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Terms Used In Wisconsin Statutes 49.46

  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Dependent: A person dependent for support upon another.
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • Following: when used by way of reference to any statute section, means the section next following that in which the reference is made. See Wisconsin Statutes 990.01
  • Minor: means a person who has not attained the age of 18 years, except that for purposes of investigating or prosecuting a person who is alleged to have violated a state or federal criminal law or any civil law or municipal ordinance, "minor" does not include a person who has attained the age of 17 years. See Wisconsin Statutes 990.01
  • Month: means a calendar month unless otherwise expressed. See Wisconsin Statutes 990.01
  • Person: includes all partnerships, associations and bodies politic or corporate. See Wisconsin Statutes 990.01
  • Population: means that shown by the most recent regular or special federal census. See Wisconsin Statutes 990.01
  • Preceding: when used by way of reference to any statute section, means the section next preceding that in which the reference is made. See Wisconsin Statutes 990.01
  • Promulgate: when used in connection with a rule, as defined under…. See Wisconsin Statutes 990.01
  • State: when applied to states of the United States, includes the District of Columbia, the commonwealth of Puerto Rico and the several territories organized by Congress. See Wisconsin Statutes 990.01
  • Week: means 7 consecutive days. See Wisconsin Statutes 990.01
  • Year: means a calendar year, unless otherwise expressed; "year" alone means "year of our Lord". See Wisconsin Statutes 990.01
   (1)    Eligibility.
      (a)    The following shall receive medical assistance under this section:
         1.    Notwithstanding s. 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 s. 49.19.
         1g.    Notwithstanding s. 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) (f).
         1m.    Any pregnant woman whose income does not exceed the standard of need under s. 49.19 (11) and whose pregnancy is medically verified. Eligibility continues to the last day of the month in which the 60th day or, if approved by the federal government, the 90th day after the last day of the pregnancy falls.
         3.    Any essential person.
         4.    Any person receiving benefits under s. 49.77 or federal Title XVI.
         4m.    Any child for whom a payment is made under s. 49.775.
         5.    Any child in an adoption assistance, foster care, or subsidized guardianship placement under ch. 48 or 938, as determined by the department.
         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.
         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.
         9.    Any pregnant woman not described under subd. 1., 1g., or 1m. whose family income does not exceed 133 percent of the poverty line for a family the size of the woman’s family.
         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 percent of the poverty line for a family the size of the child’s family.
         11.    If a waiver under s. 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 percent of the poverty line for a family the size of the child’s family. If a waiver under s. 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 percent of the poverty line for a family the size of the child’s family.
         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 s. 49.19 (11).
         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.
         14.    Any person who would meet the financial and other eligibility requirements for home or community-based services under s. 46.277 or 46.2785 but for the fact that the person engages in substantial gainful activity under 42 U.S. Code § 1382c (a) (3), if a waiver under s. 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 s. 46.277 or 46.2785.
         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 U.S. Code § 1382c (a) (3), if a waiver under s. 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.
         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 U.S. Code § 1381 to 1383d. For purposes of this subdivision, “income” has the meaning given for “family income” in s. 49.471 (1) (f).
         16.    Any child who is living with a relative who is eligible to receive payments under s. 48.57 (3m) or (3n) with respect to that child, if the department determines that no other insurance is available to the child.
      (am)   
         1.    If the change requested under subd. 2. in the approved state plan for services under 42 U.S. Code § 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:
            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 percent 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 percent of the poverty line for a family the size of the woman’s family.
            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 percent 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 percent of the poverty line for a family the size of the child’s family.
            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.
         2.    The department shall request a change in the approved state plan for services under 42 U.S. Code § 1396 to allow, pursuant to the authority granted under 42 U.S. Code § 1396a (r) (2), the use of federal matching funds to provide medical assistance coverage to individuals under subd. 1., beginning on July 1, 1994.
      (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.
      (c)    Except as provided under par. (cr), a family that becomes ineligible for aid to families with dependent children under s. 49.19 because of increased income from employment or increased hours of employment shall receive medical assistance for 4 calendar months, or, if required under federal law, up to 12 months, following the month in which a parent, caretaker, or dependent child of the family becomes ineligible for aid to families with dependent children if all of the following apply:
         1g.    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.
         1r.    The family continues to include a child who is, or would be if needy, a dependent child under s. 49.19.
      (cg)    Except as provided under par. (cr), 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.
      (cr)    To the extent approved by the federal department of health and human services, an individual or family described in par. (c) or (cg) is not eligible for Medical Assistance if the federal department of health and human services approves a request from the department to deny all or some transitional Medical Assistance benefits to that individual or family, if approval is required. The department shall allow individuals who are receiving transitional Medical Assistance benefits on December 31, 2013, to continue to receive those benefits until their 12-month period ends, if required under federal law. If the federal department of health and human services approves the department’s request to charge a premium to recipients of continued transitional Medical Assistance benefits, the department may charge a premium to any recipient of continued transitional Medical Assistance benefits whose income exceeds 100 percent of the poverty line.
      (d)    For the purposes of this section:
         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 s. 46.215, 46.22, or 46.23 will be considered as recipients of aid to families with dependent children.
         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.
         3.    Any child adopted under s. 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.
         4.    A child who meets the conditions under 42 U.S. Code § 1396a (e) (3) shall be considered a recipient of benefits under s. 49.77 or federal Title XVI.
      (e)    If an application under s. 49.47 (3) shows that the individual meets the income limits under s. 49.19 or meets the income and resource requirements under federal Title XVI or s. 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.
      (em)    To the extent approved by the federal government, for the purposes of determining financial eligibility and any cost-sharing requirements of an individual under par. (a) 6m., 14., or 14m., (d) 2., or (e), the department or its designee shall exclude any assets accumulated in a person’s independence account, as defined in s. 49.472 (1) (c), and any income or assets from retirement benefits earned or accumulated from income or employer contributions while employed and receiving medical assistance under s. 49.472.
      (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 or, if approved by the federal government, the 90th day after the last day of the pregnancy falls without regard to any change in the individual’s family income.
      (k)   
         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.
         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.
      (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 s. 49.19, except to the extent that that determination is inconsistent with 42 U.S. Code § 1396a (a) 17., and excludes income that would be excluded in determining eligibility for aid to families with dependent children under s. 49.19. For the purposes of par. (am), “income” shall be determined in accordance with the approved state plan for services under 42 U.S. Code § 1396.
      (m)   
         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.
         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.
   (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.
   (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 s. 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.
   (2)   Benefits.
      (a)    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.
      (b)    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.
         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.
         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 U.S. Code § 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).
         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).
      (bc)    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).
      (be)    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.
      (bh)    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.
      (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 U.S. Code § 1396a (z) (2).
      (br)    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.
      (bt)   
         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.
      (c)   
         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 U.S. Code § 1395c to 1395f.
            b.    “Entitled to coverage under part B of medicare” means eligible for and enrolled in part B of medicare under 42 U.S. Code § 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 U.S. Code § 1395 to 1395zz that are not paid under 42 U.S. Code § 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 U.S. Code § 1396; the monthly premiums payable under 42 U.S. Code § 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 U.S. Code § 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 U.S. Code § 1395 to 1395i that are not paid under 42 U.S. Code § 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 U.S. Code § 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 U.S. Code § 1395 to 1395zz that are not paid under 42 U.S. Code § 1395 to 1395zz, including those Medicare services that are not included in the approved state plan for services under 42 U.S. Code § 1396. Payment of coinsurance for a service under Part B of Medicare under 42 U.S. Code § 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 U.S. Code § 1395 to 1395i that are not paid under 42 U.S. Code § 1395 to 1395i, including those Medicare services that are not included in the approved state plan for services under 42 U.S. Code § 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 U.S. Code § 1395j to 1395w, including those Medicare services that are not included in the approved state plan for services under 42 U.S. Code § 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 U.S. Code § 9902 (2).
      (cm)   
         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 U.S. Code § 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.
      (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 U.S. Code § 291c (e), in effect on April 30, 1980, or relief funded by a relief block grant.
      (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 C.F.R. 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 C.F.R. 423.4, covers the Part D drug.
      (dm)    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.
      (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.

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