Chapter 49

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.

49.45(30e)(d) (d) Provision of services on regional basis. Notwithstanding par. (c) and subject to par. (e), in counties that elect to deliver the services under s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to criteria established by the department, the department shall reimburse a provider of the services for the amount of the allowable charges for those services under the Medical Assistance program that is provided by the federal government and for the amount of the allowable charges that is not provided by the federal government.

49.45(30e)(e) (e) Report; release of funds.

49.45(30e)(e)1. 1. Prior to implementing, and receiving funding for implementing, the regional basis provision of services under par. (d), the department shall submit to the joint committee on finance, no later than March 1, 2014, a request for the release of funds and a report on its proposal for implementation that includes all of the following:

49.45(30e)(e)1.a. a. A description of the criteria that the department will apply in its regionalization model.

49.45(30e)(e)1.b. b. A description of how the regions will be established and the degree of county participation in that process.

49.45(30e)(e)1.c. c. An updated list of the counties that have indicated, by the date of the report, that they will offer the services under s. 49.46 (2) (b) 6. Lm. through the Medical Assistance program on a regional basis according to the criteria established by the department.

49.45(30e)(e)1.d. d. An evaluation of the estimated long-term costs of the proposed regional model.

49.45(30e)(e)2. 2. If the cochairpersons of the committee do not notify the department within 14 working days after the date that the department submits the report and the funding request that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released and the department may implement its proposal for the regional basis provision of services on July 1, 2014. If, within 14 working days after the date that the department submits the report and the funding request, the cochairpersons notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposal for implementation and the funding request, the funding shall be released, and the department may implement its proposal for the regional basis provision of services, only upon approval of the committee.

49.45(30f) (30f) Psychotherapy and alcohol and other drug abuse services. The department shall include licensed mental health professionals, as defined in s. 632.89 (1) (dm), and psychologists as providers of psychotherapy and of alcohol and other drug abuse services. Except for services provided under sub. (30e), the department may not require that licensed mental health professionals or licensed psychologists be supervised; may not require that clinical psychotherapy or alcohol and other drug abuse services be provided under a certified program; and, notwithstanding subs. (9) and (9m), may not require that a physician or other health care provider first prescribe psychotherapy or alcohol and other drug abuse services to be provided by a licensed mental health professional or licensed psychologist before the professional or psychologist may provide the services to the recipient. This subsection does not affect the department’s powers under ch. 50 or 51 to establish requirements for facilities that are licensed, certified, or operated by the department.

49.45(30g) (30g) Community recovery services.

49.45(30g)(a) (a) When services are reimbursable. Community recovery services under s. 49.46 (2) (b) 6. Lo. provided to an individual are reimbursable under the Medical Assistance program only if all of the following conditions are met:

49.45(30g)(a)1. 1. An approved amendment to the state medical assistance plan permits reimbursement for the services under s. 49.46 (2) (b) 6. Lo. in the manner provided under this subsection.

49.45(30g)(a)2. 2. The county in which the individual resides elects to provide the community recovery services under s. 49.46 (2) (b) 6. Lo. through the Medical Assistance program.

49.45(30g)(a)3. 3. The individual, the community recovery services, and the community recovery services provider meet any condition set forth in the approved amendment to the medical assistance plan.

49.45(30g)(b) (b) Limit on the amount of reimbursement. If community recovery services are reimbursable under par. (a), the department shall reimburse each participating county for the portion of the federal share of allowable charges for the community recovery services provided by the county that exceeds that county’s proportionate share of $600,000 in fiscal year 2010-2011 and for 95 percent of the federal share of allowable charges for the community recovery services provided by the county in each fiscal year thereafter. The portion of the federal share of allowable charges not reimbursed to counties shall be transferred to the appropriation account under s. 20.435 (5) (kx).

49.45(30j) (30j) Reimbursement for peer recovery coach services.

49.45(30j)(a) (a) In this subsection:

49.45(30j)(a)1. 1. “Competent mental health professional” means a physician who has completed a residence in psychiatry; a psychologist; a private practice school psychologist who is licensed under ch. 455; a marriage and family therapist who is licensed under s. 457.10 or 457.11; a professional counselor who is licensed under s. 457.12 or 457.13 or who is exercising the professional counselor privilege to practice, as defined in s. 457.50 (2) (s), in this state; an advanced practice social worker who holds a certificate under s. 457.08 (2); an independent social worker who holds a certificate under s. 457.08 (3); a clinical social worker who is licensed under s. 457.08 (4); a clinical substance abuse counselor or independent clinical supervisor who is certified under s. 440.88, or any of these individuals who is practicing under a currently valid training or temporary license or certificate granted under applicable provisions of ch. 457. “Competent mental health professional” does not include an individual whose license, certificate, or privilege is suspended, revoked, or voluntarily surrendered, or whose license, certificate, or privilege is limited or restricted, when practicing in areas prohibited by the limitation or restriction.

49.45(30j)(a)2. 2. “Peer recovery coach” means an individual who practices in the recovery field and who provides support and assistance to individuals who are in treatment or recovery from mental illness or a substance use disorder.

49.45(30j)(b) (b) The department shall reimburse under the Medical Assistance program under this subchapter any service provided by a peer recovery coach if the service satisfies all of the following conditions:

49.45(30j)(b)1. 1. The recipient of the service provided by a peer recovery coach is in treatment for or recovery from mental illness or a substance use disorder.

49.45(30j)(b)2. 2. The peer recovery coach provides the service under the supervision of a competent mental health professional who has been trained in all of the following subjects:

49.45(30j)(b)2.a. a. Understanding the peer role in recovery and supporting clear and meaningful peer roles.

49.45(30j)(b)2.b. b. Recovery orientation.

49.45(30j)(b)2.c. c. Model principles of recovery.

49.45(30j)(b)2.d. d. Training of peer recovery coaches.

49.45(30j)(b)2.e. e. Professional health system navigation.

49.45(30j)(b)2.f. f. Applicable laws and policies.

49.45(30j)(b)2.g. g. Community resources.

49.45(30j)(b)2.h. h. Quality, strength-based, and person-centered supervision.

49.45(30j)(b)2.i. i. Identification and evaluation of peer competencies.

49.45(30j)(b)2.j. j. Confidentiality, ethics, and professional boundaries.

49.45(30j)(b)2.k. k. Antidiscrimination in employment, staff development, and employment practices.

49.45(30j)(b)2.L. L. Peer-delivered services advocacy.

49.45(30j)(b)3. 3. The peer recovery coach provides the service in coordination with the Medical Assistance recipient’s individual treatment plan and in accordance with the recipient’s individual treatment goals.

49.45(30j)(b)4. 4. The peer recovery coach providing the service has completed all of the following training requirements, as established by the department by rule, after consulting with members of the recovery community:

49.45(30j)(b)4.a. a. Forty hours of training in advocacy, mentoring and education, recovery and wellness support, and ethical responsibility that includes training of at least 10 hours in advocacy, at least 10 hours in mentoring and education, at least 10 hours in recovery and wellness support, and at least 10 hours in ethical responsibility.

49.45(30j)(b)4.b. b. Twenty-four hours of supervised volunteer or paid work experience involving advocacy, mentoring and education, recovery and wellness support, ethical responsibility, or a combination of those areas.

49.45(30j)(c) (c) The department shall certify under Medical Assistance peer recovery coaches to provide services in accordance with this subsection.