Chapter 49

49.45(49) (49) Prescription drug prior authorization.

49.45(49)(a) (a) The secretary shall exercise his or her authority under s. 15.04 (1) (c) to create a prescription drug prior authorization committee to advise the department on issues related to prior authorization decisions made concerning prescription drugs on behalf of medical assistance recipients. The secretary shall appoint as members at least all of the following:

49.45(49)(a)1. 1. Two physicians, as defined in s. 448.01 (5), who are currently in practice.

49.45(49)(a)2. 2. Two pharmacists, as defined in s. 450.01 (15).

49.45(49)(a)3. 3. One advocate for recipients of medical assistance who has sufficient medical background, as determined by the department, to evaluate a prescription drug’s clinical effectiveness.

49.45(49)(b) (b) The prescription drug prior authorization committee shall accept information or commentary from representatives of the pharmaceutical manufacturing industry in the committee’s review of prior authorization policies.

49.45(49g) (49g) Billing for prescription drugs.

49.45(49g)(a) (a) In this subsection:

49.45(49g)(a)1d. 1d. “Abortion” has the meaning given in s. 253.10 (2) (a).

49.45(49g)(a)1g. 1g. “Abortion provider” means a person that provides abortion services or is an affiliate of a person that provides abortion services.

49.45(49g)(a)1m. 1m. “Covered entity” has the meaning given in 42 USC 256b (a) (4) (C) and (K).

49.45(49g)(a)2. 2. “Prescription drug” has the meaning given in s. 450.01 (20).

49.45(49g)(b) (b) When billing the Medical Assistance program under this subchapter for reimbursement for a prescription drug, a covered entity that is an abortion provider shall bill the actual acquisition cost of the prescription drug for which coverage is provided under s. 49.46 (2) (b) 6. h. and a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h.

49.45(49m) (49m) Prescription drug cost controls; purchasing agreements.

49.45(49m)(a) (a) In this section:

49.45(49m)(a)1. 1. “Brand name” has the meaning given in s. 450.12 (1) (a).

49.45(49m)(a)2. 2. “Generic name” has the meaning given in s. 450.12 (1) (b).

49.45(49m)(a)3. 3. “Prescription drug” has the meaning given in s. 450.01 (20).

49.45(49m)(b) (b) The department may enter into a multi-state purchasing agreement with another state or a purchasing agreement with a purchaser of prescription drugs if the other state or purchaser agrees to participate in one or more of the activities specified in par. (c) 1. to 4.

49.45(49m)(c) (c) The department may design and implement a program to reduce the cost of prescription drugs and to maintain high quality in prescription drug therapies, which shall include all of the following:

49.45(49m)(c)1. 1. A list of the prescription drugs that are included as a benefit under ss. 49.46 (2) (b) 6. h. and 49.471 (11) (a) that identifies preferred choices within therapeutic classes and includes prescription drugs that bear only generic names.

49.45(49m)(c)2. 2. Establishing supplemental rebates under agreements with prescription drug manufacturers for prescription drugs provided to recipients under Medical Assistance and Badger Care and to eligible persons under s. 49.688 and, if it is possible to implement the program without adversely affecting supplemental rebates for Medical Assistance, Badger Care, and prescription drug assistance under s. 49.688, to beneficiaries of participants under par. (b).

49.45(49m)(c)3. 3. Utilization management and fraud and abuse controls.

49.45(49m)(c)4. 4. Any other activity to reduce the cost of or expenditures for prescription drugs and maintain high quality in prescription drug therapies.

49.45(49m)(d) (d) The department may enter into a contract with an entity to perform any of the duties and exercise any of the powers of the department under this subsection.

49.45(49r) (49r) Value-based purchasing.

49.45(49r)(a) (a) In this subsection, “manufacturer” has the meaning given in s. 450.01 (12).

49.45(49r)(b) (b) Subject to par. (e), the department may enter into a value-based purchasing arrangement for the Medical Assistance program by written agreement with a manufacturer based on agreed upon metrics to which the department and the manufacturer agree in writing. A value-based purchasing arrangement under this paragraph may include any of the following:

49.45(49r)(b)1. 1. Rebates.

49.45(49r)(b)2. 2. Discounts.

49.45(49r)(b)3. 3. Price reductions.

49.45(49r)(b)4. 4. Risk sharing.

49.45(49r)(b)5. 5. Reimbursements.

49.45(49r)(b)6. 6. Payment deferrals or installment payments.

49.45(49r)(b)7. 7. Guarantees.

49.45(49r)(b)8. 8. Shared savings payments.

49.45(49r)(b)9. 9. Withholds.

49.45(49r)(b)10. 10. Bonuses.

49.45(49r)(b)11. 11. Any other thing of value.

