Chapter 49

49.46(2)(b)21. 21. Subject to s. 49.45 (61), consultations between providers conducted through interactive telehealth described under s. 49.45 (61) (c) 1.

49.46(2)(b)22. 22. Subject to s. 49.45 (61), asynchronous telehealth services and remote patient monitoring described under s. 49.45 (61) (c) 2.

49.46(2)(b)23. 23. Subject to s. 49.45 (61), services described under s. 49.45 (61) (c) 3. that are provided through communication technology and that are covered under the federal Medicare program and any telehealth services that the department specifies by rule under s. 49.45 (61) (d).

49.46(2)(bc) (bc) Subject to s. 49.45 (24j), the department may provide any of the services described in par. (a) or (b) through a medical home initiative under s. 49.45 (24j).

49.46(2)(be) (be) Benefits for an individual eligible under sub. (1) (a) 9. are limited to those services under par. (a) or (b) that are related to pregnancy, including postpartum services and family planning services, as defined in s. 253.07 (1) (b), or related to other conditions which may complicate pregnancy.

49.46(2)(bh) (bh) The department shall provide reimbursement for services that are reimbursable under this section and that are provided by a licensed pharmacist within the scope of his or her license or are services performed under s. 450.033. If the department determines it is unable to implement this paragraph without a state plan amendment or waiver of federal law, the department shall submit to the federal department of health and human services any necessary state plan amendment or waiver of federal law necessary to implement this paragraph. If the federal government disapproves the amendment or waiver request, the department is not required to implement this paragraph.

49.46(2)(bm) (bm) Benefits for an individual who is eligible for medical assistance only under sub. (1) (a) 15. are limited to those services related to tuberculosis that are described in 42 USC 1396a (z) (2).

49.46(2)(br) (br) If the federal department of health and human services approves the department’s request to offer a benchmark plan under this paragraph, the department may enroll any child who is receiving services through the early intervention program under s. 51.44 in a benchmark plan under this paragraph. The department may not require a child who is receiving services through the early intervention program under s. 51.44 to enroll in a benchmark plan offered under this paragraph. The department may not charge a copayment to a child who is enrolled in the benchmark plan under this paragraph for services described in par. (b) 19.

49.46(2)(bt) (bt)

49.46(2)(bt)1. 1. For the purposes of par. (b) 14m., a “medically monitored treatment service” is a 24-hour, community-based service providing observation, monitoring, and treatment by a multidisciplinary team under supervision of a physician, with a minimum of 12 hours of counseling provided per week for each patient.

49.46(2)(bt)2. 2. For the purposes of par. (b) 14m., a “transitional residential treatment service” is a clinically supervised, peer-supported, therapeutic environment with clinical involvement providing substance abuse treatment in the form of counseling for 3 to 11 hours provided per week for each patient.

49.46(2)(bt)3. 3. If approval by the federal department of health and human services of a state plan amendment or waiver request is necessary for federal reimbursement of the services under par. (b) 14m., the department is not required to pay for services described in par. (b) 14m. if the department does not receive the necessary approval.

49.46(2)(bt)4. 4. The department may not provide reimbursement for services under par. (b) 14m. that are provided before July 1, 2016, or before the date of approval of the state plan amendment or waiver request described under subd. 3., whichever is later.

49.46(2)(c) (c)

49.46(2)(c)1. 1. In this paragraph and par. (cm):

49.46(2)(c)1.a. a. “Entitled to coverage under part A of medicare” means eligible for and enrolled in part A of medicare under 42 USC 1395c to 1395f.

49.46(2)(c)1.b. b. “Entitled to coverage under part B of medicare” means eligible for and enrolled in part B of medicare under 42 USC 1395j to 1395L.

49.46(2)(c)2. 2. For an individual who is entitled to coverage under Part A of Medicare, entitled to coverage under Part B of Medicare, meets the eligibility criteria under sub. (1), and meets the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that are not paid under 42 USC 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums payable under 42 USC 1395v; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under Part A of Medicare. Payment of coinsurance for a service under Part B of Medicare under 42 USC 1395j to 1395w and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)3. 3. For an individual who is only entitled to coverage under Part A of Medicare, meets the eligibility criteria under sub. (1), and meets the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that are not paid under 42 USC 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under Part A of Medicare. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)4. 4. For an individual who is entitled to coverage under Part A of Medicare, entitled to coverage under Part B of Medicare, and meets the eligibility criteria for Medical Assistance under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that are not paid under 42 USC 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of coinsurance for a service under Part B of Medicare under 42 USC 1395j to 1395w and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)5. 5. For an individual who is only entitled to coverage under Part A of Medicare and meets the eligibility criteria for Medical Assistance under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that are not paid under 42 USC 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)5m. 5m. For an individual who is only entitled to coverage under Part B of Medicare and meets the eligibility criteria under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395j to 1395w, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of coinsurance for a service under Part B of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.46(2)(c)6. 6. The income limitation under this paragraph is income that is equal to or less than 100 percent of the poverty line, as established under 42 USC 9902 (2).

49.46(2)(cm) (cm)

49.46(2)(cm)1. 1. Beginning on January 1, 1993, for an individual who is entitled to coverage under part A of medicare, is entitled to coverage under part B of medicare, meets the eligibility criteria under sub. (1) and meets the limitation on income under subd. 2., medical assistance shall pay the monthly premiums under 42 USC 1395r.

49.46(2)(cm)2. 2. Benefits under subd. 1. are available for an individual whose income is greater than 100 percent of the poverty line but less than 120 percent of the poverty line.

49.46(2)(d) (d) Benefits authorized under this subsection may not include payment for that part of any service payable through 3rd-party liability or any federal, state, county, municipal or private benefit system to which the beneficiary is entitled. “Benefit system” does not include any public assistance program such as, but not limited to, Hill-Burton benefits under 42 USC 291c (e), in effect on April 30, 1980, or relief funded by a relief block grant.

49.46(2)(dc) (dc) For an individual who is eligible for medical assistance and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under par. (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug.

49.46(2)(dm) (dm) Except as provided under s. 49.45 (53m), benefits under this section may not include payment for services to individuals aged 21 to 64 who are residents of an institution for mental diseases and who are otherwise eligible for medical assistance, except for individuals under 22 years of age who were receiving these services immediately prior to reaching age 21 and continuously thereafter and except for services to individuals who are on convalescent leave or are conditionally released from the institution for mental diseases. For purposes of this paragraph, the department shall define “convalescent leave” and “conditional release” by rule.

49.46(2)(f) (f) Benefits under this subsection may not include payment for gastric bypass surgery or gastric stapling surgery unless it is performed because of a medical emergency.

49.46 History History: 1971 c. 125, 211, 215; 1973 c. 90, 147; 1975 c. 39; 1977 c. 29 ss. 592m, 1656 (18); 1977 c. 389, 418; 1979 c. 34, 221; 1981 c. 20, 93, 317; 1983 a. 27; 1983 a. 189 s. 329 (5); 1983 a. 245 ss. 10, 15; 1983 a. 538; 1985 a. 29, 120, 176, 253; 1987 a. 27, 307, 339, 399, 413; 1989 a. 9; 1989 a. 31 ss. 1454d to 1460 and 2909g, 2909i; 1989 a. 122, 173, 333, 336, 351; 1991 a. 39, 178, 269, 316; 1993 a. 16, 99, 269, 277, 446, 450, 491; 1995 a. 27, 77, 164, 289, 303, 457; 1997 a. 27, 35, 105, 237; 1999 a. 9; 2001 a. 16; 2003 a. 33; 2005 a. 25, 253; 2007 a. 20, 91; 2009 a. 28, 221; 2011 a. 10, 32; 2013 a. 20; 2013 a. 116 s. 29; 2013 a. 117 s. 2, 3; 2015 a. 55; 2017 a. 59, 119, 306; 2019 a. 9, 56, 122; 2021 a. 58, 98; 2021 a. 240 s. 29.

49.46 Cross-reference Cross-reference: See also chs. DHS 102, 103, and 107, Wis. adm. code.

49.46 Annotation A categorically needy person applying for assistance under this section was not required to comply with divestment requirements under s. 49.47. Sinclair v. DHSS, 77 Wis. 2d 322, 253 N.W.2d 245 (1977).

49.46 Annotation Sub. (1) (b) and s. 49.47 (6) (d) limit retroactive medical assistance payments to services received not more than three months prior to the date the application is submitted. St. Paul Ramsey Medical Center v. DHSS, 186 Wis. 2d 37, 519 N.W.2d 681 (Ct. App. 1994).

49.46 Annotation States need not fund nontherapeutic abortions. Beal v. Doe, 432 U.S. 438, 97 S. Ct. 2366, 53 L. Ed. 2d 464 (1977).

49.463 49.463 Ineligibility for noncompliance with child support determinations and obligations.

49.463(1) (1) Definitions. In this section:

49.463(1)(a) (a) “Able-bodied adult” means an adult who is not elderly, as defined in s. 49.468 (1) (a) 2., or disabled, as defined in s. 49.471 (1) (cm), who is not pregnant, and who is able-bodied, as defined by the department.

49.463(1)(b) (b) “Custodial parent” has the meaning given in s. 49.141 (1) (b).

49.463(1)(c) (c) “Noncustodial parent” has the meaning given in s. 49.141 (1) (h).

49.463(2) (2) Eligibility denial; child support noncompliance.

49.463(2)(a) (a) In this subsection, what constitutes a refusal to cooperate is determined by the department in accordance with 42 USC 1396k and any federal regulations promulgated under 42 USC 1396k.

49.463(2)(b) (b) An able-bodied adult is ineligible for the Medical Assistance program under this subchapter in a month in which any of the following is true:

49.463(2)(b)1. 1. The able-bodied adult satisfies all of the following:

49.463(2)(b)1.a. a. The able-bodied adult is a custodial parent of or lives with and exercises parental control over a child who is under the age of 18 and who has an absent parent.

49.463(2)(b)1.b. b. The able-bodied adult refuses to cooperate fully, in good faith, with efforts directed at establishing or enforcing any support order or obtaining any other payments or property to which that adult or the child may have rights.

49.463(2)(b)1.c. c. The able-bodied adult does not have good cause for refusing to cooperate, as determined by the department in accordance with 42 USC 1396k and any federal regulations promulgated under 42 USC 1396k.

49.463(2)(b)2. 2. The able-bodied adult is a noncustodial parent of a child under the age of 18 and the adult refuses to cooperate in providing or obtaining support for the child.

49.463(3) (3) Eligibility denial; paternity.

49.463(3)(a) (a) In this subsection, what constitutes a refusal to cooperate is determined by the department in accordance with 42 USC 1396k and any federal regulations promulgated under 42 USC 1396k.

49.463(3)(b) (b) An able-bodied adult is ineligible for the Medical Assistance program under this subchapter in a month in which any of the following is true:

49.463(3)(b)1. 1. The able-bodied adult satisfies all of the following:

49.463(3)(b)1.a. a. The able-bodied adult is a custodial parent of or lives with and exercises parental control over a child who is under the age of 18 and who has an absent parent.

49.463(3)(b)1.b. b. The able-bodied adult refuses to cooperate fully, in good faith, with applicable efforts directed at establishing the paternity of the child.

49.463(3)(b)1.c. c. The able-bodied adult does not have good cause for refusing to cooperate, as determined by the department in accordance with 42 USC 1396k and any federal regulations promulgated under 42 USC 1396k.

49.463(3)(b)2. 2. The able-bodied adult is one of the following and refuses to cooperate fully, in good faith, with efforts directed at establishing the paternity of the child:

49.463(3)(b)2.a. a. Alleged to be the father under s. 767.80 of a child under the age of 18.

49.463(3)(b)2.b. b. A noncustodial parent of a child under the age of 18 for whom paternity has not been established.

49.463(4) (4) Eligibility denial; delinquent support. An able-bodied adult is ineligible for the Medical Assistance program under this subchapter in a month in which the adult is obligated by order granted inside or outside this state to provide support payments and is delinquent in making those payments, unless any of the following is true:

49.463(4)(a) (a) The delinquency balance equals less than 3 months of the ordered support payment amount.

49.463(4)(b) (b) A court or a county child support agency under s. 59.53 (5) is allowing the able-bodied adult to delay the child support payments.

49.463(4)(c) (c) The able-bodied adult is complying with a payment plan approved by a county child support agency under s. 59.53 (5) to provide support for the child of the adult.

49.463(4)(d) (d) The able-bodied adult is participating in an employment and training program, as determined by the department.

49.463(4)(e) (e) The able-bodied adult is participating in a substance abuse treatment program, as determined by the department.

49.463(5) (5) Exception for eligibility of child. A dependent child remains eligible for the Medical Assistance program under this subchapter even if a person charged with the care and custody of the dependent child is ineligible for the Medical Assistance program because he or she did not comply with this section.

49.463(5m) (5m) Notification requirement. The department or the county department under s. 46.215 or 46.22 shall notify an applicant for Medical Assistance of the requirements of this section at the time of application.

49.463(6) (6) Federal approval. If the department of health services or the department of children and families determines that federal approval is required to implement any part of this section, the applicable department shall submit a state plan amendment or request for a waiver to the federal department of health and human services. The departments shall implement this section to the extent that the federal department of health and human services does not disapprove of the plan amendment or waiver request and if the department of children and families determines that this section as it pertains to child support and paternity order establishment and compliance is able to be implemented in a way that is substantially state budget neutral in regard to child support fees.

49.463 History History: 2017 a. 268.

49.465 49.465 Presumptive medical assistance eligibility.

49.465(1) (1) In this section, “qualified provider” means a provider which satisfies the requirements under 42 USC 1396r-1 (b) (2), as determined by the department.

49.465(2) (2) A pregnant woman is eligible for medical assistance benefits, as provided under sub. (3), during the period beginning on the day on which a qualified provider determines, on the basis of preliminary information, that the woman’s family income does not exceed the highest level for eligibility for benefits under s. 49.46 (1) or 49.47 (4) (am) or (c) 1. and ending as follows:

49.465(2)(a) (a) If the woman applies for benefits under s. 49.46 or 49.47 within the time required under sub. (4), the day on which the department or the county department under s. 46.215, 46.22 or 46.23 determines whether the woman is eligible for benefits under s. 49.46 or 49.47.

49.465(2)(c) (c) If the woman does not apply for benefits under s. 49.46 or 49.47 within the time required under sub. (4), the last day of the month following the month in which the provider makes the determination under this subsection.

49.465(3) (3) The department shall audit and pay allowable charges to a provider certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a recipient under this section only for ambulatory prenatal care covered under s. 49.46 (2).

49.465(4) (4) A woman who is determined to be eligible under this section shall apply for benefits under s. 49.46 or 49.47 on or before the last day of the month following the month in which the qualified provider makes that determination.

49.465(5) (5) A qualified provider which determines that a woman is eligible under this section shall do all of the following:

49.465(5)(a) (a) Notify the department of that determination within 5 working days after the day the determination is made.

49.465(5)(b) (b) Notify the woman of the requirement under sub. (4).

49.465(6) (6) The department shall provide qualified providers with application forms for medical assistance under ss. 49.46 and 49.47 and information on how to assist women in completing the forms.

49.465 History History: 1987 a. 27, 307, 413; 1989 a. 9; 1989 a. 31 ss. 1460p, 2909g, 2909i; 1991 a. 269; 1995 a. 289; 1997 a. 27; 2011 a. 10, 32.

49.468 49.468 Expanded medicare buy-in.

49.468(1) (1) 

49.468(1)(a) (a) In this subsection and sub. (1m):

49.468(1)(a)1. 1. “Disabled” means blind, as defined under 42 USC 1382c (a) (2) and disabled, as defined under 42 USC 1382c (a) (3).

49.468(1)(a)2. 2. “Elderly” means 65 years of age or older.

49.468(1)(a)3. 3. “Entitled to coverage under part A of medicare” means eligible for and enrolled in part A of medicare under 42 USC 1395c to 1395f.

49.468(1)(a)4. 4. “Entitled to coverage under part B of medicare” means eligible for and enrolled in part B of medicare under 42 USC 1395j to 1395L.

49.468(1)(b) (b) For an elderly or disabled individual who is entitled to coverage under Part A of Medicare, entitled to coverage under Part B of Medicare, and who does not meet the eligibility criteria for Medical Assistance under s. 49.46 (1), 49.465, 49.47 (4), or 49.471 but meets the limitations on income and resources under par. (d), Medical Assistance shall pay the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that are not paid under 42 USC 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums payable under 42 USC 1395v; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under Part A of Medicare. Payment of coinsurance for a service under Part B of Medicare under 42 USC 1395j to 1395w and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.

49.468(1)(c) (c) For an elderly or disabled individual who is only entitled to coverage under Part A of Medicare and who does not meet the eligibility criteria for Medical Assistance under s. 49.46 (1), 49.465, 49.47 (4), or 49.471 but meets the limitations on income and resources under par. (d), Medical Assistance shall pay the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that are not paid under 42 USC 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty for premiums under Part A of Medicare, if applicable. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment.