Chapter 49

49.45(2)(b)4. 4. Audit claims filed by any provider of medical assistance, and as part of that audit, request of any such provider, and review, medical records of individuals who have received benefits under the medical assistance program.

49.45(2)(b)5. 5. Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.

49.45(2)(b)6m. 6m. Limit the number of providers of particular services that may be certified under par. (a) 11. or the amount of resources, including employees and equipment, that a certified provider may use to provide particular services to medical assistance recipients, if the department finds that existing certified providers and resources provide services that are adequate in quality and amount to meet the need of medical assistance recipients for the particular services; and if the department finds that the potential for medical assistance fraud or abuse exists if additional providers are certified or additional resources are used by certified providers. The department shall promulgate rules to implement this subdivision.

49.45(2)(b)7. 7. Require, as a condition of certification under par. (a) 11., all providers of a specific service that is among those enumerated under s. 49.46 (2), 49.47 (6) (a), or 49.471 (11), as specified in this subdivision, to file with the department a surety bond issued by a surety company licensed to do business in this state. Providers subject to this subdivision provide those services specified under s. 49.46 (2), 49.47 (6) (a), or 49.471 (11) for which providers have demonstrated significant potential to violate s. 49.49 (3p) or (4m) (a) or 946.91 (2), (3) (a) or (b), (4), (5), or (6), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13. The surety bond shall be payable to the department in an amount that the department determines is reasonable in view of amounts of former recoveries against providers of the specific service and the department’s costs to pursue those recoveries. The department shall promulgate rules to implement this subdivision that specify all of the following:

49.45(2)(b)7.a. a. Services under Medical Assistance for which providers have demonstrated significant potential to violate s. 49.49 (3p) or (4m) (a) or 946.91 (2), (3) (a) or (b), (4), (5), or (6), to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13.

49.45(2)(b)7.b. b. The amount or amounts of the surety bonds.

49.45(2)(b)7.c. c. Terms of the surety bond, including amounts, if any, without interest to be refunded to the provider upon withdrawal or decertification from the medical assistance program.

49.45(2)(b)8. 8. Require a person who takes over the operation, as defined in sub. (21) (ag), of a provider, to first obtain certification under par. (a) 11. for the operation of the provider, regardless of whether the person is currently certified. The department may withhold the certification required under this subdivision until any outstanding repayment under sub. (21) is made. The department shall promulgate rules to implement this subdivision.

49.45(2)(b)9. 9. After providing reasonable notice and opportunity for a hearing, charge an assessment to a provider that repeatedly has been subject to recoveries under par. (a) 10. a. because of the provider’s failure to follow identical or similar billing procedures or to follow other identical or similar program requirements. The assessment shall be used to defray in part the costs of audits and investigations by the department under sub. (3) (g) and may not exceed $1,000 or 200 percent of the amount of any such repeated recovery made, whichever is greater. The provider shall pay the assessment to the department within 10 days after receipt of notice of the assessment or the final decision after administrative hearing, whichever is later. The department may recover any part of an assessment not timely paid by offsetting the assessment against any medical assistance payment owed to the provider and may refer any unpaid assessments not collected in this manner to the attorney general, who may proceed with collection under this subdivision. Failure to timely pay in any manner an assessment charged under this subdivision, other than an assessment that is offset against any medical assistance payment owed to the provider, is grounds for decertification under par. (a) 12. A provider’s payment of an assessment does not relieve the provider of any other legal liability incurred in connection with the recovery for which the assessment is charged, but is not evidence of violation of a statute or rule. The department shall credit all assessments received under this subdivision to the appropriation account under s. 20.435 (4) (iL). The department shall promulgate rules to implement this subdivision.

49.45(2n) (2n) Report on Medical Assistance program changes and finances.

49.45(2n)(a) (a) In this subsection, “Medical Assistance program” includes any program operated under this subchapter, demonstration program operated under 42 USC 1315, and program operated under a waiver of federal law relating to medical assistance that is granted by the federal department of health and human services.

49.45(2n)(b) (b) Before January 1, 2015, and every 90 days thereafter, the department shall submit to the joint committee on finance a report that contains all of the following information:

49.45(2n)(b)1. 1. An updated description of any Medical Assistance program changes implemented by the department, including any amendments to the Medical Assistance state plan.

49.45(2n)(b)2. 2. An updated estimate of the projected savings associated with any changes described under subd. 1.

49.45(2n)(b)3. 3. An updated projection of the total Medical Assistance program benefit expenditures during the fiscal biennium and an analysis of how these projected expenditures compare to the funding provided in the most recent biennial budget act.

