49.46(2)(a)3.

3. Rural health clinic services.

49.46(2)(a)4.

4. The following medical services if prescribed by a physician:

49.46(2)(b)1.c.

c. Restorative services.

49.46(2)(b)1.d.

d. Endodontic services.

49.46(2)(b)1.e.

e. Periodontic services.

49.46(2)(b)1.f.

f. Oral and maxillofacial surgery services.

49.46(2)(b)1.g.

g. Emergency treatment of dental pain.

49.46(2)(b)5.

5. Eyeglasses.

49.46(2)(b)6.b.

b. Physical and occupational therapy.

49.46(2)(b)6.c.

c. Speech, hearing and language disorder services.

49.46(2)(b)6.d.

d. Medical supplies and equipment.

49.46(2)(b)6.h.

h. Legend drugs, as listed in the Wisconsin medical assistance drug index.

49.46(2)(b)6.i.

i. Over-the-counter drugs listed by the department in the Wisconsin medical assistance drug index.

49.46(2)(b)6.k.

k. Alcohol and other drug abuse day treatment services.

49.46(2)(b)6.m.

m. Respiratory care services for ventilator-dependent individuals.

49.46(2)(b)10.

10. Hospice care as defined in 42 USC 1396d (o) (1).

49.46(2)(b)11.

11. Podiatrists’ services.

49.46(2)(b)12.

12. Care coordination for women with high-risk pregnancies.

49.46(2)(b)1.hm.

hm. Removable prosthodontic services.

49.46(2)(b)1.im.

im. Fixed prosthodontic services.

49.46(2)(b)2.

2. Optometrists’ or opticians’ services.

49.46(2)(b)4.

4. Chiropractors’ services.

49.46(2)(b)6.f.

f. Medical day treatment services, mental health services and alcohol and other drug abuse services, including services provided by a psychiatrist.

49.46(2)(b)6.g.

g. Nursing services, including services performed by a nurse practitioner, as defined in rules that the department shall promulgate.

49.46(2)(c)

(c)

49.46(2)(c)1.a.

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.

49.46(1)(c)2.a.

a. The family chooses to continue to receive medical assistance.

49.46(1)(c)2.c.

c. The family complies with reporting requirements established by the department by rule.

49.46

49.46 Medical assistance; recipients of social security aids.

49.46(1)

(1) Eligibility.

49.46(1)(a)

(a) The following shall receive medical assistance under this section:

49.46(1)(a)1.

1. Notwithstanding § 49.19 (20), any individual who, without regard to the individual’s resources, would qualify for a grant of aid to families with dependent children under § 49.19.

49.46(1)(a)3.

3. Any essential person.

49.46(1)(am)

(am)

49.46(1)(c)1.c.

c. The family complies with reporting requirements established by the department by rule.

49.46(1)(a)1g.

1g. Notwithstanding § 49.19 (20), any individual who, without regard to the individual’s resources, would qualify for a grant of aid to families with dependent children but who would not receive the aid solely because of the application of s. 49.19 (11) (a) 7.

49.46(1)(a)1m.

1m. Any pregnant woman whose income does not exceed the standard of need under § 49.19 (11) and whose pregnancy is medically verified. Eligibility continues to the last day of the month in which the 60th day after the last day of the pregnancy falls.

49.46(1)(a)4.

4. Any person receiving benefits under § 49.77 or federal Title XVI.

49.46(1)(a)4m.

4m. Any child for whom a payment is made under § 49.775.

49.46(1)(a)5.

5. Any child in an adoption assistance, foster care, or subsidized guardianship placement under ch. 48 or 938, as determined by the department.

49.46(1)(a)6.

6. Any person not described in pars. (c) to (e) who, without regard to the individual’s resources, would be considered, under federal law, to be receiving aid to families with dependent children for the purpose of determining eligibility for medical assistance.

49.46(1)(a)6m.

6m. Any person not described in pars. (c) to (e) who is considered, under federal law, to be receiving supplemental security income for the purpose of determining eligibility for medical assistance.

49.46(1)(a)9.

9. Any pregnant woman not described under subd. 1., 1g., or 1m. whose family income does not exceed 133% of the poverty line for a family the size of the woman’s family.

49.46(1)(a)10.

10. Any child not described under subd. 1. or 1g. who is under 6 years of age and whose family income does not exceed 133% of the poverty line for a family the size of the child’s family.

49.46(1)(a)11.

11. If a waiver under § 49.665 is granted and in effect, any child not described under subd. 1. or 1g. who has attained the age of 6 but has not attained the age of 19 and whose family income does not exceed 100% of the poverty line for a family the size of the child’s family. If a waiver under § 49.665 is not granted or in effect, any child not described in subd. 1. or 1g. who was born after September 30,1983, who has attained the age of 6 but has not attained the age of 19 and whose family income does not exceed 100% of the poverty line for a family the size of the child’s family.

49.46(1)(a)12.

12. Any child not described under subd. 1. or 1g. who is under 19 years of age and whose income does not exceed the standard of need under § 49.19 (11).

49.46(1)(a)13.

13. Any child who is under one year of age, whose mother was determined to be eligible under subd. 9. and who lives with his or her mother.

49.46(1)(a)14m.

14m. Any person who would meet the financial and other eligibility requirements for home or community-based services under the family care benefit but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3), if a waiver under § 46.281 (1d) is in effect or federal law permits federal financial participation for medical assistance coverage of the person and if funding is available for the person under the family care benefit.

49.46(1)(a)14.

14. Any person who would meet the financial and other eligibility requirements for home or community-based services under § 46.27 (11), 46.277, or 46.2785 but for the fact that the person engages in substantial gainful activity under 42 USC 1382c (a) (3), if a waiver under § 49.45 (38) is in effect or federal law permits federal financial participation for medical assistance coverage of the person and if funding is available for the person under § 46.27 (11), 46.277, or 46.2785.

49.46(1)(a)15.

15. Any individual who is infected with tuberculosis and meets the income and resource eligibility requirements for the federal Supplemental Security Income program under 42 USC 1381 to 1383d.

49.46(1)(a)16.

16. Any child who is living with a relative who is eligible to receive payments under § 48.57 (3m) or (3n) with respect to that child, if the department determines that no other insurance is available to the child.

49.46(1)(am)1.

1. If the change requested under subd. 2. in the approved state plan for services under 42 USC 1396 is approved by the federal department of health and human services, the department shall disregard income from the following individuals, in an amount sufficient for the individual to become eligible for medical assistance under this section:

49.46(1)(am)1.a.

a. A pregnant woman whose family income, before any income is disregarded under this paragraph, does not exceed, in state fiscal year 1994-95, 155% of the poverty line for a family the size of the woman’s family; and, in each state fiscal year after the 1994-95 state fiscal year, 185% of the poverty line for a family the size of the woman’s family.

49.46(1)(am)1.b.

b. A child who is under 6 years of age and whose family income, before any income is disregarded under this paragraph, does not exceed, in state fiscal year 1994-95, 155% of the poverty line for a family the size of the child’s family; and, in each state fiscal year after the 1994-95 state fiscal year, 185% of the poverty line for a family the size of the child’s family.

49.46(1)(am)1.c.

c. A child who is under one year of age, whose mother was determined to be eligible under subd. 1. a. and who lives with his or her mother.

49.46(1)(am)2.

2. The department shall request a change in the approved state plan for services under 42 USC 1396 to allow, pursuant to the authority granted under 42 USC 1396a (r) (2), the use of federal matching funds to provide medical assistance coverage to individuals under subd. 1., beginning on July 1, 1994.

49.46(1)(b)

(b) Any person shall be considered a recipient of aid for 3 months prior to the month of application if the proper agency determines eligibility existed during such prior month.

49.46(1)(c)

(c) Except as provided under para. (co), a family that becomes ineligible for aid to families with dependent children under § 49.19 because of increased income from employment or increased hours of employment or because of the expiration of the time during which the disregards under s. 49.19 (5) (a) 4. or 4m. or (am) apply shall receive medical assistance for:

49.46(1)(c)1.

1. Six calendar months following the month in which the family becomes ineligible for aid to families with dependent children if all of the following apply:

49.46(1)(c)1.a.

a. The family is eligible for aid to families with dependent children for at least 3 of the 6 months immediately preceding the month in which the family becomes ineligible.

49.46(1)(c)1.b.

b. The family continues to include a child who is, or would be if needy, a dependent child under § 49.19.

49.46(1)(c)2.

2. Six calendar months following the 6 months under subd. 1. if all of the following apply:

49.46(1)(c)2.b.

b. The family continues to include a child who is, or would be if needy, a dependent child under § 49.19.

49.46(1)(c)2.d.

d. The caretaker relative has earnings in each month of the period unless the caretaker lacks earnings because of illness, involuntary loss of employment or other good cause as determined by the department.

49.46(1)(c)2.e.

e. The family’s average gross monthly earnings, less the cost of child care necessary for the employment of the caretaker relative, during the immediately preceding 3-month period do not exceed 185% of the poverty line for a family the size of the family.

49.46(1)(cg)

(cg) Medical assistance shall be provided to a dependent child, a relative with whom the child is living or the spouse of the relative, if the spouse meets the requirements of s. 49.19 (1) (c) 2. a. or b., for 4 calendar months beginning with the month in which the child, relative or spouse is ineligible for aid to families with dependent children because of the collection or increased collection of maintenance or support, if the child, relative or spouse received aid to families with dependent children in 3 or more of the 6 months immediately preceding the month in which that ineligibility begins.

49.46(1)(co)

(co)

49.46(1)(co)1.

1. Except as provided under subd. 2., medical assistance shall be provided to a family for 12 consecutive calendar months following the month in which the family becomes ineligible for aid to families with dependent children because of increased income from employment, because the family no longer receives the earned income disregard under s. 49.19 (5) (a) 4. or 4m. or (am) due to the expiration of the time limit during which the disregards are applied or because of the application of the monthly employment time eligibility limitation under 45 CFR 233.100 (a) (1) (i).

49.46(1)(co)2.

2. If a waiver under subd. 3. is granted, the department may select individuals to receive medical assistance benefits as provided under para. (c), rather than under subd. 1., as a control group for part or all of the period during which the waiver is in effect.

49.46(1)(d)

(d) For the purposes of this section:

49.46(1)(d)1.

1. Children who are placed in licensed foster homes by the department and who would be eligible for payment of aid to families with dependent children in foster homes except that their placement is not made by a county department under § 46.215, 46.22, or 46.23 will be considered as recipients of aid to families with dependent children.

49.46(1)(k)

(k)

49.46(1)(m)

(m)

49.46(1)(co)3.

3. The department shall request a waiver from the secretary of the federal department of health and human services to permit the extension of medical assistance benefits under subds. 1. and 2. Subdivision 1. does not apply unless a federal waiver is in effect. If a waiver is received, the department shall implement subds. 1. and 2. no later than the first day of the 6th month beginning after the waiver is approved.

49.46(1)(d)2.

2. Any accommodated person or any patient in a public medical institution shall be considered a recipient for purposes of this section if such person or patient would have inadequate means to meet his or her need for care and services if living in his or her usual living arrangement.

49.46(1)(d)3.

3. Any child adopted under § 48.48 (12) shall be considered a recipient for any medical condition which exists at the time of the adoption or develops subsequent to the adoption.

49.46(1)(d)4.

4. A child who meets the conditions under 42 USC 1396a (e) (3) shall be considered a recipient of benefits under § 49.77 or federal Title XVI.

49.46(1)(j)

(j) An individual determined to be eligible for benefits under par. (a) 9. remains eligible for benefits under par. (a) 9. for the balance of the pregnancy and to the last day of the month in which the 60th day after the last day of the pregnancy falls without regard to any change in the individual’s family income.

49.46(1)(k)1.

1. If a child eligible for benefits under par. (a) 10. is receiving inpatient services covered under sub. (2) on the day before the birthday on which the child attains the age of 6 and, but for attaining that age, the child would remain eligible for benefits under par. (a) 10., the child remains eligible for benefits until the end of the stay for which the inpatient services are furnished.

49.46(1)(e)

(e) If an application under § 49.47 (3) shows that the individual meets the income limits under § 49.19 or meets the income and resource requirements under federal Title XVI or § 49.77, or that the individual is an essential person, an accommodated person, or a patient in a public medical institution, the individual shall be granted the benefits enumerated under sub. (2) whether or not the individual requests or receives a grant of any of such aids.

49.46(2)(b)6.Lo.

Lo. Subject to the limitations under § 49.45 (30g), community recovery services.

49.46(2)(b)6.Lr.

Lr. Psychotherapy and alcohol and other drug abuse services, as specified under § 49.45 (30f).

49.46(2)(b)8.

8. Home or community-based services, if provided under § 46.27 (11), 46.275, 46.277, 46.278, 46.2785, 46.99, or under the family care benefit if a waiver is in effect under § 46.281 (1d), or under the disabled children’s long-term support program, as defined in § 46.011 (1g).

49.46(2)(b)9.

9. Case management services, as specified under § 49.45 (24) or (25).

49.46(1)(k)2.

2. If a child eligible for benefits under par. (a) 11. is receiving inpatient services covered under sub. (2) on the day before the birthday on which the child attains the age of 19 and, but for attaining that age, the child would remain eligible for benefits under par. (a) 11., the child remains eligible for benefits until the end of the stay for which the inpatient services are furnished.

49.46(2)(b)12m.

12m. Prenatal, postpartum and young child care coordination services under § 49.45 (44).

49.46(2)(b)13.

13. Care coordination and follow-up, including lead investigations, as defined in § 254.11 (8s), of persons having lead poisoning or lead exposure, as defined in § 254.11 (9).

49.46(2)(b)14.

14. School medical services under § 49.45 (39).

49.46(2)(b)15.

15. Mental health crisis intervention services under § 49.45 (41).

49.46(2)(b)16.

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 § 49.45 (43).

49.46(2)(b)17.

17. Services under § 49.45 (54)(b) for children participating in the early intervention program under § 51.44, that are provided by a special educator.

49.46(2)(b)18.

18. Care coordination, as specified under § 49.45 (25g).

49.46(1)(L)

(L) For the purposes of par. (a) 9. to 12., “income” includes income that would be used in determining eligibility for aid to families with dependent children under § 49.19, except to the extent that that determination is inconsistent with 42 USC 1396a (a) 17., and excludes income that would be excluded in determining eligibility for aid to families with dependent children under § 49.19. For the purposes of para. (am), “income” shall be determined in accordance with the approved state plan for services under 42 USC 1396.

49.46(2)(be)

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

49.46(2)(bm)

(bm) 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).

49.46(2)(c)1.

1. In this paragraph and para. (cm):

49.46(2)(c)5.

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.

49.46(1)(m)1.

1. Except as provided in subd. 2., any individual who is otherwise eligible under this subsection and who is eligible for enrollment in a group health plan shall, as a condition of eligibility for medical assistance and if the department determines it is cost-effective to do so, apply for enrollment in the group health plan, except that, for a minor, the parent of the minor shall apply on the minor’s behalf.

49.46(1)(m)2.

2. If a parent of a minor fails to enroll the minor in a group health plan in accordance with subd. 1., the failure does not affect the minor’s eligibility under this subsection.

49.46(1)(n)

(n) If the department creates a policy under s. 49.45 (2m) (c) 8., 9., or 10., this subsection does not apply to the extent that it conflicts with the policy.

49.46(1m)

(1m) Pilot project for working recipients of supplemental security income or social security disability income. The department shall request that the secretary of the federal department of health and human services and the commissioner of the federal social security administration waive the income and asset requirements for recipients of benefits under federal Title II or XVI to allow the department to conduct a pilot project to allow those recipients to work without losing eligibility for benefits under federal Title II or XVI or for medical assistance or medicare, as defined in s. 49.45 (3) (L) 1. b. If the request is approved, the department may implement the program and may require participants in the program to pay, on a sliding scale, a copayment for the cost of the program.

49.46(1p)

(1p) Demonstration project for persons with HIV. The department shall request a waiver from the secretary of the federal department of health and human services to allow the department to provide under this section coverage of services specified under sub. (2) for persons who have HIV infection, as defined in § 252.01 (2). If a waiver is granted and in effect, the department shall provide coverage for the services specified under sub. (2) for persons who qualify under the terms of the waiver.

49.46(2)

(2) Benefits.

49.46(2)(a)

(a) Except as provided in para. (be) and unless otherwise provided by the department by a policy created under § 49.45 (2m)(c), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits:

49.46(2)(a)1.

1. Physicians’ services, excluding services provided under par. (b) 6. f.

49.46(2)(c)2.

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.

49.46(2)(c)3.

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.

49.46(2)(c)5m.

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.

49.46(2)(cm)1.

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.

49.46(2)(a)2.

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.

49.46(2)(c)4.

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.

49.46(2)(cm)2.

2. Benefits under subd. 1. are available for an individual whose income is greater than 100% of the poverty line but less than 120% of the poverty line.

49.46(2)(d)

(d) 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.

49.46(2)(dc)

(dc) 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.

49.46(2)(dm)

(dm) 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.

49.46(2)(f)

(f) 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.

49.46(2)(a)4.a.

a. Inpatient hospital services other than services in an institution for mental diseases, including psychiatric and alcohol or other drug abuse treatment services.

49.46(2)(a)4.b.

b. Services specified in this paragraph, provided by any hospital on an outpatient basis.

49.46(2)(a)4.c.

c. Skilled nursing home services other than in an institution for mental diseases, except as limited under § 49.45 (6c) and (30m) (b) and (c).

49.46(2)(a)4.d.

d. Home health services, subject to the limitation under § 49.45 (8), or, if a home health agency is unavailable,