Chapter 49

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.

49.45(9p)(a)3. 3. A 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(9p)(b) (b) The department may not require any person to obtain prior authorization from the department for a repair to a wheelchair used by a recipient of medical assistance that satisfies the following criteria:

49.45(9p)(b)1. 1. If the repair is to a power wheelchair, the cost of the repair is less than $300.

49.45(9p)(b)2. 2. If the repair is to a manual wheelchair, the cost of the repair is less than $150.

49.45(9p)(b)3. 3. The cost of the repair is a covered benefit under the program of which the individual is a recipient.

49.45(9r) (9r) Complex rehabilitation technology.

49.45(9r)(a) (a) In this subsection:

49.45(9r)(a)1. 1. “Complex needs patient” means an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation.

49.45(9r)(a)2. 2. “Complex rehabilitation technology” means items classified within Medicare as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. “Complex rehabilitation technology” includes complex rehabilitation manual and power wheelchairs, adaptive seating and positioning items, and other specialized equipment such as standing frames and gait trainers, power seat elevation or power standing components of power wheelchairs, as well as options and accessories related to any of these items.

49.45(9r)(a)3. 3. “Individually configured” means having a combination of sizes, features, adjustments, or modifications that a qualified complex rehabilitation technology supplier can customize to the specific individual by measuring, fitting, programming, adjusting, or adapting as appropriate so that the device operates in accordance with an assessment or evaluation of the individual by a qualified health care professional and is consistent with the individual’s medical condition, physical and functional needs and capacities, body size, period of need, and intended use.

49.45(9r)(a)4. 4. “Medicare” means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395 et seq.

49.45(9r)(a)5. 5. “Qualified complex rehabilitation technology professional” means an individual who is certified as an assistive technology professional by the Rehabilitation Engineering and Assistive Technology Society of North America.

49.45(9r)(a)6. 6. “Qualified complex rehabilitation technology supplier” means a company or entity that meets all of the following criteria:

49.45(9r)(a)6.a. a. Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology.

49.45(9r)(a)6.b. b. Is an employer of at least one qualified complex rehabilitation technology professional to analyze the needs and capacities of the complex needs patient in consultation with qualified health care professionals, to participate in the selection of appropriate complex rehabilitation technology for those needs and capacities of the complex needs patient, and to provide training in the proper use of the complex rehabilitation technology.

49.45(9r)(a)6.c. c. Requires a qualified complex rehabilitation technology professional to be physically present for the evaluation and determination of appropriate complex rehabilitation technology for a complex needs patient.

49.45(9r)(a)6.d. d. Has the capability to provide service and repair by qualified technicians for all complex rehabilitation technology it sells.

49.45(9r)(a)6.e. e. Provides written information at the time of delivery of the complex rehabilitation technology to the complex needs patient stating how the complex needs patient may receive service and repair for the complex rehabilitation technology.

49.45(9r)(a)7. 7. “Qualified health care professional” means any of the following:

49.45(9r)(a)7.a. a. A physician licensed under subch. II of ch. 448.

49.45(9r)(a)7.b. b. A physical therapist who is licensed under subch. III of ch. 448 or who holds a compact privilege under subch. XI of ch. 448.

49.45 Note NOTE: Subd. 7. b. is shown as affected by 2021 Wis. Acts 23 and 251 and as merged by the legislative reference bureau under s. 13.92 (2) (i). The cross-reference to subch. XI of ch. 448 was changed from subch. X of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. X of ch. 448.

49.45(9r)(a)7.c. c. An occupational therapist who is licensed under subch. VII of ch. 448 or who holds a compact privilege under subch. XII of ch. 448.

49.45 Note NOTE: The cross-reference to subch. XII of ch. 448 was changed from subch. XI of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. XI of ch. 448.

49.45(9r)(a)7.d. d. A chiropractor licensed under ch. 446.

49.45(9r)(a)7.e. e. A physician assistant who is licensed under subch. IX of ch. 448 or who holds a compact privilege under subch. XIII of ch. 448.

49.45 Note NOTE: The cross-reference to subch. IX of ch. 448 was changed from subch. VIII of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. VIII of ch. 448.

49.45(9r)(b) (b) The department shall promulgate rules and other policies for use of complex rehabilitation technology by recipients of Medical Assistance. The department shall include in the rules all of the following:

49.45(9r)(b)1. 1. Designation of billing codes as complex rehabilitation technology including creation of new billing codes or modification of existing billing codes. The department shall include provisions allowing quarterly updates to the designations under this subdivision.

49.45(9r)(b)2. 2. Establishment of specific supplier standards for companies or entities that provide complex rehabilitation technology and limiting reimbursement only to suppliers that are qualified complex rehabilitation technology suppliers.

49.45(9r)(b)3. 3. A requirement that Medical Assistance recipients who need a complex rehabilitation manual wheelchair, complex rehabilitation power wheelchair, or other complex rehabilitation seating component to be evaluated by all of the following:

49.45(9r)(b)3.a. a. A qualified health care professional who does not have a financial relationship with a qualified complex rehabilitation technology supplier.

49.45(9r)(b)3.b. b. A qualified complex rehabilitation technology professional.

49.45(9r)(b)4. 4. Establishment and maintenance of payment rates for complex rehabilitation technology that are adequate to ensure complex needs patients have access to complex rehabilitation technology, taking into account the significant resources, infrastructure, and staff needed to appropriately provide complex rehabilitation technology to meet the unique needs of complex needs patients.

49.45(9r)(b)5. 5. A requirement for contracts with the department that managed care plans providing services to Medical Assistance recipients comply with this subsection and the rules promulgated under this subsection.

49.45(9r)(b)6. 6. Protection of access to complex rehabilitation technology for complex needs patients.

49.45(9r)(c) (c) This subsection is not intended to affect coverage of speech generating devices, including healthcare common procedure coding system codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, and E2599, under the Medical Assistance program.

49.45(9r)(d) (d) When reviewing prior authorization requests for complex rehabilitation technology items, the department and managed care plans shall act within 10 working days of receiving complete, clinically relevant written documentation necessary to make a determination.

49.45(9r)(dm) (dm) The department may not require a prescription or prior authorization to reimburse a provider for the repair of complex rehabilitation technology if the complex rehabilitation technology has been prescribed and reimbursed as provided in this subsection. This paragraph does not apply to the repair of complex rehabilitation technology if the complex rehabilitation technology is intended for use by an individual who is enrolled in a managed care organization.

49.45(9r)(e) (e) Except as provided in par. (dm), the department shall, consistent with this subsection and without imposing any additional requirements or restrictions under this subsection, reimburse a provider for a complex rehabilitation technology with prior authorization when prescribed by a physician, medically necessary, and used by a recipient of Medical Assistance who is a resident of a nursing home if the complex rehabilitation technology will do any of the following:

49.45(9r)(e)1. 1. Contribute to the recipient’s independent completion of activities of daily living.

49.45(9r)(e)2. 2. Support the recipient’s occupational, vocational, or psychosocial activities.

49.45(9r)(e)3. 3. Provide the recipient the independent ability to move about the facility or to attain or retain self-care.

49.45(9r)(f) (f)

49.45(9r)(f)1. 1. In this paragraph, “KU modifier” means a modifier used in the federal Medicare program related to an exemption from competitive bidding pricing.

49.45(9r)(f)2. 2. For dates of service beginning on March 24, 2024, the department shall, for healthcare common procedure coding system codes relating to complex rehabilitation technology wheelchair repair and accessories, apply a reimbursement rate under the Medical Assistance program equivalent to the maximum fee paid in Wisconsin under the federal Medicare program, including fees under the KU modifier, if applicable.

49.45(9r)(f)3. 3. Beginning July 1, 2025, and annually thereafter, the department shall submit to the chief clerk of each house of the legislature for distribution to the legislature under s. 13.172 (2) a report that includes all of the following information:

49.45(9r)(f)3.a. a. The total number of units.

49.45(9r)(f)3.b. b. The total number of claims.

49.45(9r)(f)3.c. c. The total number of claims per provider.

49.45(9r)(f)3.d. d. The average dollar amount of all paid claims.

49.45(9r)(f)3.e. e. The average dollar amount of claims paid per provider.

49.45(9r)(f)3.f. f. The total dollar amount paid per provider.

49.45(9r)(f)3.g. g. A calculation of the amount paid to the provider compared to the amount paid to the provider if the reimbursement were through fee-for-service under the Medical Assistance program under this subchapter.

49.45(9r)(f)3.h. h. The number of repairs done per unit during the last year.

49.45(9s) (9s) Disclosure. Any person who is an employee of, or an owner, partner, member, stockholder or investor in, any legal entity providing services which are reimbursed under this section, shall notify the department, on forms provided by the department for that purpose, if such person is an employee of, or an owner, partner, member, stockholder or investor in, any other legal entity providing services which are reimbursed under this section.

49.45(10) (10) Rule-making powers and duties. The department is authorized to promulgate such rules as are consistent with its duties in administering medical assistance. The department shall promulgate a rule defining the term “part-time intermittent care” for the purpose of s. 49.46.

49.45(11) (11) Penalty. Any person who receives or assists another in receiving assistance under this section, to which the recipient is not entitled, shall be subject to the penalties under ss. 946.91 and 946.93.

49.45(12) (12) Machine-readable medical assistance cards.

49.45(12)(b) (b) If the commissioner of insurance promulgates rules under s. 601.57 (2), 2021 stats., establishing a health insurance identification card system and its computerized support system, the department shall develop a plan to coordinate a system of machine-readable identification cards for medical assistance recipients with the systems established by the commissioner and shall submit the plan to the governor, and to the legislature under s. 13.172 (2), before issuing a request for proposals under par. (c).

49.45(12)(c) (c) The department shall request proposals for a system of machine-readable identification cards for medical assistance recipients and a computerized support system for the cards that will accept and respond to electronically conveyed requests from health care providers for information related to medical assistance recipients, such as eligibility, coverages and authorizations. The request for proposals shall specify that the systems are to be operating by January 1, 1997.

49.45(13) (13) Financial reports.

49.45(13)(a) (a) The department may require service providers to prepare and submit cost reports or financial reports for purposes of rate certification under Title XIX, cost verification, fee schedule determination or research and study purposes. These financial reports may include independently audited financial statements which shall include balance sheets and statements of revenues and expenses. The department may withhold reimbursement or may decrease or not increase reimbursement rates if a provider does not submit the reports required under this paragraph or if the costs on which the reimbursement rates are based cannot be verified from the provider’s cost or financial reports or records from which the reports are derived.

49.45(13)(b) (b) The department may require any provider who fails to submit a cost report or financial report under par. (a) within the period specified by the department to forfeit not less than $10 nor more than $100 for each day the provider fails to submit the report.

49.45(15) (15) Community care organization project guarantee. Upon termination of the community care organization demonstration projects in Barron, La Crosse and Milwaukee counties, any client who was receiving services through any of those projects may continue to receive the full range of community care organization services. The cost of the services shall continue to be paid by medical assistance.

49.45(15r) (15r) Emergency medical transportation reimbursement. The department shall submit a state plan amendment to the federal department of health and human services to allow payment of supplemental reimbursements under the Medical Assistance program under this subchapter to public ambulance service providers, as defined in s. 256.01 (3), for ground emergency medical transportation through certified public expenditures. For purposes of this subsection, any ambulance service provider that is owned by any municipality or group of municipalities, regardless of whether or not the ambulance service provider is organized as a nonprofit corporation, is considered a public ambulance service provider. If the state plan amendment under this subsection is approved, the department shall pay to an ambulance service provider that complies with a certified public expenditure arrangement, as established by the department, a supplemental reimbursement equal to the amount of federal financial participation for ground emergency medical transportation services in accordance with state and federal law and regulations, except that the total reimbursement under the Medical Assistance program for the transportation may not exceed the actual cost to the ambulance service provider of providing the transportation. If the federal department of health and human services disapproves the state plan amendment, the department may not pay the supplement under this subsection.

49.45(16) (16) Certification. On or after January 1, 1984, the department may only continue to certify as a medical assistance provider a community-based residential facility that is so certified on December 31, 1983. On or after January 1, 1984, no community-based residential facility may be certified for more beds than the number for which it was certified on December 31, 1983.

49.45(18) (18) Recipient cost sharing.

49.45(18)(ac) (ac) Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.

49.45(18)(ag) (ag) Except as provided in pars. (am), (b), and (c), and subject to par. (d), a recipient specified in par. (ac) shall pay all of the following:

49.45(18)(ag)1. 1. A copayment of $1 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b).

49.45(18)(ag)2. 2. A copayment of $3 for each prescription of a drug that bears a brand name, as defined in s. 450.12 (1) (a).

49.45(18)(am) (am)

49.45(18)(am)1. 1. Except as provided in subd. 2., no person is liable under this subsection for services provided through prepayment contracts.

49.45(18)(am)2. 2. A person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 is liable under this subsection for services provided through a prepayment contract in the amounts and according to the procedures specified by the department.

49.45(18)(b) (b) The following services are not subject to recipient cost sharing under this subsection:

49.45(18)(b)1. 1. Any service provided to a person receiving care as an inpatient in a skilled nursing home or intermediate care facility certified under 42 USC 1396 to 1396k.

49.45(18)(b)2. 2. Any service provided to a person who is less than 18 years old. This subdivision does not apply if the person’s family income exceeds 100 percent of the poverty line and he or she is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471.

49.45(18)(b)3. 3. Any service provided under s. 49.46 (2) to a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy.

49.45(18)(b)4. 4. Emergency services.

49.45(18)(b)5. 5. Family planning services, as defined in s. 253.07 (1) (b).

49.45(18)(b)6. 6. Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under s. 46.215 or 46.22.