49.45(49r)(c) (c) Nothing in this subsection may be interpreted to require a manufacturer or the department to enter into an arrangement described under par. (b).

49.45(49r)(d) (d) Nothing in this subsection may be construed to alter or modify coverage requirements under the Medical Assistance program.

49.45(49r)(e) (e) If the department determines it is unable to implement this subsection without a waiver of federal law, state plan amendment, or other federal approval, the department shall request from the secretary of the federal department of health and human services any waiver of federal law, state plan amendment, or other federal approval necessary to implement this subsection. If the federal department of health and human services does not approve a waiver of federal law, state plan amendment, or other federal approval under this paragraph, the department is not required to implement this subsection.

49.45(50) (50) Disease management.

49.45(50)(a) (a) In this subsection, “disease management” means an integrated and systematic approach for managing the health care needs of patients who are at risk of or are diagnosed with a specific disease, using all of the following:

49.45(50)(a)1. 1. Best practices.

49.45(50)(a)2. 2. Prevention strategies.

49.45(50)(a)3. 3. Clinical practice improvement.

49.45(50)(a)4. 4. Clinical interventions and protocols.

49.45(50)(a)5. 5. Outcomes research, information, and technology.

49.45(50)(a)6. 6. Other tools and resources to reduce overall costs and improve measurable outcomes.

49.45(50)(b) (b) The department may contract with an entity, under the department’s request-for-proposal procedures, to engage in disease management activities on behalf of recipients of medical assistance.

49.45(52) (52) Payment adjustments; federal funding for certain services.

49.45(52)(a) (a)

49.45(52)(a)1. 1. If the department provides the notice under par. (c) selecting the payment procedure in this paragraph, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payment adjustments to county departments under s. 46.215, 46.22, 46.23, 51.42, or 51.437 or to local health departments, as defined in s. 250.01 (4), as appropriate, for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16., except for services specified under s. 49.46 (2) (b) 6. b. and c. provided to children participating in the early intervention program under s. 51.44. Payment adjustments under this paragraph shall include the state share of the payments. The total of any payment adjustments under this paragraph and Medical Assistance payments made from appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), may not exceed applicable limitations on payments under 42 USC 1396a (a) (30) (A).

49.45(52)(a)2. 2. The department may require a county department or local health department to submit a certified cost report that meets the requirements of the federal department of health and human services for covered services described in subd. 1.

49.45(52)(b) (b) If the department provides the notice under par. (c) selecting the payment procedure in this paragraph, all of the following apply:

49.45(52)(b)1. 1. Annually, a county department under s. 46.215, 46.22, 46.23, 51.42, or 51.437 shall submit a certified cost report that meets the requirements of the federal department of health and human services for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and (b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16., except for services specified under s. 49.46 (2) (b) 6. b. and c. provided to children participating in the early intervention program under s. 51.44.

49.45(52)(b)2. 2. For services described under subd. 1., the department shall base the amount of a claim for federal medical assistance funds on certified cost reports submitted by county departments under subd. 1. to the extent the reports comply with federal requirements.

49.45(52)(b)3. 3. The department shall pay county departments a percentage of the federal funds claimed under subd. 2. for services described under subd. 1., which percentage is established in the most recent biennial budget.

49.45(52)(b)4. 4. The department may pay a local health department, as defined in s. 250.01 (4), that submits certified cost reports for services described under subd. 1. a percentage of the federal funds claimed for those services, which percentage is established in the most recent biennial budget.

49.45(52)(c) (c) The department shall select a payment procedure under either par. (a) or (b) and may change which procedure under par. (a) or (b) is selected. The department shall notify each county department and local health department, as applicable, of the selected payment procedure before the date on which payment for services is made under that selected or newly selected procedure.

49.45(53) (53) Payments for certain services. Beginning on January 1, 2003, the department may, from the appropriation account under s. 20.435 (7) (b), make Medical Assistance payments to providers for covered services under ss. 49.46 (2) (a) 4. d. and (b) 6. j. and m. and 49.471 (11) (f) that are provided before January 1, 2012.

49.45(53m) (53m) Coverage program for institutions for mental disease. Subject to any necessary waiver or other approval from the federal department of health and human services, or as otherwise permitted under federal law, the department shall, if federal funding participation is available, provide Medical Assistance coverage of services provided in an institution for mental disease to persons ages 21 to 64.

49.45(54) (54) Therapy for children participating in the birth to 3 program.

49.45(54)(a) (a) Federal share for county expenditures. If a county certifies to the department that the amount the county expended to provide services specified under s. 49.46 (2) (b) 6. b. and c. to children participating in the early intervention program under s. 51.44 exceeds the amount the county received as reimbursement under this section, based on reimbursement rates established by the department for those services, and the federal government pays the state the federal share of Medical Assistance for the amount by which the county expenditures exceed the reimbursement, the department may disburse the federal share to the county. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under s. 51.44 or for services under the disabled children’s long-term support program, as defined in s. 46.011 (1g).

