

AB56,688 Section 688. 49.46 (1) (j) of the statutes is amended to read:

AB56,544,16 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.

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

AB56,544,21 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).

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

AB56,544,24 49.46 (2) (b) 12p. Subject to the limitations under s. 49.45 (30y), services provided by a certified doula.

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

AB56,545,2 49.46 (2) (b) 15. Mental health crisis Crisis intervention services under s. 49.45 (41).

AB56,692 Section 692. 49.46 (2) (b) 21. of the statutes is created to read:

AB56,545,5 49.46 (2) (b) 21. Subject to par. (bv), nonmedical services that contribute to the determinants of health.

AB56,693 Section 693. 49.46 (2) (bv) of the statutes is created to read:

AB56,545,13 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.

AB56,694 Section 694. 49.463 of the statutes is repealed.

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

AB56,545,18 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.

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

AB56,545,24 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).