Chapter 49

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.

49.45(30j)(d) (d) The department shall request from the federal department of health and human services any waiver of federal Medicaid law, state plan amendment, or other federal approval necessary to implement this subsection and s. 49.46 (2) (b) 14p.

49.45(30m) (30m) Certain services for developmentally disabled.

49.45(30m)(a) (a) Except as provided in par. (am), a county shall provide the portion of payment that is not provided by the federal government for all of the following services to individuals with developmental disability who are eligible for medical assistance:

49.45(30m)(a)1. 1. Services under s. 51.06 (1m) (d).

49.45(30m)(a)2. 2. Services in an intermediate care facility for persons with an intellectual disability, as defined in s. 46.278 (1m) (am), other than a state center for the developmentally disabled.

49.45(30m)(a)3. 3. Services for which payment is permitted under sub. (6c) (d) 2. that are provided in a nursing facility, as defined in s. 46.279 (1) (c).

49.45(30m)(am) (am)

49.45(30m)(am)1. 1. The department shall provide the portion of the payment that is not provided by the federal government for any of the services specified in par. (a) 1. to 3. that are provided to an individual with developmental disability who is eligible for medical assistance, as determined under the contract under s. 46.279 (4m).

49.45(30m)(am)2. 2. For individuals receiving the family care benefit under s. 46.286, the care management organization that manages the family care benefit for the recipient shall pay the portion of the payment that is not covered by the federal government for services that are described under par. (a) 1. and are covered services under the family care benefit; the department shall pay the remainder of the portion of the payment that is not covered by the federal government.

49.45(30m)(b) (b) No payment under this section may be made for services specified under par. (a) or (am) unless the individual who receives the services is provided protective placement under s. 55.06 (9) (a), 2003 stats., or s. 55.12, is provided emergency protective services under s. 55.05 (4), 2003 stats., or s. 55.13, or is provided an emergency protective placement under s. 55.06 (11) (a), 2003 stats., or s. 55.135 or a temporary protective placement under s. 55.06 (11) (c), 2003 stats., or s. 55.135 (5) or 55.055 (5).

49.45(30m)(c) (c) No payment under this section may be made for services specified under par. (a) 2. or 3. that are provided to an individual who was placed in or admitted to an intermediate facility, as defined in s. 46.279 (1) (b), or nursing facility, as defined in s. 46.279 (1) (c), unless one of the following applies:

49.45(30m)(c)1. 1. Any placement or admission that is made after April 30, 2005, complied with the requirements of s. 46.279.

49.45(30m)(c)2. 2. For an individual who was provided protective placement under ch. 55 at any time, any annual review that is conducted under s. 55.18 (1) (a) (intro.) after April 30, 2005, complies with the requirements of s. 55.18 (1) (ar).

49.45(30r) (30r) Services in a mental health institute. A county shall provide the portion of payment that is not provided by the federal government for services under s. 49.46 (2) (b) 6. e. in a mental health institute under s. 51.05.

49.45(30x) (30x) Licensed midwife services.

49.45(30x)(a) (a) Provider reimbursement. Beginning January 1, 2016, services under s. 49.46 (2) (b) 12t. provided to an individual are reimbursable under the Medical Assistance program if an amendment to the state medical assistance plan approved by the federal department of health and human services permits reimbursement under s. 49.46 (2) (b) 12t.

49.45(30x)(b) (b) Plan amendment. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan to permit the application of par. (a). The department may not pay reimbursement under par. (a) unless the amendment to the state plan allowing reimbursement under s. 49.46 (2) (b) 12t. is approved and in effect.

49.45(31) (31) Long-Term Care Partnership Program.

49.45(31)(a) (a) The department shall submit to the federal department of health and human services, not later than 3 months after October 27, 2007, an amendment to the state medical assistance plan that establishes in this state a Long-Term Care Partnership Program, as described in this subsection, and shall implement the program if the amendment to the state plan is approved. Under the program, the department shall exclude an amount equal to the amount of benefits that an individual receives under a qualifying long-term care insurance policy, as described in par. (b), when determining any of the following:

49.45(31)(a)1. 1. The individual’s resources for purposes of determining the individual’s eligibility for medical assistance.