49.45(2p) (2p) Approval of Medical Assistance program changes. After March 1, 2018, the department may not expand eligibility under section 2001 (a) (1) (C) of the Patient Protection and Affordable Care Act, P.L. 111-148, for the Medical Assistance program under this subchapter unless the state legislature has passed legislation to allow the expansion and that legislation is in effect.

49.45(2t) (2t) Submission of state plan amendments and provider payments.

49.45(2t)(a) (a) The department may not submit a Medical Assistance state plan amendment to the federal department of health and human services or implement a change to the reimbursement rate for or make a supplemental payment to a provider under the Medical Assistance program under this subchapter when the amendment, rate change, or payment has an expected fiscal effect of $7,500,000 or more from all revenue sources over a 12-month period following the implementation date of the amendment, rate change, or payment without submitting the proposed state plan amendment, rate change, or payment to the joint committee on finance for review. If the cochairpersons of the joint committee on finance do not notify the department within 14 working days after the date of the submittal under this paragraph that the committee has scheduled a meeting for the purpose of reviewing the proposed state plan amendment, rate change, or payment, the department may submit the state plan amendment, implement the rate change, or make the payment. If, within 14 working days after the date of the submittal under this paragraph by the department, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the proposed state plan amendment, rate change, or payment, the department may submit the state plan amendment, implement the rate change, or make the payment only upon approval by the committee.

49.45(2t)(c) (c) Notwithstanding par. (a), the department is not required to submit a proposed change to a reimbursement rate for or supplemental payment to a provider under the Medical Assistance program under this subchapter to the joint committee on finance under par. (a) if explicit expenditure authority or funding for the specific change or supplemental payment is included in enacted legislation.

49.45(3) (3) Payment.

49.45(3)(a) (a) Reimbursement shall be made to each county department under ss. 46.215, 46.22, and 46.23 for any administrative services performed in the Medical Assistance program on the basis of s. 49.78 (8).

49.45(3)(ag) (ag) Reimbursement shall be made to each entity contracted with under s. 46.283 (2) for functional screenings performed by the entity.

49.45(3)(b) (b)

49.45(3)(b)1. 1. The contractor, if any, administering benefits or providing prepaid health care under s. 49.46, 49.465, 49.468, 49.47, or 49.471 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in sub. (2) (a) 4., but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.

49.45(3)(b)2. 2. The contractor, if any, insuring benefits under s. 49.46, 49.465, 49.468, 49.47, or 49.471 shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the persons eligible to receive them and for its services as insurer.

49.45(3)(c) (c) Payment for services provided under this section shall be made directly to the hospital, skilled and intermediate nursing homes, prepaid health care group, other organization or individual providing such services or to an organization which provides such services or arranges for their availability on a prepayment basis.

49.45(3)(d) (d) No payment may be made for inpatient hospital services, skilled nursing home services, intermediate care facility services, tuberculosis institution services or inpatient mental institution services, unless the facility providing such services has in operation a utilization review program and meets federal regulations governing such utilization review program.

49.45(3)(dm) (dm) After distribution of computer software has been made under 1993 Wisconsin Act 16, section 9126 (13h), no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under s. 49.46, 49.47, or 49.471 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under 42 USC 1395.

49.45(3)(e) (e)

49.45(3)(e)1. 1. The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital’s total reimbursement or payment to that which would be provided to an economically and efficiently operated facility.

49.45(3)(e)2. 2. A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented under subd. 1. shall annually prepare a report of cost and other data in the manner prescribed by the department.

49.45(3)(e)3. 3. The department may adopt a prospective payment system under subd. 1. which may include consideration of an average rate per diem, diagnosis-related groups or a hospital-specific prospective rate per discharge.

49.45(3)(e)4. 4. If the department maintains a retrospective reimbursement system under subd. 1. for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital’s fiscal year may not exceed the lower of the hospital’s charges for the services or the actual and reasonable allowable costs to the hospital of providing the services, plus any disproportionate share funding that the hospital is qualified to receive under 42 USC 1396r-4.

49.45(3)(e)7. 7. The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under 42 USC 1320c to 1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.

49.45(3)(e)7m. 7m. Notwithstanding subd. 7., the daily reimbursement or payment rate for services at a hospital established under s. 45.50 (10) provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50.

49.45(3)(e)9. 9. Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital’s reimbursement or payment rate under subd. 1.

49.45(3)(e)10. 10. Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.

49.45(3)(e)10m. 10m. All facilities listed in a certificate of approval issued to the University of Wisconsin Hospitals and Clinics Authority under s. 50.35 are a hospital for purposes of reimbursement under this section.

49.45(3)(e)10r. 10r. All facilities listed in a certificate of approval issued to a free-standing pediatric teaching hospital under s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician clinic reimbursement rates to reimburse the facilities under this section for types of services for which, before July 1, 2009, the department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.