49.45(54)(c) (c) Special services. From the appropriations under s. 20.435 (4) (b) and (o) and (7) (bt), the department may pay the costs of services provided under the early intervention program under s. 51.44 that are included in program participant’s individualized family service plan and that were not authorized for payment under the state Medicaid plan or a department policy before July 1, 2017, including any services under the early intervention program under s. 51.44 that are delivered by a type of provider that becomes certified to provide Medical Assistance service on July 1, 2017, or after.

49.45(56) (56) Disease management program. Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57), the department shall develop and implement, for Medical Assistance recipients, disease management programs. These programs shall have at least the following characteristics:

49.45(56)(a) (a) The use of information science to improve health care delivery by summarizing a patient’s health status and providing reminders for preventive measures.

49.45(56)(b) (b) Educating health care providers on health care process improvement by developing best practice models.

49.45(56)(c) (c) The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.

49.45(56)(d) (d) Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.

49.45(56)(e) (e) Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.

49.45(57) (57) Physical health risk assessment. The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.

49.45(58) (58) Program for all-inclusive care for the elderly. The department may administer the program of all-inclusive care for the elderly under 42 USC 1396u-4.

49.45(59) (59) Health maintenance organization payments to hospitals.

49.45(59)(a) (a) The department shall, from the appropriation accounts under s. 20.435 (4) (xc) and (xe), pay each health maintenance organization with which it contracts to provide medical assistance a monthly amount that the health maintenance organization shall use to make payments to hospitals under par. (b).

49.45(59)(b) (b) Health maintenance organizations shall pay all of the moneys they receive under par. (a) to eligible hospitals, as defined in s. 50.38 (1), within 15 days after receiving the moneys. The department shall specify in contracts with health maintenance organizations to provide medical assistance a method that health maintenance organizations shall use to allocate the amounts received under par. (a) among eligible hospitals based on the number of discharges from inpatient stays and the number of outpatient visits for which the health maintenance organization paid such a hospital in the previous month for enrollees who are recipients of medical assistance. Payments under this paragraph shall be in addition to any amount that a health maintenance organization is required by agreement between the health maintenance organization and a hospital to pay the hospital for providing services to the health maintenance organization’s enrollees.

49.45(59)(c) (c) Each health maintenance organization that provides medical assistance shall report to the department each month the amount it paid each hospital under par. (b) and the percentage of the total payments it made under par. (b) that it paid to each hospital.

49.45(59)(d) (d) Each health maintenance organization that provides medical assistance shall report monthly to each hospital to which the health maintenance organization makes payments under par. (b) such information regarding the payments that the department specifies in its contract with the health maintenance organization to provide medical assistance.

49.45(59)(e) (e)

49.45(59)(e)1. 1. If the department determines that a health maintenance organization has not complied with a requirement under pars. (b) to (d), the department shall order the health maintenance organization to comply with the requirement within 15 days after the department’s determination of noncompliance.

49.45(59)(e)2. 2. The department may terminate a contract with a health maintenance organization to provide medical assistance if the health maintenance organization fails to comply with a requirement under pars. (b) to (d).

49.45(59)(e)3. 3. The department may audit a health maintenance organization to determine whether the health maintenance organization has complied with the requirements under pars. (b) to (d).

49.45(59)(f) (f) The department shall specify in contracts with health maintenance organizations to provide medical assistance the method for adjusting payments under par. (b) to correct a health maintenance organization’s inaccurate counting of inpatient discharges or outpatient visits in calculating a monthly payment to a hospital under par. (b).

49.45(59)(g) (g) If a health maintenance organization and hospital do not agree on the amount of a monthly payment that the health maintenance organization is required to pay the hospital under par. (b), either the health maintenance organization or the hospital, within 6 months after the first day of the month in which the payment is due, may request that the department determine the amount of the payment. The department shall determine the amount of the payment within 60 days after the request for a determination is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under ch. 227 on the department’s determination.

49.45(60) (60) Savings account program. The department shall submit to the federal department of health and human services a request for a waiver of federal Medicaid law to establish and implement a savings account program that is similar in function and operation to health savings accounts in the Medical Assistance program under this subchapter. The department shall exclude from any requirement to have a Medical Assistance savings account under the waiver request under this subsection any individual who is elderly, blind, or disabled and any child.

49.45(61) (61) Services provided through telehealth and communications technology.

49.45(61)(a) (a) In this subsection:

49.45(61)(a)1. 1. “Asynchronous telehealth service” is telehealth that is used to transmit medical data about a patient to a provider when the transmission is not a 2-way, real-time, interactive communication.