AB56,657 Section 657. 49.45 (3m) (a) (intro.) of the statutes is amended to read:

AB56,533,25 49.45 (3m) (a) (intro.) Subject to par. (c) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay to hospitals that serve a disproportionate share of low-income patients an amount equal to the sum of $27,500,000 $56,500,000, as the state share of payments, and the matching federal share of payments. The department may make a payment to a hospital under this subsection under the calculation method described in par. (b) if the hospital meets all of the following criteria:

AB56,658 Section 658. 49.45 (3m) (b) 3. a. of the statutes is amended to read:

AB56,534,5 49.45 (3m) (b) 3. a. No single hospital receives more than $4,600,000 $9,200,000, except that a hospital that is a free-standing pediatric teaching hospital located in Wisconsin that has a percentage calculated under subd. 1. a. greater than 50 percent may receive up to $12,000,000 each fiscal year.

AB56,659 Section 659. 49.45 (3p) (a) of the statutes is amended to read:

AB56,534,20 49.45 (3p) (a) Subject to par. (c) and notwithstanding sub. (3) (e), from the appropriations under s. 20.435 (4) (b) and (o), in each fiscal year, the department shall pay to hospitals that would are not eligible for payments under sub. (3m) but that meet the criteria under sub. (3m) (a) except that the hospitals do not provide obstetric services 1. and 2. and that, in the most recent year for which information is available, charged at least 6 percent of overall charges for services to the Medical Assistance program for services provided to Medical Assistance recipients an amount equal to the sum of $250,000 $500,000, as the state share of payments, and the matching federal share of payments. The department may make a payment to a hospital under this subsection under a calculation method determined by the department that provides a fee-for-service supplemental payment that increases as the hospital's percentage of inpatient days for Medical Assistance recipients at the hospital the total amount of the hospital's overall charges for services that are charges to the Medical Assistance program increases.

AB56,660 Section 660. 49.45 (5) (a) of the statutes is amended to read:

AB56,535,2 49.45 (5) (a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing, except as provided in par. (ag) or (ar).

AB56,661 Section 661. 49.45 (5) (ag) of the statutes is created to read:

AB56,535,9 49.45 (5) (ag) A person shall request a hearing within 90 days of the date of receipt of a notice from a care management organization or managed care organization upholding its adverse benefit determination relating to any of the following or within 90 days of the date the care management organization or managed care organization failed to act on the contested matter within the time specified by the department:

AB56,535,12 1. Denial or limited authorization of a requested services, including a determination based on the type or level of service, requirement for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

AB56,535,15 2. Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.

AB56,535,16 3. Denial, in whole or in part, of payment for a service.

AB56,535,17 4. Failure to provide services in a timely manner.

AB56,535,20 5. Failure of a care management organization or managed care organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

AB56,535,23 6. Denial of an enrollee's request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

AB56,536,3 7. Denial of an enrollee, who is a resident of a rural area with only one care management organization or managed care organization, to obtain services outside the organization's network of contracted providers.

AB56,662 Section 662. 49.45 (5) (ar) of the statutes is created to read:

AB56,536,6 49.45 (5) (ar) If a federal regulation specifies a different time limit to request a hearing than par. (a) or (ag), the time limit in the federal regulation shall apply.

AB56,663 Section 663. 49.45 (5) (b) 1. (intro.) of the statutes is amended to read:

AB56,536,21 49.45 (5) (b) 1. (intro.) Upon receipt of a timely petition under par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under s. 46.215, 46.22, or 46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a certified copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:

AB56,664 Section 664. 49.45 (5) (b) 1. d. of the statutes is created to read:

AB56,537,2 49.45 (5) (b) 1. d. The issue is an adverse benefit determination described in par. (ag) 1. to 7. made by a care management organization or managed care organization and the person requesting the hearing has not exhausted the internal appeal procedure with the organization.

AB56,665 Section 665. 49.45 (6m) (c) 5. of the statutes is amended to read:

AB56,537,6 49.45 (6m) (c) 5. Admit only patients assessed or who waive or are exempt from the requirement of assessment under s. 46.27 (6) (a) or, if required under s. 50.035 (4n) or 50.04 (2h), who have been referred to a resource center.

AB56,666 Section 666. 49.45 (6m) (L) of the statutes is amended to read:

AB56,537,13 49.45 (6m) (L) For purposes of ss. 46.27 (11) (c) 7. and 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. 46.27 (11) (c) 7. or 46.277 (5) (e).

AB56,667 Section 667. 49.45 (6xm) of the statutes is created to read:

AB56,537,18 49.45 (6xm) Pediatric inpatient supplement. (a) From the appropriations under s. 20.435 (4) (b), (o), and (w), the department shall, using a method determined by the department, distribute a total sum of $2,000,000 each state fiscal year to hospitals that meet all of the following criteria: