49.49 Annotation The only state of mind required 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 W (2d) 80, 505 NW (2d) 468 (Ct. App. 1993).
49.49 Annotation Nursing home guarantor agreements may violate (4) after resident becomes certified Medicaid eligible. 76 Atty. Gen. 295.
49.493 49.493 Benefits under uninsured health plans.
49.493(1) (1) In this section:
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, [49.046] or 253.05 or medical assistance.
49.493 Note NOTE: Section 49.046 was repealed by 1995 Wis. Act 27.
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) (3) An uninsured health plan may not do any of the following:
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.
49.493(3)(c) (c) Provide different benefits of coverage to a person or the person's dependent because the person or the dependent is eligible for medical assistance than it provides to persons and their dependents who are not eligible for medical assistance.
49.493(3)(d) (d) Impose on the department or contract provider, as assignee of a person or a person's dependent who is covered under the uninsured health plan and who is eligible for medical benefits or assistance, requirements that are different from those imposed on any other agent or assignee of a person who is covered under the uninsured health plan.
49.493(4) (4) Benefits provided by an uninsured health plan shall be primary to medical benefits or assistance.
49.493 History History: 1991 a. 178, 214; 1993 a. 481; 1995 a. 27, 407.
49.495 49.495 Jurisdiction of the department of justice. The department of justice or the district attorney may institute, manage, control and direct, in the proper county, any prosecution for violation of criminal laws affecting the medical assistance program including but not limited to laws relating to medical assistance contained in this subchapter and laws affecting the health, safety and welfare of recipients of medical assistance. For this purpose the department of justice shall have and exercise all powers conferred upon district attorneys in such cases. The department of justice or district attorney shall notify the medical examining board or the interested affiliated credentialing board of any such prosecution of a person holding a license granted by the board or affiliated credentialing board.
49.495 History History: 1977 c. 418; 1985 a. 340; 1993 a. 107; 1995 a. 27.
49.496 49.496 Recovery of correct medical assistance payments.
49.496(1)(1)Definitions. In this section:
49.496(1)(a) (a) "Disabled" has the meaning given in s. 49.468 (1) (a) 1.
49.496(1)(b) (b) "Home" means property in which a person has an ownership interest consisting of the person's dwelling and the land used and operated in connection with the dwelling.
49.496(1)(c) (c) "Nursing home" has the meaning given in s. 50.01 (3).
49.496(1)(d) (d) "Recipient" means a person who receives or received medical assistance.
49.496(2) (2)Liens on the homes of nursing home residents.
49.496(2)(a)(a) Except as provided in par. (b), the department may obtain a lien on a recipient's home if the recipient resides in a nursing home and cannot reasonably be expected to be discharged from the nursing home and return home. The lien is for the amount of medical assistance paid on behalf of the recipient while the recipient resides in a nursing home.
49.496(2)(b) (b) The department may not obtain a lien under this subsection if any of the following persons lawfully reside in the home:
49.496(2)(b)1. 1. The recipient's spouse.
49.496(2)(b)2. 2. The recipient's child who is under age 21 or is disabled.
49.496(2)(b)3. 3. The recipient's sibling who has an ownership interest in the home and who has lived in the home continuously beginning at least 12 months before the recipient was admitted to the nursing home.
49.496(2)(c) (c) Before obtaining a lien on a recipient's home under this subsection, the department shall do all of the following:
49.496(2)(c)1. 1. Notify the recipient in writing of its determination that the recipient cannot reasonably be expected to be discharged from the nursing home, its intent to impose a lien on the recipient's home and the recipient's right to a hearing on whether the requirements for the imposition of a lien are satisfied.
49.496(2)(c)2. 2. Provide the recipient with a hearing if he or she requests one.
49.496(2)(d) (d) The department shall obtain a lien under this subsection by recording a lien claim in the office of the register of deeds of the county in which the home is located.
49.496(2)(e) (e) The department may not enforce a lien under this subsection while the recipient lives unless the recipient sells the home and does not have a living child who is under age 21 or disabled or a living spouse.
49.496(2)(f) (f) The department may not enforce a lien under this subsection after the death of the recipient as long as any of the following survive the recipient:
49.496(2)(f)1. 1. A spouse.
49.496(2)(f)2. 2. A child who is under age 21 or disabled.
49.496(2)(f)3. 3. A child of any age who resides in the home, if that child resided in the home for at least 24 months before the recipient was admitted to the nursing home and provided care to the recipient that delayed the recipient's admission to the nursing home.
49.496(2)(f)4. 4. A sibling who resides in the home, if the sibling resided in the home for at least 12 months before the recipient was admitted to the nursing home.
49.496(2)(g) (g) The department may enforce a lien imposed under this subsection by foreclosure in the same manner as a mortgage on real property.
49.496(2)(h) (h) The department shall file a release of a lien imposed under this subsection if the recipient is discharged from the nursing home and returns to live in the home.
49.496(3) (3)Recovery from estates.
49.496(3)(a)(a) Except as provided in par. (b), the department shall file a claim against the estate of a recipient or against the estate of the surviving spouse of a recipient for all of the following unless already recovered by the department under this section:
49.496(3)(a)1. 1. The amount of medical assistance paid on behalf of the recipient while the recipient resided in a nursing home or while the recipient was an inpatient in a medical institution and was required to contribute to the cost of care.
49.496(3)(a)2. 2. The following medical assistance services paid on behalf of the recipient after the recipient attained 55 years of age:
49.496(3)(a)2.a. a. Home-based or community-based services under 42 USC 1396d (7) and (8) and under any waiver granted under 42 USC 1396n (c) (4) (B) or 42 USC 1396u.
49.496(3)(a)2.b. b. Related hospital services, as specified by the department by rule.
49.496(3)(a)2.c. c. Related prescription drug services, as specified by the department by rule.
49.496(3)(ag) (ag) The affidavit of a person designated by the secretary to administer this subsection is evidence of the amount of the claim.
49.496(3)(am) (am) The court shall reduce the amount of a claim under par. (a) by up to $3,000 if necessary to allow the recipient's heirs or the beneficiaries of the recipient's will to retain the following personal property:
49.496(3)(am)1. 1. The decedent's wearing apparel and jewelry held for personal use.
49.496(3)(am)2. 2. Household furniture, furnishings and appliances.
49.496(3)(am)3. 3. Other tangible personal property not used in trade, agriculture or other business, not to exceed $1,000 in value.
49.496(3)(b) (b) A claim under par. (a) is not allowable if the decedent has a surviving child who is under age 21 or disabled or a surviving spouse.
49.496(3)(c) (c) If the department's claim is not allowable because of par. (b) and the estate includes an interest in a home, the court exercising probate jurisdiction shall, in the final judgment, assign the interest in the home subject to a lien in favor of the department for the amount described in par. (a). The personal representative shall record the final judgment as provided in s. 863.29.
49.496(3)(d) (d) The department may not enforce the lien under par. (c) as long as any of the following survive the decedent:
49.496(3)(d)1. 1. A spouse.
49.496(3)(d)2. 2. A child who is under age 21 or disabled.
49.496(3)(e) (e) The department may enforce a lien under par. (c) by foreclosure in the same manner as a mortgage on real property.
49.496(4) (4)Administration. The department may require a county department under s. 46.215, 46.22 or 46.23 or the governing body of a federally recognized American Indian tribe administering medical assistance to gather and provide the department with information needed to recover medical assistance under this section. The department shall pay to a county department or tribal governing body an amount equal to 5% of the recovery collected by the department relating to a beneficiary for whom the county department or tribal governing body made the last determination of medical assistance eligibility. A county department or tribal governing body may use funds received under this subsection only to pay costs incurred under this subsection and, if any amount remains, to pay for improvements to functions required under s. 49.33 (2). The department may withhold payments under this subsection for failure to comply with the department's requirements under this subsection. The department shall treat payments made under this subsection as costs of administration of the medical assistance program.
49.496(5) (5)Use of funds. From the appropriation under s. 20.435 (1) (im), the department shall pay the amount of the payments under sub. (4) that is not paid from federal funds, shall pay to the federal government the amount of the funds recovered under this section equal to the amount of federal funds used to pay the benefits recovered under this section and shall spend the remainder of the funds recovered under this section for medical assistance benefits under this subchapter
49.496(6) (6)Applicability.
49.496(6)(a)(a) The department may recover amounts under this section for medical assistance benefits paid on and after August 15, 1991.
49.496(6)(b) (b) The department may file a claim under sub. (3) only with respect to a recipient who dies after September 30, 1991.
49.496(6m) (6m)Waiver due to hardship. The department shall promulgate rules establishing standards for determining whether the application of this section would work an undue hardship in individual cases. If the department determines that the application of this section would work an undue hardship in a particular case, the department shall waive application of this section in that case.
49.496 History History: 1991 a. 39, 269; 1993 a. 301, 437, 491; 1995 a. 27.
49.496 Annotation Preserving the Homestead of the Small Estate: Wisconsin's Medical Recovery Law. Gilbert. Wis. Law. July 1992.
49.496 Annotation Recovery of benefits from the estate of a recipient's surviving spouse under sub. (3) (a) exceeds the authority granted by federal law. DHSS v. Estate of Budney, 197 W (2d) 949, 541 NW (2d) 245 (Ct. App. 1995).
49.497 49.497 Recovery of incorrect medical assistance payments.
49.497(1)(1) The department may recover any payment made incorrectly for benefits specified under s. 49.46, 49.468 or 49.47 if the incorrect payment results from any misstatement or omission of fact by a person supplying information in an application for benefits under s. 49.46, 49.468 or 49.47. The department may also recover if a medical assistance recipient or any other person responsible for giving information on the recipient's behalf fails to report the receipt of income or assets in an amount that would have affected the recipient's eligibility for benefits. The department's right of recovery is against any medical assistance recipient to whom or on whose behalf the incorrect payment was made. The extent of recovery is limited to the amount of the benefits incorrectly granted. The county department under s. 46.215 or 46.22 or the governing body of a federally recognized American Indian tribe administering medical assistance shall begin recovery actions on behalf of the department according to rules promulgated by the department.
49.497(2) (2) A county or governing body of a federally recognized American Indian tribe may retain 15% of benefits distributed under s. 49.46, 49.468 or 49.47 that are recovered under sub. (1) due to the efforts of an employe or officer of the county or tribe.
49.497(3) (3) Cash assets of medical assistance recipients that exceed asset limitations shall be applied against the cost of medical assistance benefits provided.
49.497 Annotation See note to 767.51 citing In re Paternity of N.L.M., 166 W (2d) 306, 479 NW (2d) 237 (Ct. App. 1991).
49.498 49.498 Requirements for skilled nursing facilities.
49.498(1)(1)Definitions. In this section:
49.498(1)(a) (a) "Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. "Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.
49.498(1)(b) (b) "Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.
49.498(1)(c) (c) "Developmental disability" means any of the following:
49.498(1)(c)1. 1. Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.
49.498(1)(c)2. 2. A severe, chronic disability that meets all of the conditions for individuals with related conditions as specified in 42 CFR 435.1009.
49.498(1)(d) (d) "Licensed health professional" has the meaning given under 42 USC 1396r (b) (5) (G).
49.498(1)(e) (e) "Managing employe" means a general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the operation of the facility.
49.498(1)(f) (f) "Medicare" means coverage under part A or part B of Title XVIII of the federal social security act, 42 USC 1395 to 1395zz.
49.498(1)(g) (g) "Mental illness" has the meaning given under 42 USC 1396r (e) (7) (G) (i).
49.498(1)(h) (h) "Nurse's assistant" has the meaning given for "nurse aide" under 42 USC 1396r (b) (5) (F).
49.498(1)(i) (i) "Nursing facility" has the meaning given under 42 USC 1396r (a).
49.498(1)(j) (j) "Physician" has the meaning given under s. 448.01 (5).
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