49.45(31)(a)2. 2. The amount to be recovered from the individual’s estate if the individual receives medical assistance.

49.45(31)(b) (b) To be eligible for the program, an individual must have been a resident of this state when the long-term care insurance policy was issued, and the policy must satisfy all of the following criteria:

49.45(31)(b)1. 1. The policy was not issued before the date specified in the amendment to the state plan, which may not be before the first day of the calendar quarter in which the amendment is submitted to the federal department of health and human services.

49.45(31)(b)2. 2. The policy meets the definition of a qualified long-term care insurance policy under 26 USC 7702B (b).

49.45(31)(b)3. 3. The policy meets the long-term care insurance model regulations and the requirements of the long-term care insurance model act promulgated by the National Association of Insurance Commissioners that are specified in 42 USC 1396p (b) (5).

49.45(31)(b)4. 4. The policy includes the applicable inflation protection specified in 42 USC 1396p (b) (1) (C) (iii) (IV).

49.45(31)(b)5. 5. The commissioner of insurance certifies to the department that the policy meets the criteria under subds. 2. to 4.

49.45(31)(c) (c)

49.45(31)(c)1. 1. The department and the office of the commissioner of insurance shall approve a training program for individuals who sell long-term care insurance policies in the state to ensure that those individuals understand the relation of long-term care insurance to the Medical Assistance program and are able to explain to consumers the protections offered by long-term care insurance and how this type of insurance relates to private and public financing of long-term care.

49.45(31)(c)2. 2. The training program approved under this paragraph shall include initial training that is not less than 8 hours long and ongoing training sessions that are not less than 4 hours long per session. Individuals who sell long-term care insurance policies shall be required to attend an ongoing training session every 24 months after the initial training. The commissioner may approve the initial and ongoing training sessions for continuing education requirements under s. 628.04 (3).

49.45(31)(c)3. 3. The training under this paragraph shall cover at a minimum long-term care insurance, long-term care services, qualified partnerships, and the relationship between qualified partnerships and other public and private coverage of long-term care costs.

49.45(31)(d) (d) An insurer that issues a long-term care insurance policy described in par. (b) shall be required to submit reports to the secretary of the federal department of health and human services, in accordance with regulations developed by the secretary, that include notice of when benefits are paid under the policy, the amount of the benefits, notice of the termination of the policy, and any other information required by the secretary.

49.45(31)(e) (e)

49.45(31)(e)1. 1. Notwithstanding par. (b) (intro.), the department, when making a determination under par. (a) 1. or 2. with respect to an individual, shall disregard an amount equal to the insurance benefit payments that are made to or on behalf of the individual under a qualified long-term care insurance policy under 26 USC 7702B (b) that was purchased in a state that had a state plan amendment that provided for a qualified state long-term care partnership, as defined in 42 USC 1396p (b) (1) (C) (iii), at the time of the purchase of the policy.

49.45(31)(e)2. 2. The department shall comply with standards established by the federal department of health and human services in accordance with section 6021 (b) of the federal Deficit Reduction Act of 2005.

49.45(32) (32) Community care for the elderly. The department may request a waiver under 42 USC 1315 to permit the establishment of a community care for the elderly demonstration project to provide medical care, case management services, adult day care and other support services that promote independence and enhance the quality of life of frail elderly persons. If the waiver is approved, the department may establish the community care for the elderly demonstration project and pay a fixed per person fee for the services.

49.45(34) (34) Medical assistance manual. The department shall prepare a medical assistance manual that is clear, comprehensive and consistent with this subchapter and 42 USC 1396a to 1396u and shall, no later than July 1, 1992, provide the manual to counties for use by county employees who administer the medical assistance program. 

49.45(35m) (35m) Computer system redesign. The department shall ensure that any redesign or replacement of the computer network that is used by counties on May 12, 1992, to determine eligibility for medical assistance includes the capability of determining eligibility for medical assistance under s. 49.47 (4) (c) 2.