Wisconsin Code § 49.45

(1) PURPOSE. To provide appropriate health care for eligible persons and
obtain the most benefits available under Title XIX of the federal
social security act, the department shall administer medical assistance, rehabilitative and other services to help eligible individuals
and families attain or retain capability for independence or selfcare as hereinafter provided.
(2) DUTIES. (a) The department shall:
1. Exercise responsibility relating to fiscal matters, the eligibility for benefits under standards set forth in ss. 49.46 to 49.471,
and general supervision of the medical assistance program.
2. Employ necessary personnel under the classified service
for the efficient and economical performance of the program and
shall supply residents of this state with information concerning
the program and procedures.
3. Determine the eligibility of persons for medical assistance, rehabilitative, and social services under ss. 49.46, 49.468,
49.47, and 49.471 and rules and policies adopted by the department and may, under a contract under s. 49.78 (2), delegate all, or
any portion, of this function to the county department under s.
46.215, 46.22, or 46.23 or a tribal governing body.
4. To the extent funds are available under s. 20.435 (4) (bm),
certify all proper charges and claims for administrative services
to the department of administration for payment and the department of administration shall draw its warrant forthwith.
5. Cooperate with the division for learning support in the department of public instruction to carry out the provisions of Title XIX.
6. Appoint such advisory committees as are necessary and
proper.
7. Cooperate with the federal authorities for the purpose of
providing the assistance and services available under Title XIX to
obtain the best financial reimbursement available to the state
from federal funds.
8. Periodically report to the joint committee on finance concerning projected expenditures and alternative reimbursement
and cost control policies in the medical assistance program.
9. Periodically set forth conditions of participation and reimbursement in a contract with provider of service under this
section.
10. a. After reasonable notice and opportunity for hearing,
recover money improperly or erroneously paid or overpayments
to a provider by offsetting or adjusting amounts owed the
provider under the program, crediting against a provider’s future
claims for reimbursement for other services or items furnished by
the provider under the program, or requiring the provider to make
direct payment to the department or its fiscal intermediary.
b. Establish a deadline for payment of a recovery imposed
under this subdivision and, if a provider fails to pay all of the
amount to be recovered by the deadline, require payment, by the
provider, of interest on any delinquent amount at the rate of 1 percent per month or fraction of a month from the date of the
overpayment.
c. Promulgate rules to implement this subdivision.
11. a. Establish criteria for certification of providers of medical assistance and, except as provided in par. (b) 6m. and s.
49.48, and subject to par. (b) 7. and 8., certify providers who meet
the criteria.
b. Promulgate rules to implement this subdivision.
c. The department shall accept relevant education, training,
instruction, or other experience that an applicant obtained in connection with military service, as defined in s. 111.32 (12g), to
count toward the education, training, instruction, or other experience that is required to certify providers of medical assistance if
the applicant demonstrates to the satisfaction of the department
that the education, training, instruction, or other experience that
the applicant obtained in connection with his or her military service is substantially equivalent to the education, training, instruction, or other experience required for the certification.
12. a. Decertify a provider from or restrict a provider’s participation in the medical assistance program, if after giving reasonable notice and opportunity for hearing the department finds
that the provider has violated a federal statute or regulation or a
state statute or administrative rule and the violation is, by statute,
regulation, or rule, grounds for decertification or restriction. The
department shall suspend the provider pending the hearing under
this subdivision if the department includes in its decertification
notice findings that the provider’s continued participation in the
medical assistance program pending hearing is likely to lead to
the irretrievable loss of public funds and is unnecessary to provide adequate access to services to medical assistance recipients.
As soon as practicable after the hearing, the department shall issue a written decision. No payment may be made under the medical assistance program with respect to any service or item furnished by the provider subsequent to decertification or during the
period of suspension.
b. Promulgate rules to implement this subdivision.
12r. Notify the medical examining board, or any affiliated
credentialing board attached to the medical examining board, of
any decertification or suspension of a person holding a license
granted by the board or the affiliated credentialing board if the
grounds for the decertification or suspension include fraud or a
quality of care issue.
13. Impose additional sanctions for noncompliance with the
terms of provider agreements under subd. 9. or certification criteria established under subd. 11.

14. Assure due process in implementing subds. 12. and 13.
by providing written notice, a fair hearing and a written decision.
15. Routinely provide notification to persons eligible for
medical assistance, or such persons’ guardians, of the department’s access to provider records.
16. Notify the joint committee on finance and appropriate
standing committees in each house of the legislature prior to renewing, extending or amending the claims processing contract
under the medical assistance program.
18. Conduct outreach for the early and periodic screening,
diagnosis and treatment program as required under 42 CFR 441.
This activity is limited to persons under 21 years of age who have
been determined to be eligible for medical assistance.
19. Contract with a county department under s. 46.21, 46.23,
51.42 or 51.437 to perform preadmission screening and resident
review under sub. (6c).
20. Submit a report, by May 1, 1991, and annually thereafter,
to the joint committee on finance on the participation rates of
children in the early and periodic screening and diagnosis
program.
22. After consulting with counties, independent living centers, consumer organizations and home health agencies, periodically identify those barriers to the provision of personal care services under s. 49.46 (2) (b) 6. j. which lead to a failure to respond
to the needs and preferences of individuals who are eligible for
these services and act to remove the barriers to the extent
possible.
23. Promulgate rules that define “supportive services”, “personal services” and “nursing services” provided in a certified residential care apartment complex, as defined under s. 50.01 (6d),
for purposes of reimbursement under s. 46.277 (5) (e).
24. In consultation with hospitals, health maintenance organizations, county departments of social services and of human
services and other interested parties, develop and, not later than
January 1, 1999, implement a process for expediting medical assistance eligibility determinations for persons in urgent medical
situations. The department shall promulgate any rules necessary
for the implementation of that process.
24m. Promulgate rules that require that the written plan of
care for persons receiving personal care services under medical
assistance be reviewed by a registered nurse at least every 60
days. The rules shall provide that the written plan of care shall
designate intervals for visits to the recipient’s home by a registered nurse as part of the review of the plan of care. The designated intervals for visits shall be based on the individual recipient’s needs, and each recipient shall be visited in his or her home
by a registered nurse at least once in every 12-month period. The
rules shall also provide that a visit to the recipient is also required
if, in the course of the nurse’s review of the plan of care, there is
evidence that a change in the recipient’s condition has occurred
that may warrant a change in the plan of care.
(b) The department may:
1. Direct a county department under s. 46.215, 46.22 or
46.23 to perform other functions, responsibilities and services,
including any functions related to health maintenance organizations, limited service health organizations and preferred provider
plans.
2. Contract with any organization whether or not organized
for profit to administer, in full or in part, the benefits under the
medical assistance program including prepaid health care. The
department shall accept bids on contracts for administrative services and services evaluating the medical assistance program as
provided in ch. 16, but may accept the contract deemed most advantageous for claims processing services; or contract with any
insurer authorized under the insurance code of this state to insure
the program in full or in part and on behalf of the department.
The department shall submit a report each December 31 to the
governor, the joint committee on finance and the chief clerk of
each house of the legislature, for distribution to the appropriate
standing committees under s. 13.172 (3), regarding the effectiveness of the management information system for monitoring and
analyzing medical assistance expenditures.
3. Audit all claims filed by any contractor making the payment of benefits paid under ss. 49.46 to 49.471 and make proper
fiscal adjustments.
4. Audit claims filed by any provider of medical assistance,
and as part of that audit, request of any such provider, and review,
medical records of individuals who have received benefits under
the medical assistance program.
5. Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.
6m. Limit the number of providers of particular services that
may be certified under par. (a) 11. or the amount of resources, including employees and equipment, that a certified provider may
use to provide particular services to medical assistance recipients, if the department finds that existing certified providers and
resources provide services that are adequate in quality and
amount to meet the need of medical assistance recipients for the
particular services; and if the department finds that the potential
for medical assistance fraud or abuse exists if additional
providers are certified or additional resources are used by certified providers. The department shall promulgate rules to implement this subdivision.
7. Require, as a condition of certification under par. (a) 11.,
all providers of a specific service that is among those enumerated
under s. 49.46 (2), 49.47 (6) (a), or 49.471 (11), as specified in
this subdivision, to file with the department a surety bond issued
by a surety company licensed to do business in this state.
Providers subject to this subdivision provide those services specified under s. 49.46 (2), 49.47 (6) (a) , or 49.471 (11) for which
providers have demonstrated significant potential to violate s.
49.49 (3p) or (4m) (a) or 946.91 (2), (3) (a) or (b), (4), (5), or (6),
to require recovery under par. (a) 10., or to need additional sanctions under par. (a) 13. The surety bond shall be payable to the
department in an amount that the department determines is reasonable in view of amounts of former recoveries against
providers of the specific service and the department’s costs to
pursue those recoveries. The department shall promulgate rules
to implement this subdivision that specify all of the following:
a. Services under Medical Assistance for which providers
have demonstrated significant potential to violate s. 49.49 (3p) or
(4m) (a) or 946.91 (2), (3) (a) or (b), (4), (5), or (6), to require recovery under par. (a) 10., or to need additional sanctions under
par. (a) 13.
b. The amount or amounts of the surety bonds.
c. Terms of the surety bond, including amounts, if any, without interest to be refunded to the provider upon withdrawal or decertification from the medical assistance program.
8. Require a person who takes over the operation, as defined
in sub. (21) (ag), of a provider, to first obtain certification under
par. (a) 11. for the operation of the provider, regardless of
whether the person is currently certified. The department may
withhold the certification required under this subdivision until
any outstanding repayment under sub. (21) is made. The department shall promulgate rules to implement this subdivision.
9. After providing reasonable notice and opportunity for a
hearing, charge an assessment to a provider that repeatedly has
been subject to recoveries under par. (a) 10. a. because of the
provider’s failure to follow identical or similar billing procedures
or to follow other identical or similar program requirements. The

assessment shall be used to defray in part the costs of audits and
investigations by the department under sub. (3) (g) and may not
exceed $1,000 or 200 percent of the amount of any such repeated
recovery made, whichever is greater. The provider shall pay the
assessment to the department within 10 days after receipt of notice of the assessment or the final decision after administrative
hearing, whichever is later. The department may recover any part
of an assessment not timely paid by offsetting the assessment
against any medical assistance payment owed to the provider and
may refer any unpaid assessments not collected in this manner to
the attorney general, who may proceed with collection under this
subdivision. Failure to timely pay in any manner an assessment
charged under this subdivision, other than an assessment that is
offset against any medical assistance payment owed to the
provider, is grounds for decertification under par. (a) 12. A
provider’s payment of an assessment does not relieve the provider
of any other legal liability incurred in connection with the recovery for which the assessment is charged, but is not evidence of violation of a statute or rule. The department shall credit all assessments received under this subdivision to the appropriation account under s. 20.435 (4) (iL). The department shall promulgate
rules to implement this subdivision.
(2n) REPORT ON MEDICAL ASSISTANCE PROGRAM CHANGES
AND FINANCES. (a) In this subsection, “Medical Assistance program” includes any program operated under this subchapter,
demonstration program operated under 42 USC 1315 , and program operated under a waiver of federal law relating to medical
assistance that is granted by the federal department of health and
human services.
(b) Before January 1, 2015, and every 90 days thereafter, the
department shall submit to the joint committee on finance a report that contains all of the following information:
1. An updated description of any Medical Assistance program changes implemented by the department, including any
amendments to the Medical Assistance state plan.
2. An updated estimate of the projected savings associated
with any changes described under subd. 1.
3. An updated projection of the total Medical Assistance program benefit expenditures during the fiscal biennium and an
analysis of how these projected expenditures compare to the
funding provided in the most recent biennial budget act.
(2p) APPROVAL OF M EDICAL A SSISTANCE PROGRAM
CHANGES. After March 1, 2018, the department may not expand
eligibility under section 2001 (a) (1) (C) of the Patient Protection
and Affordable Care Act, P.L. 111-148, for the Medical Assistance program under this subchapter unless the state legislature
has passed legislation to allow the expansion and that legislation
is in effect.
(2t) SUBMISSION OF STATE PLAN AMENDMENTS AND
PROVIDER PAYMENTS. (a) The department may not submit a
Medical Assistance state plan amendment to the federal department of health and human services or implement a change to the
reimbursement rate for or make a supplemental payment to a
provider under the Medical Assistance program under this subchapter when the amendment, rate change, or payment has an expected fiscal effect of $7,500,000 or more from all revenue
sources over a 12-month period following the implementation
date of the amendment, rate change, or payment without submitting the proposed state plan amendment, rate change, or payment
to the joint committee on finance for review. If the cochairpersons of the joint committee on finance do not notify the department within 14 working days after the date of the submittal under
this paragraph that the committee has scheduled a meeting for the
purpose of reviewing the proposed state plan amendment, rate
change, or payment, the department may submit the state plan
amendment, implement the rate change, or make the payment. If,
within 14 working days after the date of the submittal under this
paragraph by the department, the cochairpersons of the committee notify the department that the committee has scheduled a
meeting for the purpose of reviewing the proposed state plan
amendment, rate change, or payment, the department may submit
the state plan amendment, implement the rate change, or make
the payment only upon approval by the committee.
(c) Notwithstanding par. (a), the department is not required to
submit a proposed change to a reimbursement rate for or supplemental payment to a provider under the Medical Assistance program under this subchapter to the joint committee on finance under par. (a) if explicit expenditure authority or funding for the
specific change or supplemental payment is included in enacted
legislation.
(3) PAYMENT. (a) Reimbursement shall be made to each
county department under ss. 46.215, 46.22, and 46.23 for any administrative services performed in the Medical Assistance program on the basis of s. 49.78 (8).
(ag) Reimbursement shall be made to each entity contracted
with under s. 46.283 (2) for functional screenings performed by
the entity.
(b) 1. The contractor, if any, administering benefits or providing prepaid health care under s. 49.46, 49.465, 49.468, 49.47, or
49.471 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available
when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in sub. (2) (a) 4.,
but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
2. The contractor, if any, insuring benefits under s. 49.46,
49.465, 49.468, 49.47, or 49.471 shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the
persons eligible to receive them and for its services as insurer.
(c) Payment for services provided under this section shall be
made directly to the hospital, skilled and intermediate nursing
homes, prepaid health care group, other organization or individual providing such services or to an organization which provides
such services or arranges for their availability on a prepayment
basis.
(d) No payment may be made for inpatient hospital services,
skilled nursing home services, intermediate care facility services,
tuberculosis institution services or inpatient mental institution
services, unless the facility providing such services has in operation a utilization review program and meets federal regulations
governing such utilization review program.
(dm) After distribution of computer software has been made
under 1993 Wisconsin Act 16 , section 9126 (13h), no payment
may be made for home health care services provided to persons
who are enrolled in the federal medicare program and are recipients of medical assistance under s. 49.46, 49.47, or 49.471 unless
the provider of the services has in use the computer software to
maximize payments under the federal medicare program under
42 USC 1395.
(e) 1. The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital’s total reimbursement or payment to that which would be
provided to an economically and efficiently operated facility.
2. A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented
under subd. 1. shall annually prepare a report of cost and other
data in the manner prescribed by the department.

3. The department may adopt a prospective payment system
under subd. 1. which may include consideration of an average
rate per diem, diagnosis-related groups or a hospital-specific
prospective rate per discharge.
4. If the department maintains a retrospective reimbursement
system under subd. 1. for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital’s fiscal year may
not exceed the lower of the hospital’s charges for the services or
the actual and reasonable allowable costs to the hospital of providing the services, plus any disproportionate share funding that
the hospital is qualified to receive under 42 USC 1396r-4.
7. The daily reimbursement or payment rate to a hospital for
services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility,
community-based residential facility, group home, foster home,
or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under sub. (6m).
This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a
period when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a
peer review organization, established under 42 USC 1320c to
1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued
care of the recipient. In addition, the department may contract
with a peer review organization to determine the medical necessity or appropriateness of physician services or other services
provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
7m. Notwithstanding subd. 7., the daily reimbursement or
payment rate for services at a hospital established under s. 45.50
(10) provided to medical assistance recipients whose continued
hospitalization is no longer medically necessary or appropriate
during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50.
9. Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital’s reimbursement or payment rate under subd. 1.
10. Hospital procedures on an inpatient basis that could be
performed on an outpatient basis shall be reimbursed or paid at
the outpatient rate. The department shall determine which procedures this subdivision covers.
10m. All facilities listed in a certificate of approval issued to
the University of Wisconsin Hospitals and Clinics Authority under s. 50.35 are a hospital for purposes of reimbursement under
this section.
10r. All facilities listed in a certificate of approval issued to a
free-standing pediatric teaching hospital under s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician
clinic reimbursement rates to reimburse the facilities under this
section for types of services for which, before July 1, 2009, the
department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.
11. The department shall use a portion of the moneys collected under s. 50.38 (2) to pay for services provided by eligible
hospitals, as defined in s. 50.38 (1), under the Medical Assistance
Program under this subchapter, including services reimbursed on
a fee-for-service basis and services provided under a managed
care system. For state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state
share of Medical Assistance, shall equal the amount collected under s. 50.38 (2) (a) for fiscal year 2008-09 divided by 57.75 percent. For each state fiscal year after state fiscal year 2008-09, total payments required under this subdivision, including both the
federal and state share of Medical Assistance, shall equal the
amount collected under s. 50.38 (2) (a) for the fiscal year divided
by 61.68 percent. For each state fiscal year after state fiscal year
2024-25, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall
equal the amount collected under s. 50.38 (2) (a) and (b) for the
fiscal year divided by 56.1 percent.
(em) The department shall expend moneys collected under s.
256.23 (2) to supplement reimbursement for eligible ambulance
service providers, as defined in s. 256.23 (1) (a), for services provided under the Medical Assistance program under this subchapter, including services reimbursed on a fee-for-service basis and
provided under managed care, by eligible ambulance service
providers. Health plans shall be indemnified and held harmless
for any errors made by the department or its agents in calculation
of any supplemental reimbursement made under this paragraph.
(f) 1. Providers of services under this section shall maintain
records as required by the department for verification of provider
claims for reimbursement. The department may audit such
records to verify actual provision of services and the appropriateness and accuracy of claims.
2. The department may deny any provider claim for reimbursement which cannot be verified under subd. 1. or may recover the value of any payment made to a provider which cannot
be so verified. The measure of recovery will be the full value of
any claim if it is determined upon audit that actual provision of
the service cannot be verified from the provider’s records or that
the service provided was not included in s. 49.46 (2) or 49.471
(11). In cases of mathematical inaccuracies in computations or
statements of claims, the measure of recovery will be limited to
the amount of the error.
2m. The department shall adjust reimbursement claims for
hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under par. (e) 7. and that fail to meet criteria the department
may establish concerning medical necessity or appropriateness
for hospital care. In addition, the department shall deny any
provider claim for services that fail to meet criteria the department may establish concerning medical necessity or
appropriateness.
3. Contractors under sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall
provide the department access to the records upon request of the
department, and the department may audit the records.
(fm) The department shall seek, on behalf of dentists who are
providers, federal reimbursement for the cost of any equipment
that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful
in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of
the cost of the equipment that is reimbursed by the federal
government.
(g) 1. The secretary may authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of statutes, regulations,
or rules applicable to the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims

for reimbursement submitted by providers participating in the
program. Department employees authorized by the secretary under this paragraph shall be issued, and shall possess at all times
while they are performing their investigatory or audit functions
under this section, identification, signed by the secretary, that
specifically designates the bearer as possessing the authorization
to conduct medical assistance investigations or audits. Under the
request of a designated person and upon presentation of the person’s authorization, providers and medical assistance recipients
shall accord the person access to any provider personnel, records,
books, or documents or other information needed. Under the
written request of a designated person and upon presentation of
the person’s authorization, providers and recipients shall accord
the person access to any needed patient health care records of a
recipient. Authorized employees may hold hearings, administer
oaths, take testimony, and perform all other duties necessary to
bring the matter before the department for final adjudication and
determination.
2. The department shall promulgate rules to implement this
paragraph.
(h) 1m. The failure or refusal of a provider to accord department auditors or investigators access as required under par. (g) to
any provider personnel, records, books, patient health care
records of medical assistance recipients, or documents or other
information requested constitutes grounds for decertification or
suspension of the provider from participation in the medical assistance program. No payment may be made for services rendered by the provider following decertification, during the period
of suspension, or during any period of provider failure or refusal
to accord access as required under par. (g).
1n. The department shall promulgate rules to implement this
paragraph.
(j) Reimbursement for administrative contract costs under this
section is limited to the funds available under s. 20.435 (4) (bm).
(k) If a physician performs a surgical procedure that is within
the scope of practice of a podiatrist, as defined in s. 448.60 (3),
the allowable charge for the procedure may not exceed the charge
the department determines is reasonable.
(L) 1. In this paragraph:
a. “Designated health service” has the meaning given in 42
USC 1395nn (h) (6).
b. “Medicare” means coverage under Part A or Part B of Title XVIII of the federal social security act, 42 USC 1395 to
1395ccc.
c. “Physician” has the meaning given in s. 448.01 (5).
d. “Referral” has the meaning given in 42 USC 1395nn (h)
(5).
2. The department may not pay a provider for a designated
health service that is authorized under this section or s. 49.46,
49.47, or 49.471, that is provided as the result of a referral made
to the provider by a physician and that, under 42 USC 1396b (s),
if made on behalf of a beneficiary of medicare under the requirements of 42 USC 1395nn, as amended to August 10, 1993, would
result in the denial of payment for the service under 42 USC
1395nn.
3. A provider shall submit to the department information
concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under 42 USC 1395nn (f), as
amended to August 10, 1993.
4. Any person who fails to comply with subd. 3. may be required to forfeit not more than $10,000. Each day of continued
failure to comply constitutes a separate offense.
5. The department shall administer this paragraph consistently with 42 USC 1395nn and 42 USC 1396b (s).
(m) 1. To be certified under sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at
least one human service vehicle, as defined in s. 340.01 (23g),
that satisfies the requirements imposed under s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified
provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human
service vehicles that satisfy the requirements imposed under s.
110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service
vehicle to which the equipment required under s. 110.05 for
transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle
under s. 49.46 (2) (b) 3. or 49.471 (11) (m) that is provided in a
human service vehicle that is not equipped to transport a person
in a wheelchair if the person being transported does not use a
wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped
to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is
equipped to accommodate a wheelchair.
2. A person who is certified to provide transportation by specialized medical vehicle under sub. (2) (a) 11. shall ensure that
every person who drives or serves as an attendant to passengers
on a specialized medical vehicle, before driving or serving as an
attendant, has current proficiency in the use of an automated external defibrillator, as defined in s. 256.15 (1) (cr) , achieved
through instruction provided by an individual, organization, or
institution of higher education that is approved under s. 46.03
(38) to provide such instruction.
(3g) PAYMENTS TO FEDERALLY QUALIFIED HEALTH CENTERS. (a) For services provided by a federally qualified health
center before July 1, 2016, to a recipient of the Medical Assistance program under this subchapter, the department shall reimburse the federally qualified health center under a payment
methodology in effect on January 1, 2015, and in accordance
with 42 USC 1396a (bb) (6).
(b) For services provided by a federally qualified health center on or after July 1, 2016, to a recipient of the Medical Assistance program under this subchapter, the department shall reimburse the federally qualified health centers using a payment
methodology based on the Medicaid prospective payment system
under 42 USC 1396a (bb) (1) to (3). The department shall consult with federally qualified health centers in developing the payment methodology under this paragraph. The department shall
phase-in over fiscal years 2016-17, 2017-18, and 2018-19 payment of new rates under the payment methodology developed under this paragraph.
(3m) DISPROPORTIONATE SHARE HOSPITAL PAYMENTS. (a)
Subject to par. (d) 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
$71,600,000, 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:
1. The hospital is located in this state.
2. The hospital provides a wide array of services, including
services provided through an emergency department.
3. The inpatient days for Medical Assistance recipients at the
hospital were at least 6 percent of the total inpatient days at that

hospital during the most recent year for which such information is
available.
4. The hospital meets applicable, minimum requirements to
be a disproportionate share hospital under 42 USC 1396r-4 and
any other applicable federal law.
(b) The department shall comply with all of the following
when making payments to hospitals described in par. (a):
1. The department shall distribute the total amount of moneys described under par. (a) to be paid to hospitals with a disproportionate share of low-income patients by doing all of the
following:
a. Dividing the number of Medical Assistance recipient inpatient days at a hospital by the number of total inpatient days at the
hospital to obtain the percentage of Medical Assistance recipient
inpatient days at that hospital.
b. Subject to subds. 2. and 3., providing an increase to the inpatient fee-for-service base rate for each hospital that qualifies for
a disproportionate share hospital payment such that the hospital’s
overall fee-for-service add-on percentage under this subsection
increases as the hospital’s percentage of Medical Assistance recipient inpatient days increases.
2. The department shall ensure that the total amount of moneys available to pay hospitals with a disproportionate share of
low-income patients is distributed in each fiscal year.
3. The department shall limit the maximum payment to hospitals such that all of the following are true for disproportionate
share hospital payments under this subsection in a fiscal year:
a. No single hospital receives more than $4,600,000. Beginning in fiscal year 2021-22, the amount specified under this subd.
3. a. shall equal 6.77 percent of the total amount of the state and
federal shares available for disproportionate share hospital payments for the fiscal year.
b. The amount of payment is in accordance with federal rules
concerning the hospital specific limit.
(c) If the department needs data to calculate the payments under this subsection other than the data available from the Medicaid Management Information System, the fiscal survey data, or
the federal centers for Medicare and Medicaid services public
records, the department shall collect the necessary data from
hospitals.
(d) The department shall seek any necessary approval from
the federal department of health and human services to implement the hospital payment methodology described under pars. (a)
and (b). If approval is necessary and approval from the federal
department of health and human services is received, the department shall implement the payment methodology described under
pars. (a) and (b). If approval is necessary and the department and
the federal department of health and human services negotiate a
methodology for making payments to hospitals with a disproportionate share of low-income patients that is different from the
methodology described under pars. (a) and (b), the department,
before implementing the negotiated payment methodology, shall
submit to the joint committee on finance the negotiated payment
methodology. If the cochairpersons of the committee do not notify the department within 14 working days after the date of the
submittal by the department that the committee has scheduled a
meeting for the purpose of reviewing the negotiated payment
methodology, the department may implement the negotiated payment methodology. If, within 14 working days after the date of
the submittal by the department, the cochairpersons of the committee notify the department that the committee has scheduled a
meeting for the purpose of reviewing the negotiated payment
methodology, the negotiated payment methodology may be implemented only on approval of the committee.
(3p) RURAL CRITICAL CARE ACCESS SUPPLEMENT. (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 an amount equal to the sum of $4,500,000,
as the state share of payments, and the matching federal share of
payments, to hospitals that are not eligible for payments under
sub. (3m) but that meet the criteria under sub. (3m) (a) 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. 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 percentage of the total
amount of the hospital’s overall charges for services that are
charges to the Medical Assistance program increases.
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 an
amount equal to the sum of $4,500,000, as the state share of payments, and the
matching federal share of payments, to hospitals that would not be eligible for
payments under s. 49.45 (3m), 2023 stats., as determined by the department,
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. 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 percentage of the total amount of the hospital’s overall charges for services that are charges to the Medical Assistance
program increases.
(b) The department shall ensure that the total amount of moneys available to pay hospitals described under this subsection is
distributed in each fiscal year.
(c) The department shall limit the maximum payment to hospitals under this subsection such that the amount of payment is in
accordance with federal rules concerning any hospital specific
limit.
(d) The department shall seek any necessary approval from
the federal department of health and human services to implement the hospital payment supplement described under par. (a).