49.45(3)(e)11. 11. The department shall use a portion of the moneys collected under s. 50.38 (2) (a) to pay for services provided by eligible hospitals, as defined in s. 50.38 (1), other than critical access hospitals, under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for fiscal year 2008-09 divided by 57.75 percent. For each state fiscal year after state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for the fiscal year divided by 61.68 percent.

49.45(3)(e)12. 12. The department shall use a portion of the moneys collected under s. 50.38 (2) (b) to pay for services provided by critical access hospitals under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For each state fiscal year, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (b) for the fiscal year divided by 61.68 percent.

49.45(3)(em) (em) The department shall expend moneys collected under s. 256.23 (2) to supplement reimbursement for eligible ambulance service providers, as defined in s. 256.23 (1) (a), for services provided under the Medical Assistance program under this subchapter, including services reimbursed on a fee-for-service basis and provided under managed care, by eligible ambulance service providers. Health plans shall be indemnified and held harmless for any errors made by the department or its agents in calculation of any supplemental reimbursement made under this paragraph.

49.45(3)(f) (f)

49.45(3)(f)1. 1. Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.

49.45(3)(f)2. 2. The department may deny any provider claim for reimbursement which cannot be verified under subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider’s records or that the service provided was not included in s. 49.46 (2) or 49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.

49.45(3)(f)2m. 2m. The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.

49.45(3)(f)3. 3. Contractors under sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.

49.45(3)(fm) (fm) The department shall seek, on behalf of dentists who are providers, federal reimbursement for the cost of any equipment that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of the cost of the equipment that is reimbursed by the federal government.

49.45(3)(g) (g)

49.45(3)(g)1. 1. The secretary may authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of statutes, regulations, or rules applicable to the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees authorized by the secretary under this paragraph shall be issued, and shall possess at all times while they are performing their investigatory or audit functions under this section, identification, signed by the secretary, that specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Under the request of a designated person and upon presentation of the person’s authorization, providers and medical assistance recipients shall accord the person access to any provider personnel, records, books, or documents or other information needed. Under the written request of a designated person and upon presentation of the person’s authorization, providers and recipients shall accord the person access to any needed patient health care records of a recipient. Authorized employees may hold hearings, administer oaths, take testimony, and perform all other duties necessary to bring the matter before the department for final adjudication and determination.

49.45(3)(g)2. 2. The department shall promulgate rules to implement this paragraph.

49.45(3)(h) (h)

49.45(3)(h)1m. 1m. The failure or refusal of a provider to accord department auditors or investigators access as required under par. (g) to any provider personnel, records, books, patient health care records of medical assistance recipients, or documents or other information requested constitutes grounds for decertification or suspension of the provider from participation in the medical assistance program. No payment may be made for services rendered by the provider following decertification, during the period of suspension, or during any period of provider failure or refusal to accord access as required under par. (g).

49.45(3)(h)1n. 1n. The department shall promulgate rules to implement this paragraph.

49.45(3)(j) (j) Reimbursement for administrative contract costs under this section is limited to the funds available under s. 20.435 (4) (bm).

49.45(3)(k) (k) If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in s. 448.60 (3), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.

49.45(3)(L) (L)

49.45(3)(L)1. 1. In this paragraph:

49.45(3)(L)1.a. a. “Designated health service” has the meaning given in 42 USC 1395nn (h) (6).

49.45(3)(L)1.b. b. “Medicare” means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395 to 1395ccc.

49.45(3)(L)1.c. c. “Physician” has the meaning given in s. 448.01 (5).

49.45(3)(L)1.d. d. “Referral” has the meaning given in 42 USC 1395nn (h) (5).

49.45(3)(L)2. 2. The department may not pay a provider for a designated health service that is authorized under this section or s. 49.46, 49.47, or 49.471, that is provided as the result of a referral made to the provider by a physician and that, under 42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of 42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under 42 USC 1395nn.

49.45(3)(L)3. 3. A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under 42 USC 1395nn (f), as amended to August 10, 1993.

49.45(3)(L)4. 4. Any person who fails to comply with subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.

49.45(3)(L)5. 5. The department shall administer this paragraph consistently with 42 USC 1395nn and 42 USC 1396b (s).

49.45(3)(m) (m)

49.45(3)(m)1. 1. To be certified under sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in s. 340.01 (23g), that satisfies the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under s. 49.46 (2) (b) 3. or 49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.

49.45(3)(m)2. 2. A person who is certified to provide transportation by specialized medical vehicle under sub. (2) (a) 11. shall ensure that every person who drives or serves as an attendant to passengers on a specialized medical vehicle, before driving or serving as an attendant, has current proficiency in the use of an automated external defibrillator, as defined in s. 256.15 (1) (cr), achieved through instruction provided by an individual, organization, or institution of higher education that is approved under s. 46.03 (38) to provide such instruction.

49.45(3g) (3g) Payments to federally qualified health centers.

49.45(3g)(a) (a) For services provided by a federally qualified health center before July 1, 2016, to a recipient of the Medical Assistance program under this subchapter, the department shall reimburse the federally qualified health center under a payment methodology in effect on January 1, 2015, and in accordance with 42 USC 1396a (bb) (6).

49.45(3g)(b) (b) For services provided by a federally qualified health center on or after July 1, 2016, to a recipient of the Medical Assistance program under this subchapter, the department shall reimburse the federally qualified health centers using a payment methodology based on the Medicaid prospective payment system under 42 USC 1396a (bb) (1) to (3). The department shall consult with federally qualified health centers in developing the payment methodology under this paragraph. The department shall phase-in over fiscal years 2016-17, 2017-18, and 2018-19 payment of new rates under the payment methodology developed under this paragraph.

49.45(3m) (3m) Disproportionate share hospital payments.

49.45(3m)(a) (a) Subject to par. (d) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay to hospitals that serve a disproportionate share of low-income patients an amount equal to the sum of $71,600,000, as the state share of payments, and the matching federal share of payments. The department may make a payment to a hospital under this subsection under the calculation method described in par. (b) if the hospital meets all of the following criteria:

49.45(3m)(a)1. 1. The hospital is located in this state.

49.45(3m)(a)2. 2. The hospital provides a wide array of services, including services provided through an emergency department.

49.45(3m)(a)3. 3. The inpatient days for Medical Assistance recipients at the hospital were at least 6 percent of the total inpatient days at that hospital during the most recent year for which such information is available.

49.45(3m)(a)4. 4. The hospital meets applicable, minimum requirements to be a disproportionate share hospital under 42 USC 1396r-4 and any other applicable federal law.

49.45(3m)(b) (b) The department shall comply with all of the following when making payments to hospitals described in par. (a):

49.45(3m)(b)1. 1. The department shall distribute the total amount of moneys described under par. (a) to be paid to hospitals with a disproportionate share of low-income patients by doing all of the following:

49.45(3m)(b)1.a. a. Dividing the number of Medical Assistance recipient inpatient days at a hospital by the number of total inpatient days at the hospital to obtain the percentage of Medical Assistance recipient inpatient days at that hospital.

49.45(3m)(b)1.b. b. Subject to subds. 2. and 3., providing an increase to the inpatient fee-for-service base rate for each hospital that qualifies for a disproportionate share hospital payment such that the hospital’s overall fee-for-service add-on percentage under this subsection increases as the hospital’s percentage of Medical Assistance recipient inpatient days increases.

49.45(3m)(b)2. 2. The department shall ensure that the total amount of moneys available to pay hospitals with a disproportionate share of low-income patients is distributed in each fiscal year.

49.45(3m)(b)3. 3. The department shall limit the maximum payment to hospitals such that all of the following are true for disproportionate share hospital payments under this subsection in a fiscal year:

49.45(3m)(b)3.a. a. No single hospital receives more than $4,600,000. Beginning in fiscal year 2021-22, the amount specified under this subd. 3. a. shall equal 6.77 percent of the total amount of the state and federal shares available for disproportionate share hospital payments for the fiscal year.

49.45(3m)(b)3.b. b. The amount of payment is in accordance with federal rules concerning the hospital specific limit.

49.45(3m)(c) (c) If the department needs data to calculate the payments under this subsection other than the data available from the Medicaid Management Information System, the fiscal survey data, or the federal centers for Medicare and Medicaid services public records, the department shall collect the necessary data from hospitals.

49.45(3m)(d) (d) The department shall seek any necessary approval from the federal department of health and human services to implement the hospital payment methodology described under pars. (a) and (b). If approval is necessary and approval from the federal department of health and human services is received, the department shall implement the payment methodology described under pars. (a) and (b). If approval is necessary and the department and the federal department of health and human services negotiate a methodology for making payments to hospitals with a disproportionate share of low-income patients that is different from the methodology described under pars. (a) and (b), the department, before implementing the negotiated payment methodology, shall submit to the joint committee on finance the negotiated payment methodology. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the submittal by the department that the committee has scheduled a meeting for the purpose of reviewing the negotiated payment methodology, the department may implement the negotiated payment methodology. If, within 14 working days after the date of the submittal by the department, the cochairpersons of the committee notify the department that the committee has scheduled a meeting for the purpose of reviewing the negotiated payment methodology, the negotiated payment methodology may be implemented only on approval of the committee.

49.45(3p) (3p) Rural critical care access supplement.