SB490,11,2218 49.45 (24m) (intro.) From the appropriation accounts under s. 20.435 (4) (b),
19(gp), (o), and (w), and (xd), in order to test the feasibility of instituting a system of
20reimbursement for providers of home health care and personal care services for
21medical assistance recipients that is based on competitive bidding, the department
22shall:

SB490,12,924 49.45 (52) Payment adjustments. Beginning on January 1, 2003, the
25department may, from the appropriation account under s. 20.435 (7) (b), make

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1Medical Assistance payment adjustments to county departments under s. 46.215,
246.22, 46.23, or 51.42, or 51.437 or to local health departments, as defined in s. 250.01
3(4), as appropriate, for covered services under s. 49.46 (2) (a) 2. and 4. d. and f. and
4(b) 6. b., c., f., fm., g., j., k., L., Lm., and m., 9., 12., 12m., 13., 15., and 16. Payment
5adjustments under this subsection shall include the state share of the payments.
6The total of any payment adjustments under this subsection and Medical Assistance
7payments made from appropriation accounts under s. 20.435 (4) (b), (gp), (o), and (w),
8and (xd) may not exceed applicable limitations on payments under 42 USC 1396a (a)
9(30) (A).

SB490,12,2511 49.45 (58) Health maintenance organization payments to hospitals. (a) The
12department shall establish a schedule of amounts that each health maintenance
13organization that contracts with the department to provide medical assistance
14services or services under s. 49.665 for a capitated payment rate shall pay monthly
15to each hospital that serves recipients of medical assistance services or recipients of
16services under s. 49.665. The amounts shall be based on any increase in the capitated
17rate that the department pays a health maintenance organization, which increase
18is intended to cover inpatient and outpatient hospital services and which is
19associated with the assessment imposed on hospitals under s. 50.375. The
20department shall use the information that it uses to calculate the capitated rates
21that the department pays health maintenance organizations and encounter data
22that is provided by the health maintenance organizations to calculate the amounts
23in the schedule. The department shall disclose publicly the methodology it uses to
24calculate the amounts in the schedule. The department shall recalculate the
25amounts in the schedule at least once every 12 months.

SB490,13,4

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1(b) The department shall require, as a term of contracts with health
2maintenance organizations to provide medical assistance services or services under
3s. 49.665 for a capitated payment rate, that the health maintenance organization do
4all of the following:

SB490,13,55 1. Monthly pay hospitals the applicable amounts in the schedule under par. (a).

SB490,13,116 2. For each hospital to which the health maintenance organization makes
7payments under subd. 1., calculate the amount that results from applying the rate
8increase derived using the methodology under par. (a) to services for which the
9hospital submits claims to the health maintenance organization for providing
10inpatient and outpatient services to recipients of medical assistance and recipients
11of services under s. 49.665.

SB490,13,1712 3. Every 6 months, and for each hospital to which the health maintenance
13organization makes payments under subd. 1, compare the amount that the health
14maintenance organization paid the hospital under subd. 1. for the previous 6 months
15with the amount calculated under subd. 2. for services provided during that same
16period, and, if the amount under subd. 2. exceeds the amount of the payments under
17subd. 1., pay the hospital the difference within 90 days.

SB490,13,2218 (c) If the total payments that a health maintenance organization made to a
19hospital under par. (b) 1. for a 6 month period exceed the amount calculated under
20par. (b) 2. for services provided during that same period, the hospital shall pay the
21health maintenance organization the difference within 90 days after the end of the
226-month period.

SB490,14,523 (d) If the department determines that a health maintenance organization has
24not complied with a condition under par. (b), the department shall require the health
25maintenance organization to comply with the condition within 15 days after the

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1department's determination. The department may terminate a contract with a
2health maintenance organization to provide medical assistance services or services
3under s. 49.665 for a capitated payment rate for failure to comply with a condition
4under par. (b). The department may audit health maintenance organizations to
5determine whether they have complied with the conditions under par. (b).

SB490,14,146 (e) If a health maintenance organization and hospital cannot resolve the
7amount that a health maintenance organization owes a hospital under par. (b) 3. or
8that a hospital owes a health maintenance organization under par. (c), and either the
9health maintenance organization or the hospital, within 6 months after the end of
10the time period to which the disputed amount relates, requests that the department
11determine the amount owed, the department shall determine the amount within 90
12days after the request is made. The health maintenance organization or hospital is,
13upon request, entitled to a contested case hearing under ch. 227 on the department's
14determination.

SB490,14,2116 49.472 (6) (a) Notwithstanding sub. (4) (a) 3., from the appropriation account
17under s. 20.435 (4) (b), (gp), or (w), or (xd), the department shall, on the part of an
18individual who is eligible for medical assistance under sub. (3), pay premiums for or
19purchase individual coverage offered by the individual's employer if the department
20determines that paying the premiums for or purchasing the coverage will not be more
21costly than providing medical assistance.

SB490,15,223 49.472 (6) (b) If federal financial participation is available, from the
24appropriation account under s. 20.435 (4) (b), (gp), or (w), or (xd), the department may

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1pay medicare Part A and Part B premiums for individuals who are eligible for
2medicare and for medical assistance under sub. (3).

SB490,15,84 49.473 (5) The department shall audit and pay, from the appropriation
5accounts under s. 20.435 (4) (b), (gp), and (o), and (xd), allowable charges to a provider
6who is certified under s. 49.45 (2) (a) 11. for medical assistance on behalf of a woman
7who meets the requirements under sub. (2) for all benefits and services specified
8under s. 49.46 (2).

SB490,15,15 1050.375 Assessment. (1) Except as provided in subs. (2) and (7), for the
11privilege of doing business in this state, there is imposed on each hospital an annual
12assessment, based on the hospital's gross patient revenue, that each hospital shall
13pay quarterly before September 30, December 31, March 31, and June 30 of each
14year, beginning with the payment due before September 30, 2008. The assessments
15shall be deposited into the hospital assessment fund.

SB490,15,20 16(2) At the discretion of the department, a hospital that is unable timely to make
17a payment by a date specified under sub. (1) may be allowed to make a delayed
18payment. A determination by the department that a hospital may not make a
19delayed payment under this subsection is final and is not subject to review under ch.
20227.

SB490,15,23 21(3) The amount of each hospital's assessment shall be based on the information
22that shall be provided to the department under s. 153.46 (5) or shall be based on any
23other source that is approved in the state plan for services under 42 USC 1396.

SB490,16,4 24(4) The department shall verify the amount of each hospital's gross patient
25revenue and shall determine the amount of the assessment owed by each hospital

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1based on a uniform rate that is applicable to total gross patient revenue that the
2department estimates will yield the amounts specified in the appropriation schedule
3under s. 20.005 (3) for the appropriation accounts under s. 20.435 (4) (xc), (xd), and
4(xe).

SB490,16,6 5(5) The department shall levy, enforce, and collect the assessments under this
6section and shall develop and distribute forms necessary for these purposes.

SB490,16,11 7(6) If the department determines that any portion of the revenue needed to
8provide Medical Assistance payment increases for inpatient and outpatient hospital
9services as fee for service or through health maintenance organizations is not eligible
10for federal financial participation, the department will refund that amount of
11revenue to hospitals in proportion to each hospital's payment of the assessment.

SB490,16,13 12(7) This section does not apply to a critical access hospital, as defined in s. 50.33
13(1g), or to an institution for mental diseases, as defined in s. 46.011 (1m).

SB490,16,18 14(8) Sections 77.59 (1) to (5), (6) (intro.), (a), and (c), and (7) to (10), 77.60 (1) to
15(7), (9), and (10), 77.61 (9) and (12) to (14), and 77.62, as they apply to the taxes under
16subch. III of ch. 77, apply to the assessment under this section, except that the
17amount of any assessment collected under sub. (1) shall be deposited in the Medical
18Assistance trust fund.

SB490,16,21 19(9) By December 31, 2009, and by every December 31 thereafter, the
20department shall report to the joint committee on finance all of the following
21information for the immediately previous state fiscal year:

SB490,16,2222 (a) The total amount of assessments collected under this section.

SB490,16,2423 (b) The total amount of assessments collected from each hospital under this
24section.

SB490,17,2

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1(c) The total amounts that the department determines were paid to health
2maintenance organizations for increased Medical Assistance payments to hospitals.

SB490,17,43 (d) The total amount of payments made to each hospital by health maintenance
4organizations under s. 49.45 (58) (b) 1.

SB490,17,85 (e) The total amount of Medical Assistance payments made to each hospital and
6the portion of the Medical Assistance capitated payments made to health
7maintenance organizations for inpatient and outpatient hospital services from
8appropriation accounts of general purpose revenues.

SB490,17,99 (f) The total amounts obtained under pars. (c) and (e).

SB490,17,1210 (g) The results of any audits conducted by the department under s. 49.45 (58)
11concerning Medical Assistance payments and any actions taken by the department
12as a result of such an audit.

SB490,17,2015 50.375 (4) The department shall verify the amount of each hospital's gross
16patient revenue and shall determine the amount of the assessment owed by each
17hospital based on a uniform rate that is applicable to total gross patient revenue that
18the department estimates will yield the amounts specified in the appropriation
19schedule under s. 20.005 (3) for the appropriation accounts under s. 20.435 (4) (xc),
20and (xd), and (xe).