If approval is necessary and approval from the federal department
of health and human services is received, the department shall
implement the payment methodology described under par. (a). If
approval is necessary and the federal department of health and
human services does not approve, the department may not implement the hospital payment supplement under par. (a).
(4) INFORMATION RESTRICTED. The use or disclosure of any
information concerning applicants and recipients of medical assistance not connected with the administration of this section is
prohibited.
(4m) FINANCIAL RECORD MATCHING PROGRAM. (a) Definitions. In this subsection:
1. “Account” means a demand deposit account, checking account, negotiable withdrawal order account, savings account,
time deposit account, or money market mutual fund account.
2. “Applicant” means an individual applying for benefits under this subchapter.
3. “Financial institution” means any of the following:
a. A depository institution, as defined in 12 USC 1813 (c).

c. A federal credit union, as defined in 12 USC 1752, or state
credit union, as defined in 12 USC 1752.
f. A broker-dealer, as defined in s. 551.102 (4).
4. “Other individual” means an individual whose resources
are required by law to be disclosed to determine the eligibility of
an applicant or recipient.
5. “Recipient” means an individual who receives benefits under this subchapter.
(b) Matching program and agreements. 1. The department
shall operate a financial record matching program under this subsection for the purpose of verifying the assets of applicants, recipients, and other individuals with respect to any program under
this subchapter that requires asset verification.
2. The department shall enter into agreements with financial
institutions doing business in this state to operate the financial
record matching program under this subsection. An agreement
shall require the financial institution to participate in the financial record matching program by electing either the financial institution matching option under par. (c) or the state matching option under par. (d). Any changes to the conditions of the agreement shall be submitted by the financial institution or the department at least 60 days before the effective date of the change. The
department shall furnish the financial institution with a signed
copy of the agreement.
3. The department shall reimburse a financial institution up
to $125 per calendar quarter for participating in the financial
record matching program under this subsection.
4. To the extent feasible, the information to be exchanged under the matching program shall be provided by electronic data exchange as prescribed by the department in the agreement under
subd. 2.
(c) Financial institution matching option. If a financial institution with which the department has an agreement under par. (b)
elects the financial institution matching option under this paragraph, all of the following apply:
1. At least once each calendar quarter, the department shall
provide to the financial institution, in the manner specified in the
agreement under par. (b) 2., information regarding applicants, recipients, and other individuals. The information shall include
names and social security or other taxpayer identification
numbers.
2. Based on the information received under subd. 1., the financial institution shall take actions necessary to determine
whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution. If the financial institution determines that an applicant, recipient, or other individual has an ownership interest in an account at the financial institution, the financial institution shall
provide the department with a notice containing the applicant’s,
recipient’s, or other individual’s name, address of record, social
security number or other taxpayer identification number, and account information. The account information shall include the account number, the account type, the nature of the ownership interest in the account, and the balance of the account at the time
that the record match is made. The notice under this subdivision
shall be provided in the manner specified in the agreement under
par. (b) 2. and, to the extent feasible, by an electronic data
exchange.
(d) State matching option. If a financial institution with
which the department has an agreement under par. (b) elects the
state matching option under this paragraph, all of the following
apply:
1. At least once each calendar quarter, the financial institution shall provide the department with information concerning all
accounts maintained at the financial institution. For each account
maintained at the financial institution, the financial institution
shall notify the department of the name and social security number or other tax identification number of each person having an
ownership interest in the account, together with a description of
each person’s interest. The information required under this subdivision shall be provided in the manner specified in the agreement under par. (b) 2. and, to the extent feasible, by an electronic
data exchange.
2. The department shall take actions necessary to determine
whether any applicant, recipient, or other individual has an ownership interest in an account maintained at the financial institution providing information under subd. 1. Upon the request of the
department, the financial institution shall provide to the department, for each applicant, recipient, or other individual who
matches information provided by the financial institution under
subd. 1., the address of record, the account number and account
type, and the balance of the account.
(e) Use of information by financial institution; penalty. A financial institution participating in the financial record matching
program under this subsection, and the employees, agents, officers, and directors of the financial institution, may use information received from the department under par. (c) only for the purpose of matching records and may use information provided by
the department in requesting additional information under par.
(d) only for the purpose of providing the additional information.
Neither the financial institution nor any employee, agent, officer,
or director of the financial institution may disclose or retain information received from the department concerning applicants, recipients, or other individuals. Any person who violates this paragraph may be fined not less than $50 nor more than $1,000 or imprisoned in the county jail for not less than 10 days or more than
one year or both.
(f) Use of information by department. The department may
use information provided by a financial institution under this subsection only for matching records under par. (d), for administering the financial record matching program under this subsection,
and for determining eligibility or continued eligibility under this
subchapter. The department may not disclose or retain information received from a financial institution under this subsection
concerning account holders who are not applicants, recipients, or
other individuals.
(g) Financial institution liability. A financial institution is
not liable to any person for disclosing information to the department under this subsection or for any other action that the financial institution takes in good faith to comply with this subsection.
(5) APPEAL. (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).
(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:
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.
2. Reduction, suspension, or termination of a previously au-

thorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been
completed.
3. Denial, in whole or in part, of payment for a service.
4. Failure to provide services in a timely manner.
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.
6. Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance,
other cost sharing, and other member financial liabilities.
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.
(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.
(b) 1. 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 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:
a. The petitioner withdraws the petition in writing.
b. The sole issue in the petition concerns an automatic payment adjustment or change that affects an entire class of recipients and is the result of a change in state or federal law.
c. The petitioner abandons the petition. Abandonment occurs if the petitioner fails to appear in person or by representative
at a scheduled hearing without good cause, as determined by the
department.
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.
2. If a recipient requests a hearing within the timely notice
period specified in 42 CFR 431.231 (c), medical assistance coverage shall not be suspended, reduced, or discontinued until a decision is rendered after the hearing but medical assistance payments made pending the hearing decision may be recovered by
the department if the contested decision or failure to act is upheld. If a county department is responsible for making the medical assistance determination, the department shall notify the
county department of the county in which the recipient resides
that the recipient has requested a hearing. Medical assistance
coverage shall be suspended, reduced, or discontinued if:
a. The recipient is contesting a state or federal law or a
change in state or federal law and not the determination of the
payment made on the recipient’s behalf.
b. The recipient is notified of a change in his or her medical
assistance coverage while the hearing decision is pending but the
recipient fails to request a hearing on the change.
3. The recipient shall be promptly informed in writing if
medical assistance is to be suspended, reduced or terminated
pending the hearing decision.
(5g) PAYMENTS TO TRIBES. (a) Tribal care coordination
agreements. A tribal health care provider’s care coordination
agreement with a nontribal health care provider shall meet federal requirements, including that a service provided by the nontribal health care provider be at the request of the tribal health
care provider on behalf of a tribal member who remains in the
tribal health care provider’s care according to the care coordination agreement; that both the tribal health care provider and nontribal health care provider are providers, as defined in s. 49.43
(10); that an established relationship exists between the tribal
health care provider and the tribal member; and that the care be
provided pursuant to a written care coordination agreement.
(b) Amount and distribution of payments. 1. From the appropriation account under s. 20.435 (4) (b) , the department shall
make payments to eligible governing bodies of federally recognized American Indian tribes or bands or tribal health care
providers in an amount and manner determined by the department. The department shall determine payment amounts on the
basis of the difference between the state share of medical assistance payments paid for services rendered to tribal members for
whom a care coordination agreement with nontribal health care
providers is in place and the state share of medical assistance payments that would have been paid for those services absent a care
coordination agreement with nontribal partners.
2. The department shall withhold from the payments under
subd. 1. the state share of administrative costs associated with
carrying out this subsection, up to 10 percent of the amounts calculated in subd. 1.
3. Federally recognized American Indian tribes or bands
may use funds paid under this subsection for health-related purposes. The department shall consult biennially with tribes to determine the timing and distribution of payments.
(5m) SUPPLEMENTAL FUNDING FOR RURAL HOSPITALS. (am)
Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), (w) and (xc), the department shall
distribute not more than $5,000,000 in each fiscal year, to provide
supplemental funds to rural hospitals that, as determined by the
department, have high utilization of inpatient services by patients
whose care is provided from governmental sources, except that
the department may not distribute funds to a rural hospital to the
extent that the distribution would exceed any limitation under 42
USC 1396b (i) (3).
(b) The supplemental funding for rural hospitals under par.
(am) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation
to that utilization in other rural hospitals.
(5r) SUPPLEMENTAL FUNDING FOR UNCOMPENSATED CARE.
Notwithstanding sub. (3) (e), from the appropriation account under s. 20.435 (4) (w), the department shall distribute in each fiscal year $13,000,000 to the University of Wisconsin Hospital and
Clinics for care that is not otherwise compensated, except that the
department may not make payments that exceed limitations based
on customary charges under 42 USC 1396b (i) (3).
(6b) CENTERS FOR THE DEVELOPMENTALLY DISABLED. From
the appropriation under s. 20.435 (2) (gk) , the department may
reimburse the cost of services provided by the centers for the developmentally disabled. Beginning in fiscal year 2009-10, following each placement made under s. 46.275 that involves a relocation from a center for the developmentally disabled, the depart-

ment shall reduce the reimbursement to the center by an amount,
as determined by the department for each placement, that is equal
to the nonfederal share of the costs for the placement under s.
46.275.
(6c) PREADMISSION SCREENING AND RESIDENT REVIEW. (a)
Definitions. In this subsection:
1. “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 selfdetermination 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.
2. “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 indivi

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