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Medical assistance; administration – Wis. Stat. Ann. § 49.45

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Medical Assistance; Administration

This law sets forth the detailed instructions to the Department of Health Services on running the state's Medical Assistance Program. This law requires that DHS run the program in a fiscally responsible manner, while employing the right personnel and properly determining person's eligibility for assistance under the program.  The law further requires that DHS cooperate with federal authorities, periodically report financial details, handle reimbursement and promulgate necessary rules for carrying out the program. The law allows DHS to contract with organization to administer the benefits under the program and to demand audits for all claims filed by contractors and providers.


The law sets forth certain detailed requirements for (non-exclusive list):

  • Reports on the program and its finances
  • Payment – reimbursements to county departments, contractors, service provides, prohibitions on reimbursement, methods for reimbursement, use of money collected
  • Use or disclosure of information – disclosure of information about applicants or recipients is only allowed when connected with administration of medical assistance program
  • Financial Record Matching Program (for the purpose of verifying the assets of applicants and recipients) – prohibition on the use of information by financial institution participating in this program for any purpose other than to match records, prohibition of use of information by DHS except for purpose of matching records to determine eligibility
  • Appeals – how to handle appeals from any person whose application for medical assistance is denied, or who wants to dispute the payments made
  • Supplemental funding and payments for rural hospitals, centers for the developmentally disabled (preadmission screening and resident review), uncompensated care, care management organizations, essential access city hospitals, hospitals serving low income patients, certain OB/GYN care
  • Payment to facilities such as nursing homes or community-based residential facility certified as a provider of medical assistance
  • DHS's reporting responsibilities
  • Handling the personal funds of a patient who is in a facility
  • Payment to pharmacies
  • Limits on recipient's free choice of medical services
  • Prohibition on requiring prior authorization for wheelchair repair
  • DHS's rulemaking abilities
  • Establishing and maintaining a health insurance identification card system
  • DHS's ability to ask service providers for financial reports
  • DHS's certification of medical assistance providers
  • Cost sharing by the resident
  • HIV care coordination
  • Mental health services
  • Community-based services
  • Creation of a medical assistance manual
  • Computer system redesign to help with determining eligibility
  • Benefits for aliens and the homeless
  • Services in schools
  • Maternal and young child care
  • Prescription drug authorization, costs and purchase agreements

HMO payments to hospitals.

Current as of June 2015