Chapter 49

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.

49.45(3p)(a) (a) Subject to par. (c) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay an amount equal to the sum of $4,500,000, as the state share of payments, and the matching federal share of payments, to hospitals that are not eligible for payments under sub. (3m) but that meet the criteria under sub. (3m) (a) 1. and 2. and that, in the most recent year for which information is available, charged at least 6 percent of overall charges for services to the Medical Assistance program for services provided to Medical Assistance recipients. The department may make a payment to a hospital under this subsection under a calculation method determined by the department that provides a fee-for-service supplemental payment that increases as the percentage of the total amount of the hospital’s overall charges for services that are charges to the Medical Assistance program increases.

49.45(3p)(b) (b) The department shall ensure that the total amount of moneys available to pay hospitals described under this subsection is distributed in each fiscal year.

49.45(3p)(c) (c) The department shall limit the maximum payment to hospitals under this subsection such that the amount of payment is in accordance with federal rules concerning any hospital specific limit.

49.45(3p)(d) (d) The department shall seek any necessary approval from the federal department of health and human services to implement the hospital payment supplement described under par. (a). 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 par. (a). If approval is necessary and the federal department of health and human services does not approve, the department may not implement the hospital payment supplement under par. (a).

49.45(4) (4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.

49.45(4m) (4m) Financial record matching program.

49.45(4m)(a) (a) Definitions. In this subsection:

49.45(4m)(a)1. 1. “Account” means a demand deposit account, checking account, negotiable withdrawal order account, savings account, time deposit account, or money market mutual fund account.

49.45(4m)(a)2. 2. “Applicant” means an individual applying for benefits under this subchapter.

49.45(4m)(a)3. 3. “Financial institution” means any of the following:

49.45(4m)(a)3.a. a. A depository institution, as defined in 12 USC 1813 (c).

49.45(4m)(a)3.c. c. A federal credit union, as defined in 12 USC 1752, or state credit union, as defined in 12 USC 1752.

49.45(4m)(a)3.f. f. A broker-dealer, as defined in s. 551.102 (4).

49.45(4m)(a)4. 4. “Other individual” means an individual whose resources are required by law to be disclosed to determine the eligibility of an applicant or recipient.

49.45(4m)(a)5. 5. “Recipient” means an individual who receives benefits under this subchapter.

49.45(4m)(b) (b) Matching program and agreements.

49.45(4m)(b)1. 1. The department shall operate a financial record matching program under this subsection for the purpose of verifying the assets of applicants, recipients, and other individuals with respect to any program under this subchapter that requires asset verification.

49.45(4m)(b)2. 2. The department shall enter into agreements with financial institutions doing business in this state to operate the financial record matching program under this subsection. An agreement shall require the financial institution to participate in the financial record matching program by electing either the financial institution matching option under par. (c) or the state matching option under par. (d). Any changes to the conditions of the agreement shall be submitted by the financial institution or the department at least 60 days before the effective date of the change. The department shall furnish the financial institution with a signed copy of the agreement.

49.45(4m)(b)3. 3. The department shall reimburse a financial institution up to $125 per calendar quarter for participating in the financial record matching program under this subsection.

49.45(4m)(b)4. 4. To the extent feasible, the information to be exchanged under the matching program shall be provided by electronic data exchange as prescribed by the department in the agreement under subd. 2.

49.45(4m)(c) (c) Financial institution matching option. If a financial institution with which the department has an agreement under par. (b) elects the financial institution matching option under this paragraph, all of the following apply:

49.45(4m)(c)1. 1. At least once each calendar quarter, the department shall provide to the financial institution, in the manner specified in the agreement under par. (b) 2., information regarding applicants, recipients, and other individuals. The information shall include names and social security or other taxpayer identification numbers.

49.45(4m)(c)2. 2. Based on the information received under subd. 1., the financial institution shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution. If the financial institution determines that an applicant, recipient, or other individual has an ownership interest in an account at the financial institution, the financial institution shall provide the department with a notice containing the applicant’s, recipient’s, or other individual’s name, address of record, social security number or other taxpayer identification number, and account information. The account information shall include the account number, the account type, the nature of the ownership interest in the account, and the balance of the account at the time that the record match is made. The notice under this subdivision shall be provided in the manner specified in the agreement under par. (b) 2. and, to the extent feasible, by an electronic data exchange.

49.45(4m)(d) (d) State matching option. If a financial institution with which the department has an agreement under par. (b) elects the state matching option under this paragraph, all of the following apply:

49.45(4m)(d)1. 1. At least once each calendar quarter, the financial institution shall provide the department with information concerning all accounts maintained at the financial institution. For each account maintained at the financial institution, the financial institution shall notify the department of the name and social security number or other tax identification number of each person having an ownership interest in the account, together with a description of each person’s interest. The information required under this subdivision shall be provided in the manner specified in the agreement under par. (b) 2. and, to the extent feasible, by an electronic data exchange.

49.45(4m)(d)2. 2. The department shall take actions necessary to determine whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution providing information under subd. 1. Upon the request of the department, the financial institution shall provide to the department, for each applicant, recipient, or other individual who matches information provided by the financial institution under subd. 1., the address of record, the account number and account type, and the balance of the account.

49.45(4m)(e) (e) Use of information by financial institution; penalty. A financial institution participating in the financial record matching program under this subsection, and the employees, agents, officers, and directors of the financial institution, may use information received from the department under par. (c) only for the purpose of matching records and may use information provided by the department in requesting additional information under par. (d) only for the purpose of providing the additional information. Neither the financial institution nor any employee, agent, officer, or director of the financial institution may disclose or retain information received from the department concerning applicants, recipients, or other individuals. Any person who violates this paragraph may be fined not less than $50 nor more than $1,000 or imprisoned in the county jail for not less than 10 days or more than one year or both.

49.45(4m)(f) (f) Use of information by department. The department may use information provided by a financial institution under this subsection only for matching records under par. (d), for administering the financial record matching program under this subsection, and for determining eligibility or continued eligibility under this subchapter. The department may not disclose or retain information received from a financial institution under this subsection concerning account holders who are not applicants, recipients, or other individuals.

49.45(4m)(g) (g) Financial institution liability. A financial institution is not liable to any person for disclosing information to the department under this subsection or for any other action that the financial institution takes in good faith to comply with this subsection.

49.45(5) (5) Appeal.

49.45(5)(a) (a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person’s behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing, except as provided in par. (ag) or (ar).

49.45(5)(ag) (ag) A person shall request a hearing within 90 days of the date of receipt of a notice from a care management organization or managed care organization upholding its adverse benefit determination relating to any of the following or within 90 days of the date the care management organization or managed care organization failed to act on the contested matter within the time specified by the department:

49.45(5)(ag)1. 1. Denial or limited authorization of a requested services, including a determination based on the type or level of service, requirement for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

49.45(5)(ag)2. 2. Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.

49.45(5)(ag)3. 3. Denial, in whole or in part, of payment for a service.

49.45(5)(ag)4. 4. Failure to provide services in a timely manner.

49.45(5)(ag)5. 5. Failure of a care management organization or managed care organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

49.45(5)(ag)6. 6. Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

49.45(5)(ag)7. 7. Denial of an enrollee, who is a resident of a rural area with only one care management organization or managed care organization, to obtain services outside the organization’s network of contracted providers.

49.45(5)(ar) (ar) If a federal regulation specifies a different time limit to request a hearing than par. (a) or (ag), the time limit in the federal regulation shall apply.

49.45(5)(b) (b)

49.45(5)(b)1. 1. Upon receipt of a timely petition under par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if: