Chapter 49

49.45(21)(ag)5. 5. An agreement that the provider will not compete with the person at all or with respect to a patient, client, resident, service, geographical area, or other part of the provider’s business.

49.45(21)(ag)6. 6. The right to perform services that are substantially similar to services performed by the provider at the same location as those performed by the provider.

49.45(21)(ag)7. 7. The right to use any distinctive name or symbol by which the provider is known in connection with services to be provided by the person.

49.45(21)(ar) (ar) Before a person may take over the operation of a provider that is liable for repayment of improper or erroneous payments or overpayments under ss. 49.43 to 49.497, full repayment shall be made. Upon request, the department shall notify the provider or the person that intends to take over the operation of the provider as to whether the provider is liable.

49.45(21)(b) (b) If, notwithstanding the prohibition under par. (ar), a person takes over the operation of a provider and the applicable amount under par. (ar) has not been repaid, the department may, in addition to withholding certification as authorized under sub. (2) (b) 8., proceed against the provider or the person. Within 30 days after the certified provider receives notice from the department, the amount shall be repaid in full. If the amount is not repaid in full, the department may bring an action to compel payment, may proceed under sub. (2) (a) 12., or may do both.

49.45(21)(c) (c) The department may enforce this subsection within 4 years following a transfer.

49.45(21)(d) (d) This subsection supersedes any provision of chs. 180, 181, 185, and 193.

49.45(21)(e) (e) The department shall promulgate rules to implement this subsection.

49.45(22) (22) Medical assistance services provided by health maintenance organizations. If the department contracts with health maintenance organizations for the provision of medical assistance it shall give special consideration to health maintenance organizations that provide or that contract to provide comprehensive, specialized health care services to pregnant teenagers. If the department contracts with health maintenance organizations for the provision of medical assistance, the department shall determine which medical assistance recipients who have attained the age of 2 but have not attained the age of 6 and who are at risk for lead poisoning have not received lead screening from those health maintenance organizations. The department shall report annually to the appropriate standing committees of the legislature under s. 13.172 (3) on the percentage of medical assistance recipients under the age of 2 who received a lead screening test in that year provided by a health maintenance organization compared with the percentage that the department set as a goal for that year.

49.45(23) (23) Assistance for childless adults demonstration project.

49.45(23)(a) (a) The department shall request a waiver from the secretary of the federal department of health and human services to permit the department to conduct a demonstration project to provide health care coverage to adults who are under the age of 65, who have family incomes not to exceed 100 percent of the poverty line before application of the 5 percent income disregard under 42 CFR 435.603 (d), and who are not otherwise eligible for medical assistance under this subchapter, the Badger Care health care program under s. 49.665, or Medicare under 42 USC 1395 et seq.

49.45(23)(b) (b) If the waiver is granted and in effect, the department may promulgate rules defining the health care benefit plan, including more specific eligibility requirements and cost-sharing requirements. Cost sharing may include an annual enrollment fee, which may not exceed $75 per year. Notwithstanding s. 227.24 (3), the plan details under this subsection may be promulgated as an emergency rule under s. 227.24 without a finding of emergency. If the waiver is granted and in effect, the demonstration project under this subsection shall begin on the effective date of the waiver.

49.45(23)(d) (d) In determining income for purposes of eligibility under this subsection, the department shall apply s. 49.471 (7) (d) to the individual to the extent the federal department of health and human services approves, if approval is required.

49.45(23)(e) (e) The department shall apply the definition of family income under s. 49.471 (1) (f) and the regulations defining household under 42 CFR 435.603 (f) to determinations of income for purposes of eligibility under this subsection.

49.45(23)(f) (f) The department may provide services to individuals who are eligible under this subsection through a medical home initiative under sub. (24j).

49.45(23)(g) (g) The department shall submit to the secretary of the federal department of health and human services an amendment to the waiver requested under par. (a) that authorizes the department to do all of the following with respect to the childless adults demonstration project under this subsection:

49.45(23)(g)1. 1. Impose monthly premiums as determined by the department.

49.45(23)(g)2. 2. Impose higher premiums for enrollees who engage in behaviors that increase their health risks, as determined by the department.

49.45(23)(g)3. 3. Require a health risk assessment for all enrollees.

49.45(23)(g)4. 4. Limit an enrollee’s eligibility under the demonstration project to no more than 48 months. The department shall specify the eligibility formula in the waiver amendment.

49.45(23)(g)5. 5. Require, as a condition of eligibility, that an applicant or enrollee submit to a drug screening assessment and, if indicated, a drug test, as specified by the department in the waiver amendment.

49.45(23)(g)6. 6. Provide employment and training services to childless adults receiving Medical Assistance under this subsection.

49.45(23b) (23b) Childless adults demonstration project reform waiver implementation required.

49.45(23b)(a) (a) In this subsection:

49.45(23b)(a)1. 1. “Community engagement activity” includes any of the following:

49.45(23b)(a)1.a. a. Work in exchange for money, goods, or services.

49.45(23b)(a)1.b. b. Unpaid work, such as volunteer work or community service.

49.45(23b)(a)1.c. c. Self-employment.

49.45(23b)(a)1.d. d. Participation in a work, job training, or job search program, as approved by the department, including the employment and training program under s. 49.79 (9), the Wisconsin Works program under ss. 49.141 to 49.161, programs under the federal workforce innovation and opportunity act, and tribal work programs.

49.45(23b)(a)2. 2. “Exempt individual” means an individual who is any of the following:

49.45(23b)(a)2.a. a. Receiving temporary or permanent disability benefits from the federal or state government or a private source.

49.45(23b)(a)2.b. b. Determined by the department to be physically or mentally unable to work.

49.45(23b)(a)2.c. c. Verified as unable to work in a statement from a social worker or other health care professional.

49.45(23b)(a)2.d. d. Experiencing chronic homelessness.

49.45(23b)(a)2.e. e. Serving as primary caregiver for a person who cannot care for himself or herself.

49.45(23b)(a)2.f. f. Receiving or applying for unemployment compensation and complying with the work requirements for unemployment compensation.

49.45(23b)(a)2.g. g. Participating regularly in an alcohol or other drug abuse treatment or rehabilitation program, except for alcoholics anonymous or narcotics anonymous but including cultural interventions specific to American Indian tribes or bands.

49.45(23b)(a)2.h. h. Attending high school at least half time or enrolled in an institution of higher education, including vocational programs or high school equivalency programs, at least half time.

49.45(23b)(a)2.i. i. Exempt from work requirements under the food stamp program under s. 49.79.

49.45(23b)(b) (b) Beginning as soon as practicable after October 31, 2018, and ending no sooner than December 31, 2023, the department shall do all of the following with regard to the childless adults demonstration project under sub. (23):

49.45(23b)(b)1. 1. Require in each month persons, except exempt individuals, who are eligible to receive Medical Assistance under sub. (23) and who are at least 19 years of age but have not attained the age of 50 to participate in, document, and report 80 hours per calendar month of community engagement activities. The department, after finding good cause, may grant a temporary exemption from the requirement under this subdivision upon request of a Medical Assistance recipient.

49.45(23b)(b)2. 2. Require persons with incomes of at least 50 percent of the poverty line to pay premiums in accordance with par. (c) as a condition of eligibility for Medical Assistance under sub. (23).

49.45(23b)(b)3. 3. Require as a condition of eligibility for Medical Assistance under sub. (23) completion of a health risk assessment.

49.45(23b)(b)4. 4. Charge recipients of Medical Assistance under sub. (23) an $8 copayment for nonemergency use of the emergency department in accordance with 42 USC 1396o-1 (e) (1) and 42 CFR 447.54.

49.45(23b)(b)5. 5. Disenroll from Medical Assistance under sub. (23) for 6 months any individual who does not pay a required premium under subd. 2. and any individual who is required under subd. 1. to participate in a community engagement activity but who does not participate for 48 aggregate months in the community engagement activity.

49.45(23b)(c) (c)

49.45(23b)(c)1. 1. Persons who are eligible for the demonstration project under sub. (23) and who have monthly household income that exceeds 50 percent of the poverty line shall pay a monthly premium amount of $8 per household. A person who is eligible to receive an item or service furnished by an Indian health care provider is exempt from the premium requirement under this subdivision.

49.45(23b)(c)2. 2. The department may disenroll under par. (b) 5. a person for nonpayment of a required monthly premium only at annual eligibility redetermination after providing notice and reasonable opportunity for the person to pay. If a person who is disenrolled for nonpayment of premiums pays all owed premiums or becomes exempt from payment of premiums, he or she may reenroll in Medical Assistance under sub. (23).

49.45(23b)(c)3. 3. The department shall reduce the amount of the required household premium by up to half for a recipient of Medical Assistance under sub. (23) who does not engage in certain behaviors that increase health risks or who attests to actively managing certain unhealthy behaviors.

49.45(23b)(d) (d) The department shall comply with any other requirements not specified elsewhere in this subsection that are imposed by the federal department of health and human services in its approval effective October 31, 2018.

49.45(23b)(e) (e) Before December 31, 2023, the demonstration project requirements under this subsection may not be withdrawn and the department may not request from the federal government withdrawal, suspension, or termination of the demonstration project requirements under this subsection unless legislation has been enacted specifically allowing for the withdrawal, suspension, or termination.

49.45(23b)(f) (f) The department shall comply with all applicable timing in and requirements of s. 20.940.

49.45(24) (24) Primary care provider pilot. The department may request a waiver from the secretary of the federal department of health and human services under 42 USC 1396n (b) (1) to permit the establishment of a primary care provider pilot project. If the waiver is granted, the department may establish a primary care provider pilot project under which primary care providers act as case managers for medical assistance beneficiaries. If the department establishes a primary care provider pilot project, it shall reimburse a case manager for the allowable charges for case management services provided to a beneficiary participating in the pilot project.

49.45(24g) (24g) Physician practice payment pilot.

49.45(24g)(a) (a) The department shall develop a proposal to increase medical assistance reimbursement to providers to which at least one of the following applies:

49.45(24g)(a)1. 1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.

49.45(24g)(a)2. 2. The secretary determines that the provider performs well with respect to all of the following aspects of care:

49.45(24g)(a)2.a. a. Adoption of written standards for patient access and patient communication.

49.45(24g)(a)2.b. b. Use of data to show that standards for patient access and patient communication are satisfied.

49.45(24g)(a)2.c. c. Use of paper or electronic charting tools to organize clinical information.

49.45(24g)(a)2.d. d. Use of data to identify diagnoses and conditions among the provider’s patients that have a lasting detrimental effect on health.

49.45(24g)(a)2.e. e. Adoption and implementation of guidelines that are based on evidence for treatment and management of at least 3 chronic conditions.

49.45(24g)(a)2.f. f. Active support of patient self-management.

49.45(24g)(a)2.g. g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.

49.45(24g)(a)2.h. h. Systematic tracking of referrals using a paper or electronic system.

49.45(24g)(a)2.i. i. Measuring the quality of the performance of the physician practice and of individual physicians within the practice, including with respect to provision of clinical services, patient outcomes, and patient safety.

49.45(24g)(a)2.j. j. Reporting to members of the physician practice and to other persons on the quality of the performance of the physician practice and of individual physicians.

49.45(24g)(c) (c) The department’s proposal under par. (a) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (a) 1. or 2., and shall provide for payment of a monthly per-patient care coordination fee to those providers. The department shall set the increases in reimbursement rates and the monthly per-patient care coordination fee so that together they provide sufficient incentive for providers to satisfy a condition under par. (a) 1. or 2. The proposal shall specify effective dates for the increases in reimbursement rates and the monthly per-patient care coordination fee that are no sooner than July 1, 2011.

49.45(24g)(d) (d) The department shall submit the proposal under par. (a) to the joint committee on finance. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department’s submittal that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal beginning January 1, 2010. If, within 14 working days after the date of the department’s submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal, the department may implement the proposal only upon approval of the committee. If the committee reviews the proposal and approves it, the department shall, subject to approval by the U.S. department of health and human services of any required waiver of federal law relating to medical assistance and any required amendment to the state plan for medical assistance under 42 USC 1396a, implement the proposal beginning January 1, 2010.

49.45(24g)(e) (e) By October 1, 2012, the department shall, if it was required under par. (d) to increase reimbursement to providers that satisfy a condition under par. (a) 1. or 2., submit a report to the joint committee on finance on whether the increased reimbursement results in net cost reductions for the Medical Assistance program under this subchapter and a recommendation as to whether to continue the increased reimbursement. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the department’s submittal that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may implement its recommendation. If, within 14 working days after the date of the department’s submittal, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the report and recommendation, the department may discontinue the increased reimbursement only upon the approval of the committee.

49.45(24j) (24j) Medical home pilot projects.

49.45(24j)(a) (a) The department may administer the medical home initiative as a service delivery mechanism to provide and coordinate care for individuals who are eligible for a Medical Assistance program under this subchapter that provides services under a fee-for-service model. The department may administer a medical home initiative to serve individuals who are members of any of the following populations:

49.45(24j)(a)1. 1. Children who are in out-of-home care or are receiving adoption assistance under 42 USC 670 to 679c.

49.45(24j)(a)2. 2. Pregnant women.

49.45(24j)(a)3. 3. Individuals who are exiting mental health facilities or correctional facilities.

49.45(24j)(a)4. 4. Individuals with a diagnosis of serious mental illness or substance abuse disorder.

49.45(24j)(a)5. 5. Adults with two or more chronic medical conditions.

49.45(24j)(a)6. 6. Other groups of individuals with conditions that the department determines would benefit from services through a medical home.

49.45(24j)(b) (b) The department shall provide to individuals through any medical home initiative administered under this subsection the benefits described under s. 49.46 (2) (a) and (b). The department may provide to individuals though any medical home initiative administered under this subsection benefits in addition to the standard plan benefits that are targeted to the population receiving services through the medical home.

49.45(24j)(c) (c) The department may elect to administer any medical home initiative under this subsection in a limited geographical area.

49.45(24j)(d) (d) The department may make an all-inclusive payment to the provider offering services through a medical home.

49.45(24j)(e) (e) If the federal department of health and human services approves the department’s request to administer a medical home initiative, the department shall automatically enroll an individual who is eligible for a medical home initiative under this subsection in the medical home initiative. At any time after the first 6 months of enrollment in the medical home initiative, the individual who is enrolled in the medical home initiative may opt out of participation in the medical home initiative.

49.45(24k) (24k) Dental reimbursement pilot project.

49.45(24k)(a) (a)

49.45(24k)(a)1. 1. Subject to approval of the federal department of health and human services under par. (b), the department, as a pilot project, shall distribute moneys allocated in each fiscal year for the purpose of increasing the reimbursement rate under Medical Assistance for pediatric dental care and adult emergency dental services, as defined by the department, that are provided in Brown, Marathon, Polk, and Racine counties. If, after increasing the reimbursement rate for counties specified in this subdivision, the moneys allocated for this purpose exceed $100,000, the department shall increase the reimbursement rate under Medical Assistance for pediatric dental care and adult emergency dental services in other counties, as determined by the department, where Medical Assistance recipients have the greatest need for pediatric dental care and adult emergency dental services.

49.45(24k)(a)2. 2. For dental services provided on a fee-for-service basis as of July 1, 2015, the reimbursement rate increase specified in subd. 1. shall be distributed on a fee-for-service basis. For dental services provided as of July 1, 2015, by a health maintenance organization that contracts with the department to provide Medical Assistance services at a capitated rate, the department shall distribute the reimbursement rate increase under subd. 1. to the health maintenance organization. The department shall include in a contract with a health maintenance organization that provides dental services described in subd. 1. in the counties specified in subd. 1. a requirement that the health maintenance organization reimburse providers of services in accordance with the reimbursement rate increase pilot project under subd. 1. The department may not distribute the reimbursement rate increase under subd. 1. to federally qualified health centers that receive a grant under 42 USC 254b.

49.45(24k)(b) (b) The department shall request any waiver from and submit any amendments to the state Medical Assistance plan to the federal department of health and human services necessary for the reimbursement rate increase pilot project under par. (a). If any necessary waiver request or state plan amendment request is approved, the department shall implement par. (a) beginning on the effective date of the waiver or plan amendment.

49.45(24k)(c) (c) No later than January 1, 2020, and biennially thereafter, the department shall submit a report to the chief clerk of each house of the legislature under s. 13.172 (2), each standing committee of the legislature with jurisdiction over health or public benefits under s. 13.172 (3), and the joint committee on finance that includes all of the following information on the pilot project under this subsection:

49.45(24k)(c)1. 1. The number of Medical Assistance recipients who received services under the pilot program in total and specified by those who received pediatric care and who received adult emergency dental services.