Chapter 49

49.45(25g)(a) (a) In this subsection, “care coordination” includes coordination of outpatient medical care, specialty care, inpatient care, dental care, and mental health care and medical case management.

49.45(25g)(b) (b) The department shall develop a proposal to increase medical assistance reimbursement to each provider that receives a grant under s. 252.12 (2) (a) 8. and to which at least one of the following applies:

49.45(25g)(b)1. 1. The provider is recognized by the National Committee on Quality Assurance as a Patient-Centered Medical Home.

49.45(25g)(b)2. 2. The secretary determines that the provider performs well with respect to all of the following aspects of care:

49.45(25g)(b)2.a. a. Adoption of written standards for patient access and patient communication.

49.45(25g)(b)2.b. b. Use of data to show that standards for patient access and patient communication are satisfied.

49.45(25g)(b)2.c. c. Use of paper or electronic charting tools to organize clinical information.

49.45(25g)(b)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(25g)(b)2.e. e. Adoption and implementation of guidelines that are based on evidence for treatment and management of HIV-related conditions.

49.45(25g)(b)2.f. f. Active support of patient self-management.

49.45(25g)(b)2.g. g. Systematic tracking of patient test results and systematic identification of abnormal patient test results.

49.45(25g)(b)2.h. h. Systematic tracking of referrals using a paper or electronic system.

49.45(25g)(b)2.i. i. Measuring the quality of the performance of the provider and of individuals who perform services on behalf of the provider, including with respect to provision of clinical services, patient outcomes, and patient safety.

49.45(25g)(b)2.j. j. Reporting to employees and contractors of the provider and to other persons on the quality of the performance of the provider and of individuals who perform services on behalf of the provider.

49.45(25g)(c) (c) The department’s proposal under par. (b) shall specify increases in reimbursement rates for providers that satisfy the conditions under par. (b), 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. (b) 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 January 1, 2011.

49.45(25g)(d) (d) 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 under par. (b) beginning January 1, 2011.

49.45(25g)(e) (e) A provider may not seek medical assistance reimbursement under this subsection and sub. (25) (be) for the same services.

49.45(26) (26) Managed care system. The department shall study alternatives for a system to manage the usage of alcohol and other drug abuse services, including day treatment services, provided under the medical assistance program. On or before September 1, 1988, the department shall submit a plan for a medical assistance alcohol and other drug abuse managed care system to the joint committee on finance. If the cochairpersons of the committee do not notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed plan within 14 working days after the date of the department’s submittal, the department may implement the plan. 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 proposed plan, the department may not implement the plan until it is approved by the committee, as submitted or as modified. If a waiver from the secretary of the federal department of health and human services is necessary to implement the proposed plan, the department of health services may request the waiver, but it may not implement the waiver until it is authorized to implement the plan, as provided in this subsection.

49.45(26g) (26g) Intensive care coordination program.

49.45(26g)(a) (a) Subject to par. (i), the department shall create and implement a program to reimburse participating hospitals and health care systems for intensive care coordination services provided to recipients of Medical Assistance under this subchapter who are not enrolled in coverage under Medicare, 42 USC 1395 et seq.

49.45(26g)(b) (b) To apply to participate in the reimbursement program under this subsection, a hospital or health care system shall submit to the department a description of its intensive care coordination program that includes all of the following:

49.45(26g)(b)1. 1. A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.

49.45(26g)(b)2. 2. The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.

49.45(26g)(b)3. 3. A description of the hospital’s or health care system’s intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.

49.45(26g)(b)4. 4. A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care:

49.45(26g)(b)4.a. a. Discharge instructions and contacts for following up on care and treatment.

49.45(26g)(b)4.b. b. Referral information.

49.45(26g)(b)4.c. c. Appointment scheduling.

49.45(26g)(b)4.d. d. Medication instructions.

49.45(26g)(b)4.e. e. Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization.

49.45(26g)(b)4.f. f. Information about other health and social resources, such as transportation and housing.

49.45(26g)(b)5. 5. A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization.

49.45(26g)(b)6. 6. The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.

49.45(26g)(c) (c) The department shall do all of the following:

49.45(26g)(c)1. 1. Encourage, but not require, any hospital or health care system that seeks to apply to participate in the reimbursement program under this subsection to collaborate with any managed care organization with which it has an agreement to provide services to Medical Assistance recipients. The department may not limit patient populations eligible to participate in the intensive care coordination program under this subsection to either those individuals enrolled in managed care to receive Medical Assistance services or those individuals currently receiving Medical Assistance services on a fee-for-service basis. The department may not deny a hospital or health care system applicant for the reimbursement program under this subsection solely because the applicant does not have an agreement to implement an intensive care coordination program with a managed care organization.

49.45(26g)(c)2. 2. Respond to the hospital or health care system indicating whether additional information is required to evaluate the application for the reimbursement program under this subsection.

49.45(26g)(c)3. 3. After consulting with hospitals, health care systems, and other providers, develop uniform outcome measures to use in determining the efficacy of the program.

