Benefits.

Except as provided in par. (be), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits: 1. Physicians’ services, excluding services provided under par. (b) 6. f. 2. Early and periodic screening and diagnosis, including case management services, of persons under 21 years of age and all medical treatment and dentists’ services found necessary by this screening and diagnosis. 3. Rural health clinic services. 4. The following medical services if prescribed or ordered by a provider acting within the scope of the provider’s practice under statutes, rules, or regulations that govern the provider’s practice: a. Inpatient hospital services other than services in an institution for mental diseases, including psychiatric and alcohol or other drug abuse treatment services. b. Services specified in this paragraph, provided by any hospital on an outpatient basis. c. Skilled nursing home services other than in an institution for mental diseases, except as limited under s. 49.45 (6c) and (30m) (b) and (c). d. Home health services, subject to the limitation under s. 49.45 (8), or, if a home health agency is unavailable, nursing services. e. Laboratory and X-ray services. f. Services and supplies for family planning, as defined in s. 253.07 (1) (a). 4m. Nurse-midwifery services. 6. Premiums, deductibles and coinsurance and other cost-sharing obligations for items and services otherwise paid under this subsection that are required for enrollment in a group health plan, as specified in sub. (1) (m), except that, if enrollment in the group health plan requires enrollment of family members who are not eligible under this subsection, the department shall pay, if it is cost-effective, for an ineligible family member only the premium that is required for enrollment in the group health plan.

Except as provided in pars. (be) and (dc), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services: 1. Dentists’ services, limited to basic services within each of the following categories: a. Diagnostic services. b. Preventive services. c. Restorative services. d. Endodontic services. e. Periodontic services. f. Oral and maxillofacial surgery services. g. Emergency treatment of dental pain. hm. Removable prosthodontic services. im. Fixed prosthodontic services. 2. Optometrists’ or opticians’ services. 3. Transportation by emergency medical vehicle to obtain emergency medical care, transportation by specialized medical vehicle to obtain medical care including the unloaded travel of the specialized medical vehicle necessary to provide that transportation, or transportation by common carrier or private motor vehicle to obtain medical care. 4. Chiropractors’ services, subject to par. (bj). 5. Eyeglasses. 6. The following services that, other than under subd. 6. f., fm., k., and Lr., are prescribed or ordered by a provider acting within the scope of the provider’s practice under statutes, rules, or regulations that govern the provider’s practice: a. Intermediate care facility services other than in an institution for mental diseases, except as limited under s. 49.45 (30m) (b) and (c). b. Physical and occupational therapy. c. Speech, hearing and language disorder services. d. Medical supplies and equipment. dm. Subject to the requirements under s. 49.45 (9r), durable medical equipment that is considered complex rehabilitation technology, excluding speech generating devices. e. Subject to the limitation under s. 49.45 (30r), inpatient hospital, skilled nursing facility and intermediate care facility services for patients of any institution for mental diseases who are under 21 years of age, are under 22 years of age and who were receiving these services immediately prior to reaching age 21, are 65 years of age or older, or are otherwise permitted under s. 49.45 (53m). f. Medical day treatment services, mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist. fm. Subject to the limitations under s. 49.45 (45), mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist, to an individual who is 21 years of age or older in the individual’s home or in the community. g. Nursing services as defined in rules that the department shall promulgate. h. Legend drugs, as listed in the Wisconsin medical assistance drug index. i. Over-the-counter drugs listed by the department in the Wisconsin medical assistance drug index. j. Personal care services, subject to the limitation under s. 49.45 (42). k. Alcohol and other drug abuse day treatment services. L. Mental health and psychosocial rehabilitative services, including case management services, provided by the staff of a community support program certified under s. 49.45 (2) (a) 11. Lm. Subject to the limitations under s. 49.45 (30e), psychosocial services, including case management services, provided by the staff of a community-based psychosocial service program. Lo. Subject to the limitations under s. 49.45 (30g), community recovery services. Lr. Psychotherapy and alcohol and other drug abuse services, as specified under s. 49.45 (30f). m. Respiratory care services for ventilator-dependent individuals. n. Breast screenings for which coverage is required under s. 632.895 (8) (am). 8. Home or community-based services, if provided under s. 46.275, 46.277, 46.278, 46.2785, 46.99, or under the family care benefit if a waiver is in effect under s. 46.281 (1d), or under the disabled children’s long-term support program, as defined in s. 46.011 (1g). 9. Case management services, as specified under s. 49.45 (24) or (25). 10. Hospice care as defined in 42 USC 1396d (o) (1). 11. Podiatrists’ services. 12. Care coordination for women with high-risk pregnancies. 12m. Prenatal, postpartum and young child care coordination services under s. 49.45 (44). 12t. Subject to the limitations under s. 49.45 (30x), licensed midwife services provided by a certified professional midwife licensed under s. 440.982. 13. Care coordination and follow-up, including lead investigations, as defined in s. 254.11 (8s), of persons having lead poisoning or lead exposure, as defined in s. 254.11 (9). 14. School medical services under s. 49.45 (39). 14c. Subject to par. (bv), services by a psychiatric residential treatment facility. 14m. Subject to par. (bt), substance abuse treatment services provided by a medically monitored treatment service or a transitional residential treatment service. 14p. Subject to s. 49.45 (30j), services provided by a peer recovery coach. 15. Crisis intervention services under s. 49.45 (41). 16. Case management services for recipients with high-cost chronic health conditions or high-cost catastrophic health conditions, if the department operates a program under s. 49.45 (43). 17. Services under s. 49.45 (54) (c) for children participating in the early intervention program under s. 51.44. 18. Care coordination, as specified under s. 49.45 (25g). 19. Subject to par. (br), services provided by early intervention teachers, home trainers, parent-to-parent mentors, and developmental specialists to children in the benchmark plan under par. (br). 20. Subject to s. 49.45 (24j), any additional services, as determined by the department, that are targeted to a population enrolled in a medical home initiative under s. 49.45 (24j). 21. Subject to s. 49.45 (61), consultations between providers conducted through interactive telehealth described under s. 49.45 (61) (c) 1. 22. Subject to s. 49.45 (61), asynchronous telehealth services and remote patient monitoring described under s. 49.45 (61) (c) 2. 23. Subject to s. 49.45 (61), services described under s. 49.45 (61) (c) 3. that are provided through communication technology and that are covered under the federal Medicare program and any telehealth services that the department specifies by rule under s. 49.45 (61) (d).

Subject to s. 49.45 (24j), the department may provide any of the services described in par. (a) or (b) through a medical home initiative under s. 49.45 (24j).

Benefits for an individual eligible under sub. (1) (a) 9. are limited to those services under par. (a) or (b) that are related to pregnancy, including postpartum services and family planning services, as defined in s. 253.07 (1) (b), or related to other conditions which may complicate pregnancy.

The department shall provide reimbursement for services that are reimbursable under this section and that are provided by a licensed pharmacist within the scope of his or her license or are services performed under s. 450.033. If the department determines it is unable to implement this paragraph without a state plan amendment or waiver of federal law, the department shall submit to the federal department of health and human services any necessary state plan amendment or waiver of federal law necessary to implement this paragraph. If the federal government disapproves the amendment or waiver request, the department is not required to implement this paragraph.

1. The department shall provide reimbursement for services that are reimbursable under this section and that are provided by a chiropractor who is licensed under ch. 446 and is acting within the scope of his or her license. If the department determines that it is unable to implement this paragraph without a state plan amendment or waiver of federal law, the department shall submit to the federal department of health and human services any state plan amendment or waiver of federal law necessary to implement this paragraph. 2. If the federal government approves the amendment or waiver request under subd. 1., the department shall implement this paragraph. If the federal government approves the amendment or waiver request under subd. 1. in part, the department shall implement this paragraph to the greatest extent approved by the federal government. If the federal government disapproves the amendment or waiver request under subd. 1., the department is not required to implement this paragraph.

Benefits for an individual who is eligible for medical assistance only under sub. (1) (a) 15. are limited to those services related to tuberculosis that are described in 42 USC 1396a (z) (2).

If the federal department of health and human services approves the department’s request to offer a benchmark plan under this paragraph, the department may enroll any child who is receiving services through the early intervention program under s. 51.44 in a benchmark plan under this paragraph. The department may not require a child who is receiving services through the early intervention program under s. 51.44 to enroll in a benchmark plan offered under this paragraph. The department may not charge a copayment to a child who is enrolled in the benchmark plan under this paragraph for services described in par. (b) 19.

1. For the purposes of par. (b) 14m., a “medically monitored treatment service” is a 24-hour, community-based service providing observation, monitoring, and treatment by a multidisciplinary team under supervision of a physician, with a minimum of 12 hours of counseling provided per week for each patient. 2. For the purposes of par. (b) 14m., a “transitional residential treatment service” is a clinically supervised, peer-supported, therapeutic environment with clinical involvement providing substance abuse treatment in the form of counseling for 3 to 11 hours provided per week for each patient. 3. If approval by the federal department of health and human services of a state plan amendment or waiver request is necessary for federal reimbursement of the services under par. (b) 14m., the department is not required to pay for services described in par. (b) 14m. if the department does not receive the necessary approval. 4. The department may not provide reimbursement for services under par. (b) 14m. that are provided before July 1, 2016, or before the date of approval of the state plan amendment or waiver request described under subd. 3., whichever is later.

The department shall submit to the federal department of health and human services any request for a state plan amendment, waiver, or other federal approval necessary to provide reimbursement for services by a psychiatric residential treatment facility. If the federal department of health and human services approves the request or if no federal approval is necessary, the department shall provide reimbursement under par. (b) 14c. If the federal department of health and human services disapproves the request, the department may not provide reimbursement for services under par. (b) 14c.

1. In this paragraph and par. (cm): a. “Entitled to coverage under part A of medicare” means eligible for and enrolled in part A of medicare under 42 USC 1395c to 1395f. b. “Entitled to coverage under part B of medicare” means eligible for and enrolled in part B of medicare under 42 USC 1395j to 1395L. 2. For 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. (1), and meets the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment. 3. For an individual who is only entitled to coverage under Part A of Medicare, meets the eligibility criteria under sub. (1), and meets the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that 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. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment. 4. For 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. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395zz that 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 and payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment. 5. For an individual who is only entitled to coverage under Part A of Medicare and meets the eligibility criteria for Medical Assistance under sub. (1), but does not meet the limitation on income under subd. 6., Medical Assistance shall include payment of the deductible and coinsurance portions of Medicare services under 42 USC 1395 to 1395i that 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. Payment of deductibles and coinsurance for inpatient hospital services under Part A of Medicare may not exceed the allowable charge for the service under Medical Assistance minus the Medicare payment. 5m. For an individual who is only entitled to coverage under Part B of Medicare and meets the eligibility criteria under sub. (1), but does not meet the limitation on income under subd. 6., 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. 6. The income limitation under this paragraph is income that is equal to or less than 100 percent of the poverty line, as established under 42 USC 9902 (2).

1. Beginning on January 1, 1993, for an individual who is entitled to coverage under part A of medicare, is entitled to coverage under part B of medicare, meets the eligibility criteria under sub. (1) and meets the limitation on income under subd. 2., medical assistance shall pay the monthly premiums under 42 USC 1395r. 2. Benefits under subd. 1. are available for an individual whose income is greater than 100 percent of the poverty line but less than 120 percent of the poverty line.

Benefits authorized under this subsection may not include payment for that part of any service payable through 3rd-party liability or any federal, state, county, municipal or private benefit system to which the beneficiary is entitled. “Benefit system” does not include any public assistance program such as, but not limited to, Hill-Burton benefits under 42 USC 291c (e), in effect on April 30, 1980, or relief funded by a relief block grant.

For an individual who is eligible for medical assistance and who is eligible for coverage under Part D of Medicare under 42 USC 1395w-101 et seq., benefits under par. (b) 6. h. do not include payment for any Part D drug, as defined in 42 CFR 423.100, regardless of whether the individual is enrolled in Part D of Medicare or whether, if the individual is enrolled, his or her Part D plan, as defined in 42 CFR 423.4, covers the Part D drug.

Except as provided under s. 49.45 (53m), benefits under this section may not include payment for 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 paragraph, the department shall define “convalescent leave” and “conditional release” by rule.

Benefits under this subsection may not include payment for gastric bypass surgery or gastric stapling surgery unless it is performed because of a medical emergency.