Chapter 49

49.45(6m)(i)2. 2. Payment for personal or residential care is available for a person in a facility certified under 42 USC 1396 to 1396p only if the person entered a facility before the date specified in subd. 1. and has continuously resided in a facility since the date specified in subd. 1. If the person has a primary diagnosis of developmental disabilities or serious and persistent mental illness, payment for personal or residential care is available only if the person entered a facility on or before November 1, 1983.

49.45(6m)(j) (j) The department may develop a separate rate of payment, under this subsection, for persons requiring intense skilled nursing care, as defined by the department.

49.45(6m)(k) (k) Notwithstanding pars. (ag) to (b), (bp) and (br), the department may participate in a demonstration project on case mix nursing home reimbursement authorized under 42 USC 1315 (a) and may modify the payment system under this section, on an experimental basis, as necessary for participation in the demonstration project.

49.45(6m)(L) (L) For purposes of s. 46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under s. 46.277 (5) (e).

49.45(6m)(m) (m) To hold a bed in a facility, the department may pay the full payment rate under this subsection for up to 30 days for services provided to a person during the pendency of an undue hardship determination, as provided in s. 49.453 (8) (b) 3.

49.45(6tw) (6tw) Payments to city health departments. From the appropriation account under s. 20.435 (7) (b), if the department selects the payment procedure under sub. (52) (a), the department may make payments to local health departments, as defined under s. 250.01 (4) (a) 3. Payment under this subsection to such a local health department may not exceed on an annualized basis payment made by the department to the local health department under s. 49.45 (6t), 2003 stats., for services provided by the local health department in 2002.

49.45(6u) (6u) Supplemental payments to certain facilities and care management organizations.

49.45(6u)(ag) (ag) In this subsection:

49.45(6u)(ag)1. 1. “Care management organization” means a care management organization, as defined in s. 46.2805 (1), that contracts under s. 46.284 (4) (d) for provision of services with a facility that is established under s. 49.70 (2) or that is owned and operated by a city, village, or town.

49.45(6u)(ag)2. 2. “Facility” has the meaning given in sub. (6m) (a) 3.

49.45(6u)(am) (am) Notwithstanding sub. (6m), from the appropriations under s. 20.435 (4) (o), and (w), for reduction of operating deficits, as defined under the methodology used by the department in December 2000, incurred by a facility that is established under s. 49.70 (1) or that is owned and operated by a city, village, or town, and as payment to care management organizations, the department may not distribute to these facilities and to care management organizations more than $39,100,000 in each fiscal year, as determined by the department. The total amount that a county certifies under this subsection may not exceed 100 percent of otherwise-unreimbursed care. In distributing funds under this subsection, the department shall perform all of the following:

49.45(6u)(am)1. 1. Estimate the availability of federal medical assistance funds that may be matched to county funds or funds of a city, village or town for the reduction of operating deficits incurred by the facility.

49.45(6u)(am)2. 2. Based on the amount estimated available under subd. 1., develop a method to distribute this allocation to the individual facilities that have incurred operating deficits that shall include:

49.45(6u)(am)2.a. a. Development of criteria for determining operating deficits.

49.45(6u)(am)2.b. b. Agreement by the county in which is located the facility established under s. 49.70 (1) and agreement by the city, village, or town that owns and operates the facility that the applicable county, city, village, or town shall provide funds to match federal medical assistance matching funds under this paragraph.

49.45(6u)(am)2.bm. bm. Identification by the county in which is located the facility established under s. 49.70 (1) of all county funds expended in each calendar year to operate the facility, and certification by the county to the department of this amount.

49.45(6u)(am)2.c. c. Consideration of the size of a facility’s operating deficit.

49.45(6u)(am)3. 3. Distribute the allocation under the distribution method that is developed, unless a county has failed to comply with subd. 2. bm.

49.45(6u)(am)4. 4. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) and (w) that result in a lesser allocation amount than that allocated under this paragraph, allocate not more than the lesser amount so approved by the federal department of health and human services.

49.45(6u)(am)5. 5. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) and (w) that result in a lesser allocation amount than that allocated under this paragraph, submit a revision of the method developed under subd. 2. for approval by the joint committee on finance in that state fiscal year.

49.45(6u)(am)6. 6. If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds distributed under subd. 3., apply the requirements under sub. (6m) (br).

49.45(6u)(am)7. 7. If a facility that is otherwise eligible for an allocation of funds under this section is found by the federal health care financing administration or the department to be an institution for mental diseases, as defined under 42 CFR 435.1009, cease distributing to that facility funds under this section after the date on which the finding is made.

49.45(6u)(b) (b) Notwithstanding the limitation on the amount of disbursements under par. (am) (intro.), from the appropriation under s. 20.435 (4) (wm), the department shall, using the criteria specified in par. (am) 1. to 7., disburse any federal medical assistance funds that are received by the state as federal financial participation for operating deficits incurred by a facility that is operated by a county, city, village, or town and that are in excess of the amount of federal financial participation anticipated and budgeted as revenue in the biennial budget act for the fiscal year in which the funds are received.

49.45(6w) (6w) Hospital operating deficit reduction. From the appropriation under s. 20.435 (4) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a hospital, as defined under s. 50.33 (2) (a) and (b), that is operated by the state, established under s. 49.71 or owned and operated by a city or village, the department shall allocate up to $3,300,000 in each fiscal year to these hospitals, as determined by the department, and shall perform all of the following:

49.45(6w)(a) (a) For the reduction of operating deficits incurred by the hospital, estimate the availability of federal medicaid funds that may be matched to any of the following:

49.45(6w)(a)1. 1. State general purpose revenues, for a hospital operated by the state.

49.45(6w)(a)2. 2. County funds, for a hospital established under s. 49.71.

49.45(6w)(a)3. 3. Funds of a city or village, for a hospital owned and operated by a city or village.

49.45(6w)(b) (b) Based on the amount estimated available under par. (a), develop a method to distribute this allocation to the individual hospitals that have incurred operating deficits that shall include:

49.45(6w)(b)1. 1. Development of criteria for determining operating deficits.

49.45(6w)(b)2. 2. With respect to funds to match federal medicaid matching funds under this section, any of the following, as applicable:

49.45(6w)(b)2.a. a. Provision by the state of matching funds from general purpose revenues for a hospital operated by the state.

49.45(6w)(b)2.b. b. Agreement to provide matching funds by the county in which is located a hospital established under s. 49.71.

49.45(6w)(b)2.c. c. Agreement to provide matching funds by the city or village that owns and operates a hospital.

49.45(6w)(b)3. 3. Consideration of the size of a hospital’s operating deficit.

49.45(6w)(c) (c) Except as provided in par. (d), distribute the allocation under the distribution method that is developed.

49.45(6w)(d) (d) If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) that result in a lesser allocation amount than that allocated under this subsection or disallows use of the allocation of federal medicaid funds under par. (c), reduce allocations under this subsection and distribute on a prorated basis, as determined by the department.

49.45(6x) (6x) Funding for essential access city hospital.

49.45(6x)(a) (a) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department shall distribute all of the following, except that the department may not allocate funds to a hospital to the extent that the allocation would exceed any limitation under 42 USC 1396b (i) (3):

49.45(6x)(a)1. 1. Not more than $2,997,700 in fiscal year 2011-12 and not more than $2,988,700 in each fiscal year after fiscal year 2011-12 to an essential access city hospital that has previously received the supplemental payment for being an essential access city hospital.

49.45(6x)(a)2. 2. Not more than $999,200 in fiscal year 2011-12 and not more than $996,200 in each fiscal year after fiscal year 2011-12 to a hospital that would qualify for an essential access city hospital supplemental payment, under the criteria described in the 2010-11 inpatient hospital state plan, except that the hospital did not meet the criteria to be an essential access city hospital during fiscal year 1995-96.

49.45(6x)(a)3. 3. If the federal department of health and human services allows the payment, $300,000 from the appropriation account under s. 20.435 (4) (b) annually to a hospital that meets all of the following criteria:

49.45(6x)(a)3.a. a. The hospital is located in a city that has a municipal border that is also a state border.

49.45(6x)(a)3.b. b. The hospital has a Medical Assistance recipient patient mix that consists of at least 25 percent of residents from a state that borders this state.

49.45(6x)(a)3.c. c. The hospital is located in a city with a poverty level, as determined from the 2000 U.S. census, that is greater than 5 percent.

49.45(6x)(a)3.d. d. The hospital is located in a city with a population of less than 15,000 people.

49.45(6x)(b) (b) The department shall develop procedures for solicitation and review of requests for funds and a method to distribute the funds under par. (a) to an individual hospital that shall include establishment of criteria for the designation as an essential access city hospital.

49.45(6x)(c) (c) Except as provided in par. (d), the department shall distribute the funds under par. (a) under the distribution method that is developed under par. (b).

49.45(6x)(d) (d) If the federal department of health and human services approves for state expenditure in any state fiscal year amounts under s. 20.435 (4) (o) that result in a lesser distribution amount than that distributed under this subsection or disallows use of federal medicaid funds under par. (a), the department of health services shall reduce the distributions under this subsection.

49.45(6x)(e) (e) The department need not promulgate as rules under ch. 227 the procedures, method of distribution and criteria required for distribution under this subsection.

49.45(6y) (6y) Supplemental funding for certain hospitals.

49.45(6y)(a) (a) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department may distribute funding in each fiscal year to provide supplemental payment to hospitals that enter into a contract under s. 49.02 (2) to provide health care services funded by a relief block grant, as determined by the department, for hospital services that are not in excess of the hospitals’ customary charges for the services, as limited under 42 USC 1396b (i) (3). If no relief block grant is awarded under this chapter or if the allocation of funds to such hospitals would exceed any limitation under 42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into a contract under s. 49.02 (2).

49.45(6y)(ap) (ap) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (o) and (xc), the department shall distribute not more than $8,000,000 in each fiscal year as supplemental payments to hospitals that satisfy the criteria established by the American College of Surgeons for classification as a Level I adult trauma center, except that the department may not make payments that exceed limitations based on customary charges under 42 USC 1396b (i) (3).

49.45(6y)(ar) (ar) Notwithstanding sub. (3) (e), the department may, from the appropriation account under s. 20.435 (4) (xc), make supplemental payments to hospitals based on hospital performance, in accordance with a payment methodology developed by the department, except that the department may not make payments that exceed limitations based on customary charges under 42 USC 1396b (i) (3).

49.45(6y)(b) (b) The department need not promulgate as rules under ch. 227 the procedures, methods of distribution, and criteria required for distribution under par. (a).

49.45(6z) (6z) Supplemental funding for certain hospitals serving low-income patients.

49.45(6z)(a) (a) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department may distribute funding in each fiscal year to supplement payment for services to hospitals that enter into indigent care agreements, in accordance with the approved state plan for services under 42 USC 1396a, with relief agencies that administer the medical relief block grant under this chapter, if the department determines that the hospitals serve a disproportionate number of low-income patients with special needs. If no medical relief block grant under this chapter is awarded or if the allocation of funds to such hospitals would exceed any limitation under 42 USC 1396b (i) (3), the department may distribute funds to hospitals that have not entered into indigent care agreements. The department may not distribute funds under this subsection to the extent that the distribution would do any of the following:

49.45(6z)(a)1. 1. Be inconsistent with 42 USC 1396r-4 (c) (3).

49.45(6z)(a)2. 2. Exceed the limitation on payment under 42 USC 1396r-4 (f) (B) in any fiscal year.

49.45(6z)(b) (b) The department need not promulgate as rules under ch. 227 the procedures, methods of distribution and criteria required for distribution under par. (a).

49.45(7) (7) Personal funds.

49.45(7)(a) (a) Before July 1, 2024, a recipient who is a patient in a public medical institution or an accommodated person and has a monthly income exceeding the payment rates established under 42 USC 1382 (e) may retain $45 unearned income or the amount of any pension paid under 38 USC 5503 (d), whichever is greater, per month for personal needs. Beginning on July 1, 2024, the maximum amount of unearned income a recipient may retain per month under this paragraph is $55. Except as provided in s. 49.455 (4) (a), the recipient shall apply income in excess of the amount of any pension paid under 38 USC 5503 (d) or $55, whichever is greater, less any amount deducted under rules promulgated by the department, toward the cost of care in the facility.

49.45(7)(b) (b) Where a facility participating in the medical assistance program has been delegated in writing by a resident within that facility to manage and control the personal funds of the resident including but not limited to those funds identified in par. (a) the facility shall establish for the resident a personal fund account. All deposits and withdrawals of funds shall be documented by the facility to indicate the amount and date of deposit and amount, date and purpose of withdrawal. Such documentation shall be maintained in the resident’s records.

49.45(7)(c) (c) Upon the removal of a resident from the facility as a result of death or permanent transfer, the facility shall transfer the balance of the resident’s trust account to the personal representative of the resident’s estate, the legal guardian of the resident or if appropriate to the resident personally. A copy of the trust account records shall be transferred with the funds. No facility or any of its employees or representatives may benefit from the distribution of a deceased resident’s personal funds unless they are specifically named in the resident’s will or constitute an heir at law.

49.45(7)(d) (d)

49.45(7)(d)1. 1. The department shall accept from any person a verified complaint concerning any violation of this subsection. The department shall forward to the accused within 10 days a copy of such complaint. The department, upon such investigation as it deems necessary, may dismiss the complaint or may find probable cause to believe that a violation of this subsection has occurred.

49.45(7)(d)2. 2. If the department finds probable cause to believe that a violation of this subsection has occurred, it may assess a forfeiture of not less than $25 nor more than $500 for each occurrence, and in addition may order that any amount illegally charged against a resident’s account be restored. The department shall immediately inform the complainant and respondent of any such decision and the amount of forfeiture or repayment, if any. If the department is not notified in writing that a party wishes to contest a decision within 15 working days after the parties are informed of such decision, the department’s determination shall be deemed final and may not be appealed to a court.

49.45(7)(d)3. 3. The department shall inform the nursing home administrators examining board of all decisions made under this paragraph.

49.45(7)(d)4. 4. The department’s determination of serious misconduct under this subsection shall be cause for terminating the facility’s participation in the state-funded portion of the medical assistance program under this subchapter.

49.45(7)(e) (e) Nursing homes shall adopt a uniform accounting system prescribed by the department for purposes of managing residents personal fund accounts.

49.45(8) (8) Per-visit limits on home health services reimbursement.

49.45(8)(a) (a) In this subsection:

49.45(8)(a)2. 2. “Licensed practical nurse” has the meaning given in s. 146.40 (1) (c).

49.45(8)(a)2m. 2m. “Nurse aide” has the meaning given in s. 146.40 (1) (d).

49.45(8)(a)3. 3. “Occupational therapist” has the meaning given in s. 448.96 (4).

49.45(8)(a)4. 4. “Patient care visit” means a personal contact with a patient that is made by a registered nurse, licensed practical nurse, nurse aide, physical therapist, occupational therapist, or speech-language pathologist who is on the staff of or under contract or arrangement with a home health agency, or by a registered nurse or licensed practical nurse practicing independently, to provide a service that is covered under s. 49.46, 49.47, or 49.471. “Patient care visit” does not include time spent by a nurse, therapist, or nurse aide on case management, care coordination, travel, record keeping, or supervision that is related to the patient care visit.

49.45(8)(a)5. 5. “Physical therapist” has the meaning given in s. 448.50 (3).

49.45(8)(a)6. 6. “Registered nurse” has the meaning given in s. 146.40 (1) (f).

49.45(8)(a)7. 7. “Speech-language pathologist” means an individual engaged in the practice of speech-language pathology, as regulated under ch. 459.

49.45(8)(b) (b) Reimbursement under s. 20.435 (4) (b), (gm), (o), and (w) for home health services provided by a certified home health agency or independent nurse shall be made at the home health agency’s or nurse’s usual and customary fee per patient care visit, subject to a maximum allowable fee per patient care visit that is established under par. (c).

49.45(8)(c) (c) The department shall establish a maximum statewide allowable fee per patient care visit, for each type of visit with respect to provider, that may be no greater than the cost per patient care visit, as determined by the department from cost reports of home health agencies, adjusted for costs related to case management, care coordination, travel, record keeping and supervision.

49.45(8r) (8r) Payment for certain obstetric and gynecological care. The rate of payment for obstetric and gynecological care provided in primary care shortage areas, as defined in s. 36.60 (1) (cm), or provided to recipients of medical assistance who reside in primary care shortage areas, that is equal to 125 percent of the rates paid under this section to primary care physicians in primary care shortage areas, shall be paid to all certified primary care providers who provide obstetric or gynecological care to those recipients.

49.45(8v) (8v) Incentive-based pharmacy payment system. The department shall establish a system of payment to pharmacies for legend and over-the-counter drugs provided to recipients of medical assistance that has financial incentives for pharmacists who perform services that result in savings to the medical assistance program. Under this system, the department shall establish a schedule of fees that is designed to ensure that any incentive payments made are equal to or less than the documented savings. The department may discontinue the system established under this subsection if the department determines, after performance of a study, that payments to pharmacists under the system exceed the documented savings under the system.

49.45(9) (9) Free choice. Any person eligible for medical assistance under s. 49.46, 49.468, 49.47, or 49.471 may use the physician, chiropractor, dentist, pharmacist, podiatrist, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department’s alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, podiatrist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, podiatrist, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist, podiatrist, or dentist may be required to practice exclusively in the medical assistance program.

49.45(9m) (9m) Referrals. The department may, consistent with sub. (9), specify services for which reimbursement will be made only if the services are provided in accordance with a referral, in writing, which specifies the services to be rendered and the duration of such services. The referral form shall describe the referred services as required by the department.

49.45(9p) (9p) Prior authorization prohibited for wheelchair repairs.

49.45(9p)(a) (a) In this subsection, “recipient of medical assistance” means an individual who receives medical assistance under any of the following:

49.45(9p)(a)1. 1. A program operated under this subchapter.

49.45(9p)(a)2. 2. A demonstration program operated under 42 USC 1315.