49.45(26g)(c)4. 4. If the hospital or health care system is selected for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement.

49.45(26g)(c)5. 5. If the department does not receive a proposal for the reimbursement program under this subsection, solicit proposals for the reimbursement program under this subsection from other health care providers under s. 146.81 (1).

49.45(26g)(d) (d) The department shall provide as reimbursement for intensive care coordination to participants in the program under this subsection $250 initially for each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the hospital or health care system enrolls in intensive care coordination. The initial enrollment for each recipient lasts for 6 months, and if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population, the participant receives an additional $250 for each enrollee at the end of the 6 months. The program participant may enroll each Medical Assistance recipient in one additional 6-month period for an additional $250 per enrollee initial reimbursement payment and $250 per enrollee at the end of the additional 6-month period if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population. The department shall pay no more than $1,500,000 cumulatively in each fiscal year from all funding sources for reimbursements under this paragraph.

49.45(26g)(e) (e) Annually, each hospital and health care system that is participating in the reimbursement program under this subsection shall submit a report to the department containing all of the following:

49.45(26g)(e)1. 1. The number of Medical Assistance recipients served by intensive care coordination.

49.45(26g)(e)2. 2. For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination.

49.45(26g)(e)3. 3. Any demonstrated outcomes, as specified by the department under par. (c) 3., for Medical Assistance recipients.

49.45(26g)(e)4. 4. Any other information required by the department.

49.45(26g)(f) (f) For each hospital or health care system eligible for the reimbursement program under this subsection, the department shall calculate the costs saved to the Medical Assistance program by avoiding emergency department visits by subtracting the sum of reimbursements made under par. (d) to the participant from the sum of costs of visits to the emergency department as reported under par. (e) 2. that were expected to occur without intensive care coordination but did not because of enrollment in the program under this subsection. If the result of the calculation is positive in the first 6 months of the recipient’s enrollment in the program under this subsection, the department shall distribute 25 percent of the amount saved to the hospital, health care system, or managed care organization subject to pars. (g) and (i). If the result of the calculation is positive after 12 months of the recipient’s enrollment in the program under this subsection, the department shall distribute a share of the savings to the hospital, health care system, or managed care organization such that the total amount of shared savings payments made equals half of the savings for the entire 12-month period, subject to pars. (g) and (i).

49.45(26g)(g) (g) If a hospital or health care system participating in the program under this subsection provides services to Medical Assistance recipients enrolled in managed care, the department shall make any payment under the program under this subsection under par. (d) or (f) to the managed care organization with which the hospital or health care system has an agreement to provide services to Medical Assistance recipients. The managed care organization shall pass the payments made under pars. (d) and (f) on to the hospital or health care system no later than 30 days after receiving the payment from the department. The department shall make payments under pars. (d) and (f) to a hospital or health care system that provides services to Medical Assistance recipients who are not enrolled in managed care directly to the hospital or health care system.

49.45(26g)(h) (h) No later than 24 months after the date on which the first hospital or health care system is able to enroll individuals in the intensive care coordination program under this subsection, the department shall submit a report to the joint committee on finance summarizing the information reported under par. (e) including the costs saved by avoiding emergency department visits as calculated under par. (f).

49.45(26g)(i) (i) The department shall seek any necessary approval from the federal department of health and human services to implement the program under this subsection. If the federal department of health and human services disapproves the request for approval, the department may implement the reimbursement under par. (d), the savings distribution under par. (f), or both or any part of the program under this subsection.

49.45(26g)(j) (j) If the federal department of health and human services does not disapprove a request for approval under par. (i) or if federal approval is not required, the department shall implement at least 2 pilot programs under this subsection by the later of September 1, 2018, or the date that is 30 days after the date of federal approval, if approval is needed.

49.45(27) (27) Eligibility of aliens. A person who is not a U.S. citizen or an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law may not receive medical assistance benefits except as provided under 8 USC 1255a (h) (3) or 42 USC 1396b (v).

49.45(29) (29) Hospice reimbursement. The department shall promulgate rules limiting aggregate payments made to a hospice under ss. 49.46, 49.47, and 49.471.

49.45(29w) (29w) Mental health services. In providing mental health benefits under this subchapter, the department shall do all of the following:

49.45(29w)(a) (a) Allow a severely emotionally disturbed child, as defined in sub. (25) (a), to access in-home therapy without having to show a failure to succeed in outpatient therapy.

49.45(29w)(b) (b) Allow qualifying families to participate in in-home therapy even if a child in that family is enrolled in a day treatment program.

49.45(29x) (29x) Emergency detention transport reimbursement.

49.45(29x)(a) (a) Subject to par. (b), the department shall provide reimbursement as provided under s. 49.46 (2) (b) 3. to counties for transport of individuals who are recipients of medical assistance for purposes of emergency detention under s. 51.15 (2) as provided under s. 51.15 (2) (e). The department shall establish criteria that any 3rd-party vendor that is not a law enforcement agency or ambulance service provider must meet in order for the county to obtain reimbursement for transport provided by that 3rd-party vendor under the Medical Assistance program.

49.45(29x)(b) (b) The department shall request any necessary federal approval required to provide reimbursement under par. (a), and, if approval is granted or if no federal approval is required, the department shall provide reimbursement as provided under par. (a). If federal approval is necessary but not granted, the department may not provide reimbursement under par. (a).

49.45(29y) (29y) Mental health consultation reimbursement.

49.45(29y)(a) (a) In this subsection:

49.45(29y)(a)1m. 1m. “Clinical consultation” means, for a student up to age 21, communication from a mental health professional or a qualified treatment trainee working under the supervision of a mental health professional to another individual who is working with the client or to a parent of the student to inform, inquire, and instruct regarding all of the following and to direct and coordinate clinical service components:

49.45(29y)(a)1m.a. a. The client’s symptoms.

49.45(29y)(a)1m.b. b. Strategies for effective engagement, care, and intervention for the client.

49.45(29y)(a)1m.c. c. Treatment expectations for the client across service settings.

49.45(29y)(a)2m. 2m. “Parent” means any of the following:

49.45(29y)(a)2m.a. a. A parent.

49.45(29y)(a)2m.b. b. A foster parent.

49.45(29y)(a)2m.c. c. A guardian.

49.45(29y)(a)2m.d. d. A relative, other than a parent, who lives with the student.

49.45(29y)(b) (b) The department shall, subject to any approval necessary from the federal department of health and human services, reimburse clinical consultation from the Medical Assistance program under this subchapter.

49.45(29z) (29z) Buprenorphine prior authorization review. The department shall review its prior authorization policy on buprenorphine-containing products provided to Medical Assistance program recipients. On November 1, 2018, and every 6 months thereafter, the department shall submit to the standing committees of the legislature with jurisdiction over health under s. 13.172 (3) a report describing the department’s findings on the prior authorization policy on buprenorphine-containing products and its progress on eliminating prior authorization requirements for buprenorphine-containing products in populations where removal of prior authorization is appropriate. The department is not required to submit the report under this subsection after the date the prior authorization requirement for use of buprenorphine-containing products by Medical Assistance program recipients is eliminated for all appropriate populations.

49.45(30) (30) Services provided by community support programs.

49.45(30)(a) (a) A county shall provide the portion of the cost of services under s. 49.46 (2) (b) 6. L. that is not provided by the federal government.

49.45(30)(b) (b) The department shall reimburse a provider of services under s. 49.46 (2) (b) 6. L. only for the amount of the allowable charges for those services that is provided by the federal government.

49.45(30c) (30c) Licensed treatment professionals. To the extent allowable by the federal department of health and human services, the department shall certify and reimburse under the Medical Assistance program under this subchapter licensed treatment professionals, as defined in s. 51.03 (6) (a), for mental health services provided at a school regardless of whether the school site is designated as a clinic office and regardless of whether the licensed treatment professional is employed by, a contractor of, or affiliated with a clinic. The department shall seek any approval necessary from the federal department of health and human services to provide reimbursement to licensed treatment professionals under this subsection.

49.45(30e) (30e) Community-based psychosocial service programs.

49.45(30e)(a) (a) When services are reimbursable. Services under s. 49.46 (2) (b) 6. Lm. provided to an individual are reimbursable under the medical assistance program only if all of the following conditions are met:

49.45(30e)(a)1. 1. Reimbursement for the services under s. 49.46 (2) (b) 6. Lm. in the manner provided under this subsection is permitted pursuant to federal law or pursuant to a waiver from the secretary of the federal department of health and human services.

49.45(30e)(a)2. 2. The county in which the individual resides elects to make the services under s. 49.46 (2) (b) 6. Lm. available in the county through the medical assistance program.

49.45(30e)(a)3. 3. The individual’s psychosocial health needs require more than outpatient counseling, but less than the services provided by a community support program under s. 51.421.

49.45(30e)(a)4. 4. The psychosocial services are provided by a community-based psychosocial service program certified under rules promulgated by the department under par. (b) 3.

49.45(30e)(a)5. 5. Any other condition required by rule under par. (b) 4. is satisfied.

49.45(30e)(b) (b) Rules. The department shall promulgate rules regarding all of the following:

49.45(30e)(b)1. 1. Standards for determining whether an individual is eligible under par. (a) 3.

49.45(30e)(b)2. 2. The scope of psychosocial services that may be provided under s. 49.46 (2) (b) 6. Lm.

49.45(30e)(b)3. 3. Requirements for certification of community-based psychosocial service programs.

49.45(30e)(b)4. 4. Any other conditions for coverage of community-based psychosocial services under the Medical Assistance Program.

49.45(30e)(c) (c) Provider reimbursement. A county that elects to make the services under s. 49.46 (2) (b) 6. Lm. available shall reimburse a provider of the services for the amount of the allowable charges for those services under the medical assistance program that is not provided by the federal government. The department shall reimburse the provider only for the amount of the allowable charges for those services under the medical assistance program that is provided by the federal government.

49.45 Cross-reference Cross-reference: See also ch. DHS 36, Wis. adm. code.