DepartmenT of Health Services Office of Legal Counsel | STATE OF WISCONSIN |
WISCONSIN DEPARTMENT OF HEALTH SERVICES PROPOSED ORDER TO ADOPT PERMANENT RULES |
The Wisconsin Department of Health Services proposes an order to: repeal DHS 105.52 (1) (k) and (L); renumber and amend DHS 105.52 (2) (a) 9., (3), and (5) (f); amend DHS 105.52 (1) (intro.), (a) to (f), (h) to (j) and (m) to (o), (2) (a) 1. to 8., (b) (intro.) and 1. to 3., (4) (intro.), (a), (b), (c) (intro.) and 1. to 11., (e), (f) 1. to 6., and (g) to (i), (5) (title) and (a) to (e),107.34 (1) (a) 1. and 2., (b), (c) (title), (c), (d) (intro.) and 1. to 7., and (e) 1. and 2. (intro.) and a. and b., (f) (intro.) and 1. to 9., (g) (intro.) and 1. to 6., (2) (a) to (e), (3) (a) 1. to 4., and (b) to (e); repeal and recreate DHS 105.52 (1) (g), (4) (d); and create DHS 105.52 (2) (a) 9. a. and b. and 10. to 12., (c) and (d), (2m), (3) (a) to (d), (3m), (4) (c) 10g. and 10r., (j) to (m), (5) (f) 1. to 5., (6), and (7), 105.525, 107.34 (1) (e) 2. am., (3) (g) to (L), and 107.345, relating to prenatal care coordination services child care coordination services under the medical assistance program.
RULE SUMMARY
Statutes interpreted
Section 49.45 (2) (a) 1., 2., 11,, and 12., (3) (f) 2., and (44), Stats.
Section 49.46 (1) (a) lm., (j), and (2) (b) 12. and 12m., Stats.
Section 49.47 (4) (ag) 2., Stats.
Section 49.471 (6) (b), (7) (b) 1. and 2., Stats. Statutory authority
Explanation of agency authority
The department’s authority to administer medical assistance (“MA”) is provided in s. 49.45, Stats. Section 49.45 (2) (a), Stats., lists the department’s duties in administering the state MA program, including all of the following relevant obligations: — Exercising responsibility relating to fiscal matters and eligibility for MA benefits. Section 49.45 (2) (a) 1., Stats. — “[C]ooperat[ing] with federal authorities for the purpose of providing assistance and services under Title XIX to obtain the best financial reimbursement available to the state from federal funds.” Section 49.45 (2) (a) 2., Stats. — Establishing criteria for the certification of providers of medical assistance and promulgating rules to implement that authority. Section 49.45 (2) (a) 11, Stats. — Decertifying or restricting providers from participating in MA if, after providing appropriate due process, the provider has violated relevant laws and regulations, and promulgating rules to implement this authority. Section 49.45 (2) (a) 11. Subsection (3) of s. 49.45, Stats., relating to payment, requires that providers of MA maintain records as required by the department for verification of provider claims for reimbursement, and further authorizes the department to deny claims for reimbursement that cannot be verified, and to recover “the full value of any claim” if an audit determines that the actual provision of services cannot be verified or that the service was not covered. Section 49.45 (3) (f) 2., Stats. Subsection (10) of s. 49.45, Stats., further authorizes the department to “promulgate such rules as are consistent with its duties in administering medical assistance” as detailed in the above-cited provisions of s. 49.45, Stats. Section 49.46 (2). Stats., lists benefits for which “the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients.” Section 49.46 (2) (b) 12. and 12m. identify prenatal care coordination ("PNCC") and child care coordination ("CCC") as MA reimbursable services. Sections 49.46 (1) (a) lm., (j), (2) (b) 12m, and 49.471 (7) (b) 1. and 2., describe eligibility criteria for care coordination services for prenatal and postpartum women and children. Subsection (44) of s. 49.45, Stats., states that certain individuals certified to provide PNCC services who are located in Milwaukee County or the city of Racine may be certified to provide CCC services. Certified CCC providers in Milwaukee County may provide services to children under age 7. Certified CCC providers in the city of Racine may provide services to children under age 2. Section 49.471, Stats., includes provisions for BadgerCare Plus related to eligibility criteria. Subsection (12) of the statute authorizes the “department to promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.” Related statute or rule
Plain language analysis
In accordance with ss. 49.45 (2) (a) 11. and 12., and 49.46 (2) (b) 12. Stats., the department established certification criteria for PNCC providers in s. DHS 105.52, and identified covered PNCC services in s. DHS 107.34. Previously, certified PNCC providers in Milwaukee County and the City of Racine were automatically certified to provide CCC services, and rules did not contain specific CCC certification criteria or identify which specific services were covered under the CCC benefit.
Due to substantiated concerns about fraud, waste, and abuse among providers of the CCC benefit, the department ceased certifying CCC providers in accordance with a federal moratorium restricting PNCC and CCC enrollments. Enrollments ceased on November 10, 2023.
In order to mitigate the risk of future fraud, waste, and abuse within future PNCC or CCC provider enrollment and reimbursement for services, the department proposes rules for both programs to effectuate the intent of ss. 49.45 (44) and 49.46 (2) (b) (12m), Stats. Broadly, the proposed rules will achieve the following: — Update PNCC certification criteria and documentation requirements in accordance with the department's authority to set certification criteria under s. 49.45 (2) (a) 11., Stats., and to set records retention requirements under s. 49.45 (3), Stats. — Update the duration for which PNCC services are covered to align with statutes.
— Update which services are and are not covered under the PNCC benefit.
— Create CCC certification criteria and documentation requirements in ac accordance with the department's authority to set certification criteria under s. 49.45 (2) (a) 11., Stats., and to set records retention requirements under s. 49.45 (3), Stats. These criteria would apply in addition to PNCC criteria for applicable providers under s. 49.45 (44), Stats. — Identify which services are and are not covered under the CCC benefit.
Summary of, and comparison with, existing or proposed federal regulations
Section 1915 (g) (1) of the Social Security Act authorizes medical assistance program coverage of case management services. s.1915(g)(2) defines case management services as those assisting individuals eligible under the State plan in gaining access to needed medical, social, educational, and other services.
42 CFR s. 440.169 and 42 CFR s. 441.18 include requirements for covered case management services and providers.
42 CFR s. 440.210(a)(2) requires that state medical assistance programs provide, for the categorically needy, pregnancy-related services and services for other conditions that might complicate the pregnancy, including prenatal and postpartum care. 42 CFR § 435.170 extends the eligibility for pregnant women under the MA program. Comparison with rules in adjacent states
Illinois: As of August 2023, the state has rules related to Family Case Management for comprehensive service coordination for pregnant women and infants until 12 months of age. Rules are outlined under Title 77 Illinois Administrative Code Part 630 (Maternal and Child Health Services), 325 ILCS 5 (Abused and Neglected Child Reporting Act), 405 ILCS 95 (Perinatal Mental Health Disorders Prevention and Treatment Act), and 410 ILCS 212 (Illinois Family Case Management Act). Iowa: As of August 2023, the state has rules under chapter 441 Iowa Administrative Code Chapter 24 for targeted case management provider accreditation. Case Management services are defined under Iowa Administrative Code 441- 90. Michigan: As of August 2023, there is no Administrative Code found regarding Michigan’s coverage of Maternal Infant Health Program, but it is found in their Medicaid Provider Manual that outlines their provision of the program which is similar to PNCC. Minnesota: Pregnant women are eligible for services under MA under Minn. Stat. ss. 256B.055 subd. 6. and 256B.057 subd. 1. until 12 months postpartum. Minnesota does not appear to have a special program targeted to specific parts of the state like CCC, but “child welfare targeted case management services” are identified in Minn. Stat. s. 256B.094.
Summary of factual data and analytical methodologies
In accordance with s. 227.13, Stats., the department conducted informal consultation and gathered feedback from providers working with a variety of partner organizations. These included federally qualified health centers, county health organizations, and private case management providers, representing a mix of private and public providers. All feedback from the informal consultations was considered by the department and incorporated, as appropriate. Further, the department referenced current federal benefit coverage practice outlined in the Social Security Act under § 1915(g)(2). Analysis and supporting documents used to determine effect on small business
The most notable effect on small businesses will primarily relate to new administrative rule requirements for providers, specifically background checks for all staff, compliance with fit and qualified criteria for owners and principals, and the need for ongoing training and documentation. During informal consultations with the department, providers indicated that they already conduct background checks on staff and would therefore not expect a significant financial impact resulting from these requirements, but anticipate some administrative impact with respect to required background checks, fit and qualified determinations, operational and training plans, and qualified professional requirements. Furthermore, there is no change in the reimbursement amount paid to providers and there is no expected change in utilization as this benefit is simply going from fee-for-service ("FFS") responsibility to the responsibility of both FFS and MA health maintenance organizations. Therefore, there is no expected increase or decrease in Medicaid expenditures.
Effect on small business
Based on the foregoing, the proposed rules may have a moderate economic impact on small businesses.
Agency contact person
Statement on quality of agency data
The data used by the Department to prepare these proposed rules and analysis comply with s. 227.14 (2m), Stats. Place where comments are to be submitted and deadline for submission
RULE TEXT
SECTION 1. DHS 105.52 (1) (intro.) and (a) to (f) are amended to read:
DHS 105.52 (1) Agency. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be any of the following: (a) A community-based health organization;.
(b) A community-based social services agency or organization;.
(c) A county, city, or combined city and county public health agency;.
(d) A county department of human services under s. 46.23, Stats., or social services under s. 46.215 or 46.22, Stats.;
