49.49(7)(a)1.1. “Commission” means an entity that is created by contract between 2 or more political subdivisions under s. 66.0301 to operate a nursing home or intermediate care facility and to which all of the following apply:

49.49(7)(a)1.b.b. The entity is the certified provider under s. 49.45 (2) (a) 11. for the nursing home or intermediate care facility and is the recipient of medical assistance reimbursement for services provided by the nursing home or intermediate care facility.

49.49(7)(a)1.c.c. The entity owns or leases the building in which the nursing home or intermediate care facility is located.

49.49(7)(a)1.d.d. The entity provides or contracts for provision of nursing home or intermediate care facility services.

49.49(7)(a)1.f.f. The entity allocates the costs of operating the nursing home or intermediate care facility, and of providing services to residents of the nursing home or intermediate care facility, among the political subdivisions that are parties to the contract and assesses each political subdivision that is a party to the contract the portion of the costs allocated to that political subdivision.

49.49(7)(b)(b) A commission’s imposition of an assessment on a member for the costs incurred by the commission to operate the nursing home or intermediate care facility and to provide services to residents of the nursing home or intermediate care facility is a charge internal to the commission and does not constitute billing a 3rd party for services provided on behalf of an individual.

49.49(7)(c)(c) A member’s payment of an assessment described under par. (b) is a transfer of funds internal to the commission and does not constitute a purchase of services on behalf of an individual, regardless of whether the payment is made from the member’s general fund, made pursuant to a purchase of services agreement between a member’s human services department or other department and the commission, or by a combination of these payment methods.

49.49(7)(d)(d) A commission’s imposition of an assessment described under par. (b), a member’s payment of the assessment as described under par. (c), and acceptance of the payment by the commission do not constitute conduct prohibited under s. 946.91 (6) or prohibited under s. DHS 106.04 (3), Wis. Adm. Code, in effect on May 26, 2010. It is the intent of the legislature to create a mechanism whereby 2 or more political subdivisions may share in the operation, use, and funding of a nursing home or intermediate care facility without violating 42 USC 1320a-7b (d) or 42 USC 1396a (a) (25) (C).

49.49 AnnotationThe only state of mind requirement for a violation of sub. (1) (a) 1. is the intentional making or causing the making of a false statement that appears in an application; that anyone actually received a medical assistance benefit need not be proved. State v. Williams, 179 Wis. 2d 80, 505 N.W.2d 468 (Ct. App. 1993).

49.49 AnnotationSub. (3m) and related rules require medical assistance providers to refund only the amount paid by the medical assistance program on behalf of retroactively eligible persons. A private pay patient subsequently found retroactively eligible does not have a federally protected right to reimbursement from a medical assistance provider for the amount originally paid by the patient in excess of the medical assistance reimbursement. Keup v. DHFS, 2004 WI 16, 269 Wis. 2d 59, 675 N.W.2d 755, 02-0456.

49.49 AnnotationThe state had a constitutional right to a jury trial on its claim under sub. (4m). State v. Abbott Laboratories, 2012 WI 62, 341 Wis. 2d 510, 816 N.W.2d 145, 10-0232.

49.49 AnnotationWhen the defendant hospital did not send bills directly to Medical Assistance patients, but rather filed liens against the patients’ potential settlements with a tortfeasor’s insurer, the liens did not constitute “direct charges upon” the patients and were therefore permissible under the plain language of the second prohibition in sub. (3m) (a). Gister v. American Family Mutual Insurance Co., 2012 WI 86, 342 Wis. 2d 496, 818 N.W.2d 880, 09-2795.

49.49 AnnotationSub. (6) permits recovery of attorney fees for private counsel hired by the state. State v. Abbott Laboratories, 2013 WI App 31, 346 Wis. 2d 565, 829 N.W.2d 753, 10-0232.

49.49 AnnotationSub. (4m) (a) 2. unambiguously applies to the amount of payment as well as the right to be paid. State v. Abbott Laboratories, 2013 WI App 31, 346 Wis. 2d 565, 829 N.W.2d 753, 10-0232.

49.49 AnnotationNursing home guarantor agreements may violate sub. (4) after a resident becomes certified Medicaid eligible. 76 Atty. Gen. 295.

49.493(1)(a)(a) “Department or contract provider” means the department, the county providing the medical benefits or assistance or a health maintenance organization that has contracted with the department to provide the medical benefits or assistance.

49.493(1)(b)(b) “Medical benefits or assistance” means medical benefits under s. 49.02 or 253.05 or medical assistance.

49.493(1)(c)(c) “Uninsured health plan” means a partially or wholly uninsured plan, including a plan that is subject to 29 USC 1001 to 1461, providing health care benefits.

49.493(2)(2) The providing of medical benefits or assistance constitutes an assignment to the department or contract provider, to the extent of the medical benefits or assistance provided, for benefits to which the recipient would be entitled under any uninsured health plan.

49.493(3)(a)(a) Exclude a person or a person’s dependent from coverage under the uninsured health plan because the person or the dependent is eligible for medical assistance.

49.493(3)(b)(b) Terminate its coverage of a person or a person’s dependent because the person or the dependent is eligible for medical assistance.