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2023 - 2024 LEGISLATURE
2023 ASSEMBLY BILL 1087
February 13, 2024 - Introduced by Representatives SNYDER, ROZAR, KURTZ and
SUMMERFIELD, cosponsored by Senator CABRAL-GUEVARA. Referred to
Committee on Family Law.
***AUTHORS SUBJECT TO CHANGE***
AN ACT to create 49.45 (3n) and 49.45 (6r) of the statutes; relating to:
supplemental payments to hospitals with avoidable patient days and an
enhanced rate to nursing homes for bariatric and extensive wound care under
the Medical Assistance program.
Analysis by the Legislative Reference Bureau
This bill requires the Department of Health Services, at the beginning of each
quarter starting with the quarter that begins on July 1, 2024, and ending with the
quarter that begins on April 1, 2025, to provide a supplemental payment under the
Medical Assistance program to hospitals that have qualifying avoidable patient
days. Under the bill, a qualifying avoidable patient day means any day following the
seventh consecutive day on which a high-acuity patient was eligible for discharge
from a hospital, as reasonably identified by the hospital, and the hospital was not
able to identify a setting to which the patient could be safely discharged. The Medical
Assistance program is a joint federal and state program that provides health services
to individuals who have limited financial resources.
Under the bill, in each quarter during the period described in the bill, DHS
must distribute a total of $5,000,000 plus any matching federal funds to hospitals
that have qualifying avoidable patient days. The bill provides that DHS must pay
to each of these hospitals a percentage of the total distribution that equals the
hospital's percentage of the total number of qualifying avoidable patient days
reported by all hospitals for the applicable quarterly reporting period. The bill
requires that DHS limit the maximum amount of funding to any hospital under the
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ASSEMBLY BILL 1087
bill in accordance with any federal rules concerning hospital-specific funding limits.
The bill provides that in order to receive a portion of the quarterly supplemental
funding that DHS distributes each quarter, a hospital must submit, by a specific
deadline, the total number of qualifying avoidable patient days at the hospital for the
relevant period.
The bill requires DHS to submit any necessary request to the federal
Department of Health and Human Services for a state plan amendment or waiver
of federal Medicaid law to receive federal matching funds for the supplemental
payments to hospitals under the bill. The bill also provides that DHS must
implement the supplemental payments regardless of whether federal approval is
received.
The bill also requires DHS, during the 2023-25 fiscal biennium, to develop an
enhanced rate for reimbursement under the Medical Assistance program for
bariatric and extensive wound care needs for nursing home residents who are
admitted on or after July 1, 2024. Under the bill, the calculated cost of the enhanced
rate developed by the department may not exceed $10,000,000. The bill provides that
once DHS has developed an enhanced rate, DHS must implement that rate. Under
the bill, in seeking reimbursement under any enhanced rate implemented, a nursing
home may claim only one enhanced rate type for a resident and may not claim both
a bariatric care needs enhanced reimbursement rate and an extensive wound care
enhanced reimbursement rate for the same resident at the same time.
The bill requires that DHS apply certain standards with respect to the
enhanced rates developed. For the bariatric care needs enhanced rate, a nursing
home must identify bariatric care needs by a minimum data set assessment at
admission indicating a body mass index equal to or greater than 40 and total or
extensive assistance with activities of daily living. The bariatric care needs
enhanced rate applicable for a resident must be available for the duration of the
resident's stay at the nursing home. Under the bill, an enhanced rate for bariatric
care needs may be used to provide reimbursement for specialized mattresses, diets,
medical supplies, extra staff for transfers, as well as more expensive or specialized
transportation services. Finally, the enhanced rate for bariatric care needs may only
be applicable if the resident is admitted to the nursing home directly from a hospital;
the resident is non-ambulatory; and the person needs at least a two-person assist
with a lift.
With regard to an extensive wound care needs enhanced rate developed under
the bill, a nursing home must identify extensive wound care needs by a prior
authorization process that includes consideration of the number and stage of
wounds, the cost and frequency of necessary interventions and supplies, including
including vacuum-assisted closure of wounds, nutritional supplements, specialized
mattresses, and wheelchair cushions. The bill provides that the enhanced rate for
extensive wound care needs may only be applicable if the resident is admitted to the
nursing home directly from a hospital and the resident did not acquire the wound or
wounds while a resident of the nursing home. - 3 -2023 - 2024 Legislature
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ASSEMBLY BILL 1087
For further information see the state fiscal estimate, which will be printed as
an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SECTION 1. 49.45 (3n) of the statutes is created to read:
49.45 (3n) SUPPLEMENTAL PAYMENTS TO HOSPITALS. (a) In this subsection:
1. “High-acuity patient” means any of the following:
a. A hospital patient with bariatric care needs, identified by a minimum data
set assessment indicating a body mass index equal to or greater than 40 and a need
for total or extensive assistance with activities of daily living, who is non- or
semi-ambulatory, and needs at least a two-person assist with a lift.
b. A hospital patient who has a disability, has a need for extensive wound care,
has a mental illness, has high behavior needs, has a substance use disorder, is
receiving intravenous fluid or intravenous medication, or requires dialysis.
2. “Qualifying avoidable patient day” means any day following the 7th
consecutive day on which a high-acuity patient was eligible for discharge from a
hospital, as reasonably identified by the hospital, and the hospital was not able to
identify a setting to which the patient could be safely discharged.
(b) 1. At the beginning of each quarter starting with the quarter that begins on
July 1, 2024, and ending with the quarter that begins on April 1, 2025, the
department shall pay to hospitals that have qualifying avoidable patient days a
payment as calculated under this paragraph.
2. Each quarter during the period described under subd. 1., the department
shall distribute $5,000,000 plus any matching federal funds to the hospitals
described under subd. 1.
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SECTION 1 ASSEMBLY BILL 1087
3. Subject to subd. 4., the department shall pay to each hospital described
under subd. 1. a percentage of the distribution under subd. 2. that equals the
hospital's percentage of the total number of qualifying avoidable patient days
reported by all hospitals for the applicable quarterly reporting period.
4. The department shall limit the maximum amount of funding to any hospital
under this paragraph in accordance with any federal rules concerning
hospital-specific funding limits.
(c) 1. To receive a portion of the quarterly supplemental funding the
department distributes on July 1, 2024, a hospital seeking a payment under this
subsection shall submit to the department by May 1, 2024, the total number of
qualifying avoidable patient days at the hospital between January 1, 2024, and
March 31, 2024.
2. To receive a portion of the quarterly supplemental funding the department
distributes on October 1, 2024, a hospital seeking a payment under this subsection
shall submit to the department by August 1, 2024, the total number of qualifying
avoidable patient days at the hospital between April 1, 2024, and June 30, 2024.
3. To receive a portion of the quarterly supplemental funding the department
distributes on January 1, 2025, a hospital seeking a payment under this subsection
shall submit to the department by November 1, 2024, the total number of qualifying
avoidable patient days at the hospital between July 1, 2024, and September 30, 2024.
4. To receive a portion of the quarterly supplemental funding the department
distributes on April 1, 2025, a hospital seeking a payment under this subsection shall
submit to the department by February 1, 2025, the total number of qualifying
avoidable patient days at the hospital between October 1, 2024, and December 31,
2024.
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(d) The department shall submit any necessary request to the federal
department of health and human services for a state plan amendment or waiver of
federal Medicaid law to receive federal matching funds for the supplemental
payments to hospitals under this subsection. The department shall implement this
subsection regardless of whether the federal approval of any necessary state plan
amendment or waiver of federal Medicaid law, as specified in this paragraph, is
received.
SECTION 2. 49.45 (6r) of the statutes is created to read:
49.45 (6r) NURSING HOME RATES FOR BARIATRIC AND EXTENSIVE WOUND CARE NEEDS.
(a) During the 2023-25 fiscal biennium, the department shall develop an enhanced
rate for reimbursement under the Medical Assistance program under this
subchapter for bariatric and extensive wound care needs for nursing home residents
who are admitted on or after July 1, 2024. The calculated cost of the enhanced rate
developed by the department under this subsection may not exceed $10,000,000.
Once the department has developed a rate under this subsection, the department
shall implement the enhanced rate.
(b) In seeking reimbursement under the enhanced rate implemented under
this subsection, a nursing home may claim only one enhanced rate type for a resident
and may not claim both an enhanced bariatric care reimbursement rate and an
enhanced extensive wound care reimbursement rate for the same resident at the
same time.
(c) With respect to a bariatric care needs enhanced rate developed under this
subsection, the department shall apply all of the following standards:
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SECTION 2 ASSEMBLY BILL 1087
1. A nursing home shall identify bariatric care needs by a minimum data set
assessment at admission indicating a body mass index equal to or greater than 40
and total or extensive assistance with activities of daily living.
2. A bariatric care needs rate applicable for a resident under this subsection
shall be available for the duration of the resident's stay at the nursing home.
3. An enhanced rate for bariatric care needs may be used to provide
reimbursement for specialized mattresses, diets, medical supplies, extra staff for
transfers, as well as more expensive or specialized transportation services.
4. The enhanced rate for bariatric care needs shall only be applicable if all of
the following apply:
a. The resident is admitted to the nursing home directly from a hospital.
b. The resident is non- or semi-ambulatory.
c. The resident needs at least a two-person assist with a lift.
(d) With respect to an extensive wound care needs enhanced rate developed
under this subsection, the department shall apply all of the following standards:
1. A nursing home shall identify extensive wound care needs by a prior
authorization process that includes consideration of the number and stage of
wounds, the cost and frequency of necessary interventions and supplies, including
including vacuum-assisted closure of wounds, nutritional supplements, specialized
mattresses, and wheelchair cushions.
2. The enhanced rate for extensive wound care needs may only be applicable
if all of the following are true:
a. The resident is admitted to the nursing home directly from a hospital.
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b. The resident did not acquire the wound or wounds while a resident of the
nursing home.
(END)
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