49.47(6)(a)6.a.a. In this subdivision,"
entitled to coverage under part A of medicare" means eligible for and enrolled in part A of medicare under
42 USC 1395c to
1395f.
49.47(6)(a)6.ag.
ag. In this subdivision,"entitled to coverage under part B of medicare" means eligible for and enrolled in part B of medicare under
42 USC 1395j to
1395L.
49.47(6)(a)6.ar.
ar. In this subdivision,"income limitation" means income that is equal to or less than 100% of the poverty line, as established under
42 USC 9902 (2).
49.47(6)(a)6.b.
b. 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. (4) (a) and meets the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which 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 may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.47(6)(a)6.c.
c. An individual who is only entitled to coverage under part A of medicare, meets the eligibility criteria under
sub. (4) (a) and meets the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i which 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.
49.47(6)(a)6.d.
d. 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. (4) (a) but does not meet the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395zz which 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 may not exceed the allowable charge for the service under medical assistance minus the medicare payment.
49.47(6)(a)6.e.
e. An individual who is only entitled to coverage under part A of medicare and meets the eligibility criteria for medical assistance under
sub. (4) (a), but does not meet the income limitation, the deductible and coinsurance portions of medicare services under
42 USC 1395 to
1395i, including those services that are not included in the approved state plan for services under
42 USC 1396.
49.47(6)(a)6.f.
f. For an individual who is only entitled to coverage under part B of medicare and meets the eligibility criteria under
sub. (4), but does not meet the income limitation, 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.
49.47(6)(a)6m.
6m. An individual who is entitled to coverage under part A of medicare, as defined in
subd. 6. a. is entitled to coverage under part B of medicare, as defined in
subd. 6. ag. and meets the eligibility criteria under
sub. (4) (a) and whose income is greater than 100% of the poverty line but less than 120% of the poverty line for the monthly premiums under
42 USC 1395r.
49.47(6)(a)7.
7. Beneficiaries eligible under
sub. (4) (a) 2. or
(am) 1., for services under
s. 49.46 (2) (a) and
(b) that are related to pregnancy, including postpartum and family planning services, or related to other conditions which may complicate pregnancy.
49.47(6)(b)
(b) In no event may payments be made for medical assistance rendered during a period when the beneficiary would not have been eligible for benefits under this section.
49.47(6)(c)
(c) Benefits shall not include any payment with respect to:
49.47(6)(c)1.
1. Care or services in any private or public institution, unless the institution has been approved by a standard-setting authority responsible by law for establishing and maintaining standards for such institution.
49.47(6)(c)2.
2. That part of any service otherwise authorized under this section which is payable through 3rd party liability or any federal, state, county, municipal or private benefit systems, to which the beneficiary may otherwise be entitled.
49.47(6)(c)3.
3. Care or services for an individual who is an inmate of a public institution, except as a patient in a medical institution or a resident in an intermediate care facility.
49.47(6)(c)4.
4. 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 subdivision, the department shall define "convalescent leave" and "conditional release" by rule.
49.47(6)(d)
(d) No payment under this subsection may include care for services rendered earlier than 3 months preceding the month of application.
49.47(7)
(7) Reduction of benefits. If the funds appropriated become or are estimated to be insufficient to make full payment of benefits provided under this section, all charges for service so authorized shall be prorated on the basis of funds available or by limiting the benefits provided.
49.47(8)
(8) Enrollment fee. As long as an enrollment fee or premium is required for persons receiving benefits under Title XIX of the social security act, the department shall charge the minimum enrollment fee or premium required under federal law. The fee or premium so charged shall be related to the beneficiary's income, in accordance with guidelines established by the secretary of the U.S. department of health and human services.
49.47(9m)
(9m) Eligibility for long-term care insurance beneficiaries. 49.47(9m)(b)
(b) A person who meets the eligibility requirements for medical assistance under
sub. (4) except that the person has liquid assets in excess of the limits under
sub. (4) (b) is eligible for medical assistance under this section if all of the following conditions are satisfied:
49.47(9m)(b)2.
2. The person is the beneficiary of a long-term care insurance policy that is certified to meet the standards set by the department by rule.
49.47(9m)(b)3.
3. The long-term care insurance policy paid for institutional or community-based long-term care services, or both, up to the limits specified in the long-term care insurance policy.
49.47(9m)(b)4.
4. The person required the services paid for under the long-term care insurance policy because of a severe limitation in activities of daily living or because of medical necessity, as defined by the department by rule.
49.47(9m)(b)5.
5. The amount of liquid assets retained by the person does not exceed the amount paid under the policy or the actual charges, whichever is lower, for the following services provided to the beneficiary that are reimbursed under the medical assistance program:
49.47(9m)(c)
(c) A person who seeks benefits under this subsection shall apply to an office of the department designated by the department.
49.47(9m)(d)
(d) Paragraphs (b) and
(c) do not apply unless the federal department of health and human services approves a waiver of federal medical assistance eligibility limits that authorizes federal financial participation in providing medical assistance benefits to persons eligible under
par. (b). If a waiver is approved, the department shall implement
pars. (b) and
(c) no later than 3 months after the date on which it is notified of that approval.
49.47 History
History: 1971 c. 125;
1971 c. 213 s.
5;
1971 c. 215;
1973 c. 90,
147,
333;
1977 c. 29 ss.
593,
1656 (18);
1977 c. 105 s.
59;
1977 c. 273,
418;
1979 c. 34;
1981 c. 20,
93;
1981 c. 314 s.
144;
1983 a. 27,
245;
1985 a. 29;
1987 a. 27,
307,
399,
413;
1989 a. 9;
1989 a. 31 ss.
1462k to
1466d,
2909c to
2909i;
1989 a. 173,
336,
351;
1991 a. 39,
178,
269,
316;
1993 a. 16,
269,
277,
437;
1995 a. 27 ss.
3026 to
3028,
9126 (19);
1995 a. 225,
289,
295.
49.47 Annotation
Spend-down requirements discussed. Swanson v. HSS, 105 W (2d) 78, 312 NW (2d) 833 (Ct. App. 1981).
49.47 Annotation
Five-step process for evaluating disability claims applied. Clauer v. DHSS, 174 W (2d) 344, 497 NW (2d) 738 (Ct. App. 1993).
49.47 Annotation
Section 49.46 (1) (b) and sub. (6) (d) limit retroactive medical assistance payments to services received not more than three months prior to the date the application was submitted. St. Paul Ramsey Medical Center v. DHSS, 186 W (2d) 37, 519 NW (2d) 706 (Ct. App. 1994).
49.47 Annotation
Regulation which "deemed" resources of one spouse to be "available" to the other was valid. Schweiker v. Gray Panthers, 453 US 34 (1981).
49.475
49.475
Information about medical assistance beneficiaries. 49.475(2)
(2) Disclosure to department. An insurer that issues or delivers a disability insurance policy that provides coverage to a resident of this state shall provide to the department, upon the department's request, information contained in the insurer's records regarding all of the following:
49.475(2)(a)
(a) Information that the department needs to identify beneficiaries of medical assistance who satisfy any of the following:
49.475(2)(a)1.
1. Are eligible for benefits under a disability insurance policy.
49.475(2)(a)2.
2. Would be eligible for benefits under a disability insurance policy if the beneficiary were enrolled as a dependent of a person insured under the disability insurance policy.
49.475(2)(b)
(b) Information required for submittal of claims under the insurer's disability insurance policy.
49.475(2)(c)
(c) The types of benefits provided by the disability insurance policy.
49.475(3)
(3) Written agreement. Upon requesting an insurer to provide the information under
sub. (2), the department shall enter into a written agreement with the insurer that satisfies all of the following:
49.475(3)(a)
(a) Identifies in detail the information to be disclosed.
49.475(3)(b)
(b) Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.
49.475(3)(c)
(c) Specifies how the insurer's reimbursable costs under
sub. (5) will be determined and specifies the manner of payment.
49.475(4)
(4) Deadline for response; enforcement. 49.475(4)(a)(a) An insurer shall provide the information requested under
sub. (2) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer to disclose information under this section.
49.475(4)(b)
(b) An insurer shall provide the information requested under
sub. (2) within 30 days after receiving the department's request if the department has previously requested the insurer to disclose information under this section.
49.475(4)(c)
(c) If an insurer fails to comply with
par. (a) or
(b), the department may notify the commissioner of insurance, and the commissioner of insurance may initiate enforcement proceedings against the insurer under
s. 601.41 (4) (a).
49.475(5)
(5) Reimbursement of costs. From the appropriations under
s. 20.435 (1) (bm) and
(p), the department shall reimburse an insurer that provides information under this section for the insurer's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of information under this section.
49.475 History
History: 1991 a. 39.
49.49
49.49
Medical assistance offenses. 49.49(1)(a)(a)
Prohibited conduct. No person, in connection with a medical assistance program, may:
49.49(1)(a)1.
1. Knowingly and wilfully make or cause to be made any false statement or representation of a material fact in any application for any benefit or payment.
49.49(1)(a)2.
2. Knowingly and wilfully make or cause to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment.
49.49(1)(a)3.
3. Having knowledge of the occurrence of any event affecting the initial or continued right to any such benefit or payment or the initial or continued right to any such benefit or payment of any other individual in whose behalf he or she has applied for or is receiving such benefit or payment, conceal or fail to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized.
49.49(1)(a)4.
4. Having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and wilfully convert such benefit or payment or any part thereof to a use other than for the use and benefit of such other person.
49.49(1)(b)
(b)
Penalties. Violators of this subsection may be punished as follows:
49.49(1)(b)1.
1. In the case of such a statement, representation, concealment, failure, or conversion by any person in connection with the furnishing by that person of items or services for which medical assistance is or may be made, a person convicted of violating this subsection may be fined not more than $25,000 or imprisoned for not more than 5 years or both.
49.49(1)(b)2.
2. In the case of such a statement, representation, concealment, failure, or conversion by any other person, a person convicted of violating this subsection may be fined not more than $10,000 or imprisoned for not more than one year in the county jail or both.
49.49(1)(c)
(c)
Damages. If any person is convicted under this subsection, the state shall have a cause of action for relief against such person in an amount 3 times the amount of actual damages sustained as a result of any excess payments made in connection with the offense for which the conviction was obtained. Proof by the state of a conviction under this section in a civil action shall be conclusive regarding the state's right to damages and the only issue in controversy shall be the amount, if any, of the actual damages sustained. Actual damages shall consist of the total amount of excess payments, any part of which is paid by state funds. In any such civil action the state may elect to file a motion in expedition of the action. Upon receipt of the motion, the presiding judge shall expedite the action.
49.49(2)
(2) Kickbacks, bribes and rebates. 49.49(2)(a)(a)
Solicitation or receipt of remuneration. Any person who solicits or receives any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind, in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a medical assistance program, or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a medical assistance program, may be fined not more than $25,000 or imprisoned for not more than 5 years or both.
49.49(2)(b)
(b)
Offer or payment of remuneration. Whoever offers or pays any remuneration including any kickback, bribe, or rebate directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a medical assistance program, or to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service or item for which payment may be made in whole or in part under a medical assistance program, may be fined not more than $25,000 or imprisoned for not more than 5 years or both.
49.49(2)(c)
(c)
Exceptions. This subsection shall not apply to:
49.49(2)(c)1.
1. A discount or other reduction in price obtained by a provider of services or other entity under
chs. 46 to
51 and
58 if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity under a medical assistance program.
49.49(2)(c)2.
2. Any amount paid by an employer to an employe who has a bona fide employment relationship with such employer for employment in the provision of covered items or services.
49.49(3)
(3) Fraudulent certification of facilities. No person may knowingly and wilfully make or cause to be made, or induce or seek to induce the making of, any false statement or representation of a material fact with respect to the conditions or operation of any institution or facility in order that such institution or facility may qualify either upon initial certification or upon recertification as a hospital, skilled nursing facility, intermediate care facility, or home health agency. Violators of this subsection may be fined not more than $25,000 or imprisoned for not more than 5 years or both.
49.49(3m)(a)(a) No provider may knowingly impose upon a recipient charges in addition to payments received for services under
ss. 49.45 to
49.47 or knowingly impose direct charges upon a recipient in lieu of obtaining payment under
ss. 49.45 to
49.47 except under the following conditions:
49.49(3m)(a)1.
1. Benefits or services are not provided under
s. 49.46 (2) and the recipient is advised of this fact prior to receiving the service.
49.49(3m)(a)2.
2. If an applicant is determined to be eligible retroactively under
s. 49.46 (1) (b) and a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider shall, upon notification of the applicant's retroactive eligibility, submit claims for reimbursement under
s. 49.45 for covered services or benefits rendered during the retroactive period. Upon receipt of payment, the provider shall reimburse the applicant or other person who has made prior payment to the provider. No provider may be required to reimburse the applicant or other person in excess of the amount reimbursed under
s. 49.45.
49.49(3m)(b)
(b) A person who violates this subsection may be fined not more than $25,000 or imprisoned not more than 5 years or both.
49.49(3p)
(3p) Other prohibited provider charges. No provider may knowingly violate
s. 609.91 (2).
49.49(4)
(4) Prohibited facility charges. 49.49(4)(a)(a) No person, in connection with the medical assistance program when the cost of the services provided to the patient is paid for in whole or in part by the state, may knowingly and wilfully charge, solicit, accept or receive, in addition to any amount otherwise required to be paid under a medical assistance program, any gift, money, donation or other consideration, other than a charitable, religious or philanthropic contribution from an organization or from a person unrelated to the patient, as a precondition of admitting a patient to a hospital, skilled nursing facility or intermediate care facility, or as a requirement for the patient's continued stay in such a facility.
49.49(4)(b)
(b) A person who violates this subsection may be fined not more than $25,000 or imprisoned not more than 5 years or both.
49.49(4m)
(4m) Prohibited conduct; forfeitures.
