Chapter 49

49.472(1)(b) (b) “Health insurance” means surgical, medical, hospital, major medical or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time or accident benefits.

49.472(1)(c) (c) “Independence account” means an account approved by the department that consists solely of savings, and dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which an individual began receiving medical assistance under this section.

49.472(1)(d) (d) “Medical assistance purchase plan” means medical assistance, eligibility for which is determined under this section.

49.472(1)(e) (e) “Unearned income” has the meaning given in 42 USC 1382a (a) (2).

49.472(2) (2) Waivers and amendments. The department shall submit to the federal department of health and human services an amendment to the state medical assistance plan, and shall request any necessary waivers from the secretary of the federal department of health and human services, to permit the department to expand medical assistance eligibility as provided in this section. If the state plan amendment and all necessary waivers are approved and in effect, the department shall implement the medical assistance eligibility expansion under this section not later than January 1, 2000, or 3 months after full federal approval, whichever is later.

49.472(3) (3) Eligibility. Except as provided in sub. (6) (a), an individual is eligible for and shall receive medical assistance under this section if all of the following conditions are met:

49.472(3)(a) (a) The individual’s family’s net income is less than 250 percent of the poverty line for a family the size of the individual’s family. In calculating the net income, the department shall apply all of the exclusions specified under 42 USC 1382a (b) and to the extent approved by the federal government shall exclude medical and remedial expenditures and long-term care costs in excess of $500 per month that would be incurred by the individual in absence of coverage under the medical assistance purchase plan or a Medicaid long-term care program.

49.472(3)(b) (b) The individual’s assets do not exceed $15,000. In determining assets, the department may not include assets that are excluded from the resource calculation under 42 USC 1382b (a), assets accumulated in an independence account, and, to the extent approved by the federal government, assets from retirement benefits accumulated from income or employer contributions while employed and receiving medical assistance under this section or state-funded benefits under s. 46.27, 2017 stats. The department may exclude, in whole or in part, the value of a vehicle used by the individual for transportation to paid employment.

49.472(3)(c) (c) The individual would be eligible for supplemental security income for purposes of receiving medical assistance but for evidence of work, attainment of the substantial gainful activity level, earned income and unearned income in excess of the limit established under 42 USC 1396d (q) (2) (B) and (D).

49.472(3)(e) (e) The individual is legally able to work in all employment settings without a permit under s. 103.70.

49.472(3)(f) (f) The individual maintains premium payments under sub. (4) (am) and, if applicable and to the extent approved by the federal government, premium payments calculated by the department in accordance with sub. (4) (bm), unless the individual is exempted from premium payments under sub. (4) (dm).

49.472(3)(g) (g) The individual is engaged in gainful employment or is participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals. To the extent approved by the federal government, an individual shall prove gainful employment and earned income to the department by providing wage income or prove in-kind work income by federal tax filing documentation. To qualify as gainful income, the amount of in-kind income shall be equal to or greater than the minimum amount for which federal income tax reporting is required.

49.472(3)(h) (h) The individual meets all other requirements established by the department by rule.

49.472(4) (4) Premiums.

49.472(4)(am) (am) To the extent approved by the federal government and except as provided in pars. (dm) and (em), an individual who receives medical assistance under this section shall pay a monthly premium of $25 to the department.

49.472(4)(bm) (bm) To the extent approved by the federal government, in addition to the $25 monthly premium under par. (am), an individual who receives medical assistance under this section and whose individual income exceeds 100 percent of the poverty line for a single-person household shall pay 3 percent of his or her adjusted earned and unearned monthly income under par. (cm) that is in excess of 100 percent of the poverty line.

49.472(4)(cm) (cm) For the purposes of par. (bm), an individual’s adjusted earned and unearned monthly income is calculated by subtracting from the individual’s earned and unearned monthly income his or her actual out-of-pocket medical and remedial expenses, long-term care costs, and impairment-related work expenses.

49.472(4)(dm) (dm) The department shall temporarily waive an individual’s monthly premium under par. (am) and, if applicable, par. (bm) when the department determines that paying the premium would be an undue hardship on the individual.

49.472(4)(em) (em) If the department determines that a state plan amendment or waiver of federal Medicaid law is necessary to implement the premium methodology under this subsection and changes to the income and asset eligibility under sub. (3) and s. 49.47 (4) (c) 1., the department shall submit a state plan amendment or waiver request to the federal department of health and human services requesting those changes. If a state plan amendment or waiver is not necessary or if the federal department of health and human services does not disapprove the state plan amendment or waiver request, the department may implement subs. (3) and (4) and s. 49.47 (4) (c) 1. with any adjustments from the federal department of health and human services. If the federal department of health and human services disapproves the state plan amendment or waiver request in whole or in part, the department may implement the income and asset eligibility requirements and premium methodology under subs. (3) and (4), 2015 stats., and s. 49.47 (4) (c) 1., 2015 stats.

49.472(6) (6) Insured persons.

49.472(6)(a) (a) Notwithstanding sub. (4), from the appropriation accounts under s. 20.435 (4) (b), (gm), or (w), the department shall, on the part of an individual who is eligible for medical assistance under sub. (3), pay premiums for or purchase individual coverage offered by the individual’s employer if the department determines that paying the premiums for or purchasing the coverage will not be more costly than providing medical assistance.

49.472(6)(b) (b) If federal financial participation is available, from the appropriation accounts under s. 20.435 (4) (b), (gm), or (w), the department may pay medicare Part A and Part B premiums for individuals who are eligible for medicare and for medical assistance under sub. (3).

49.472(7) (7) Department duties. The department shall do all of the following:

49.472(7)(a) (a) Determine eligibility, or contract with a county department, as defined in s. 49.45 (6c) (a) 3., or with a tribal governing body to determine eligibility, of individuals for the medical assistance purchase plan in accordance with sub. (3).

49.472(7)(b) (b) Ensure, to the extent practicable, continuity of care for a medical assistance recipient under this section who is engaged in paid employment, or is enrolled in a home-based or community-based waiver program under section 1915 (c) of the Social Security Act, and who becomes ineligible for medical assistance.

49.472 History History: 1999 a. 9, 185; 2001 a. 16; 2003 a. 33; 2009 a. 2; 2011 a. 10, 32; 2015 a. 55; 2015 a. 197 s. 51; 2017 a. 59; 2019 a. 9.

49.472 Cross-reference Cross-reference: See also chs. DHS 103 and 107 and s. DHS 103.087, Wis. adm. code.

49.473 49.473 Medical assistance; women diagnosed with breast or cervical cancer or precancerous conditions.

49.473(1) (1) In this section:

49.473(1)(a) (a) “County department” means a county department under s. 46.215, 46.22, or 46.23.

49.473(1)(b) (b) “Qualified entity” has the meaning given in 42 USC 1396r-1b (b) (2).

49.473(2) (2) A woman is eligible for medical assistance as provided under sub. (5) if, after applying to the department or a county department, the department or a county department determines that she meets all of the following requirements:

49.473(2)(a) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.

49.473(2)(b) (b) The woman is under 65 years of age.

49.473(2)(c) (c) The woman is not eligible for health care coverage that qualifies as creditable coverage in 42 USC 300gg (c), excluding the coverage specified in 42 USC 300gg (c) (1) (F).

49.473(2)(d) (d) The woman has been screened for breast or cervical cancer under a breast and cervical cancer early detection program that is authorized under a grant received under 42 USC 300k.

49.473(2)(e) (e) The woman requires treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix.

49.473(3) (3) Prior to applying to the department or a county department for medical assistance, a woman is eligible for medical assistance as provided under sub. (5) beginning on the date on which a qualified entity determines, on the basis of preliminary information, that the woman meets the requirements specified in sub. (2) and ending on one of the following dates:

49.473(3)(a) (a) If the woman applies to the department or a county department for medical assistance within the time limit required under sub. (4), the day on which the department or county department determines whether the woman meets the requirements under sub. (2).

49.473(3)(b) (b) If the woman does not apply to the department or county department for medical assistance within the time limit required under sub. (4), the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.

49.473(4) (4) A woman who a qualified entity determines under sub. (3) is eligible for medical assistance shall apply to the department or county department no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.

49.473(5) (5) The department shall audit and pay, from the appropriation accounts under s. 20.435 (4) (b), (gm), and (o), allowable charges to a provider who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman who meets the requirements under sub. (2) for all benefits and services specified under s. 49.46 (2).

49.473(6) (6) A qualified entity that determines under sub. (3) that a woman is eligible for medical assistance as provided under sub. (5) shall do all of the following:

49.473(6)(a) (a) Notify the department of the determination no later than 5 days after the date on which the determination is made.

49.473(6)(b) (b) Inform the woman at the time of the determination that she is required to apply to the department or a county department for medical assistance no later than the last day of the month following the month in which the qualified entity determines that the woman is eligible for medical assistance.

49.473(7) (7) The department shall provide qualified entities with application forms for medical assistance and information on how to assist women in completing the form.

49.473 History History: 2001 a. 16, 104; 2003 a. 33; 2007 a. 20; 2009 a. 2; 2011 a. 10, 32.

49.475 49.475 Information about assistance program beneficiaries; electronic submission of claims.

49.475(1) (1) Definitions. In this section:

49.475(1)(ar) (ar) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

49.475(1)(b) (b) “Insurer” has the meaning given in s. 600.03 (27).

49.475(1)(c) (c) “Pharmacy benefits management” means the administration or management of prescription drug benefits provided by an insurer or other 3rd party, including the performance of any of the following services:

49.475(1)(c)1. 1. Dispensation of prescription drugs by mail.

49.475(1)(c)2. 2. Claims processing, retail network management, or payment of claims to pharmacies for prescription drugs dispensed to individuals.

49.475(1)(c)3. 3. Clinical formulary development and management services.

49.475(1)(c)4. 4. Rebate contracting and administration.

49.475(1)(c)5. 5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.

49.475(1)(d) (d) “Pharmacy benefits manager” means an entity that performs pharmacy benefits management.

49.475(1)(e) (e) “Recipient” means an individual or his or her spouse or dependent who has been or is one of the following:

49.475(1)(e)1. 1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.

49.475(1)(e)2. 2. An enrollee of family care.

49.475(1)(e)3. 3. A recipient of the Badger Care health care program.

49.475(1)(e)4. 4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.

49.475(1)(e)5. 5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.

49.475(1)(e)6. 6. A woman who receives services that are reimbursed under s. 255.06.

49.475(1)(f) (f) “Third party” means an entity that by statute, rule, contract, or agreement is responsible for payment of a claim for a health care item or service, including any of the following:

49.475(1)(f)1. 1. An insurer.

49.475(1)(f)2. 2. An employee benefit plan, as defined in 29 USC 1002 (3).

49.475(1)(f)3. 3. A service benefit plan, as defined in 5 USC 8903 (1).

49.475(1)(f)4. 4. A pharmacy benefits manager.

49.475(1)(f)5. 5. A group health plan, as defined in 29 USC 1191b (a) (1), including a self-insured plan.

49.475(1)(f)6. 6. The issuer of a disability insurance policy.

49.475(1)(f)7. 7. An entity that administers benefits on behalf of another risk-bearing 3rd party, including a 3rd-party administrator, a fiscal intermediary, or a managed care contractor.

49.475(2) (2) Requirements of 3rd parties.

49.475(2)(ac) (ac) As a condition of doing business in this state, a 3rd party shall do all of the following:

49.475(2)(ac)1. 1. Upon the department’s request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:

49.475(2)(ac)1.a. a. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.

49.475(2)(ac)1.b. b. If subd. 1. a. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.

49.475(2)(ac)2. 2. Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department’s right to recover any 3rd-party payment made for which assignment has not been accepted.

49.475(2)(ac)3. 3. Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.

49.475(2)(ac)4. 4. If all of the following apply, agree not to deny a claim submitted by the department under subd. 2. solely because of the claim’s submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:

49.475(2)(ac)4.a. a. The department submits the claim less than 36 months after the date on which the health care item or service was provided.

49.475(2)(ac)4.b. b. Action by the department to enforce the department’s rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.

49.475(2)(bc) (bc) A 3rd party shall accept the submission of claims from the department under par. (ac) 2. in electronic form and shall timely pay the claims in the manner provided in s. 628.46 (1) and (2). For purposes of timely payment of claims under this paragraph, “written notice” under s. 628.46 (1) includes receipt of a claim in electronic form.

49.475(2m) (2m) Limits on information to be provided.

49.475(2m)(a) (a) The information that the department may request under this section is limited to the information specified in sub. (2) (ac) 1. and does not include an employer’s name unless that information is necessary for the department or a provider to obtain 3rd-party payment for an item or service.

49.475(2m)(b) (b) If information under sub. (2) (ac) 1. may be available from more than one source that includes an employer operating a self-insured plan, the department shall seek the information first from a 3rd-party administrator or other entity identified in sub. (1) (f) 7. or pharmacy benefits manager before seeking the information from the employer.

49.475(2m)(c) (c) Information obtained under this section may be used only for the purposes specified in this section and in federal law on 3rd-party liability in Medical Assistance programs.

49.475(3) (3) Written agreement. Upon requesting a 3rd party to provide the information under sub. (2) (ac) 1., the department and the 3rd party shall enter into a written agreement that satisfies all of the following: