reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.28 - Health maintenance organization and prepaid health plan services

Current through June 24, 2024
(1) COVERED
				SERVICES.
(a)
HMOs.
1. Except as provided in subd. 2., all health
				maintenance organizations (HMOs) that contract with the department shall
				provide to enrollees all MA services that are covered services at the time the
				medicaid HMO contract becomes effective with the exception of the following:
a. EPSDT outreach services;
b. County transportation by common
				carrier;
c. Dental services; and
d. Chiropractic
				services.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.29 - Rural health clinic services

Current through June 24, 2024
Covered rural health clinic services are the
				  following:
(1) Services furnished by a
				physician within the scope of practice of the profession under state law, if
				the physician performs the services in the clinic or the services are furnished
				away from the clinic and the physician has an agreement with the clinic
				providing that the physician will be paid by it for these services;
(2) Services furnished by a physician
				assistant or nurse practitioner if the services are furnished in accordance
				with the requirements specified in s.
				DHS
				105.35;
(3) Services and supplies that are furnished
				incidental to professional services furnished by a physician, physician
				assistant or nurse practitioner;
(4) Part-time or intermittent visiting nurse
				care and related medical supplies, other than drugs and biologicals, if:
(a) The clinic is located in an area in which
				there is a shortage of home health agencies;
(b) The services are furnished by a
				registered nurse or licensed practical nurse employed by or otherwise
				compensated for the services by the clinic;
(c) The services are furnished under a
				written plan of treatment that is established and reviewed at least every 60
				days by a supervising physician of the clinic, or that is established by a
				physician, physician assistant or nurse practitioner and reviewed and approved
				at least every 60 days by a supervising physician of the clinic; and
(d) The services are furnished to a homebound
				recipient. In this paragraph, "homebound recipient" means, for purposes of
				visiting nurse care, a recipient who is permanently or temporarily confined to
				a place of residence, other than a hospital or skilled nursing facility,
				because of a medical or health condition. The person may be considered
				homebound if the person leaves the place of residence infrequently;
				and
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.30 - Ambulatory surgical center services

Current through June 24, 2024
(1) COVERED
				SERVICES. Covered ambulatory surgical center (ASC) services are those medically
				necessary services identified in this section which are provided by or under
				the supervision of a certified physician in a certified ambulatory surgical
				center. The physician shall demonstrate that the recipient requires general or
				local anesthesia, and a postanesthesia observation time, and that the services
				could not be performed safely in an office setting. These services shall be
				performed in conformance with generally-accepted medical practice. Covered
				ambulatory surgical center services shall be limited to the following
				procedures:
(a)
Surgical
				procedures:
1. Adenoidectomy or
				tonsillectomy;
2.
				Arthroscopy;
3. Breast
				biopsy;
4. Bronchoscopy;
5. Carpal tunnel;
6. Cervix biopsy or conization;
7. Circumcision;
8. Dilation and curettage;
9. Esophago-gastroduodenoscopy;
10. Ganglion resection;
11. Hernia repair;
12. Hernia - umbilical;
13. Hydrocele resection;
14. Laparoscopy, peritoneoscopy or other
				sterilization methods;
15.
				Pilonidal cystectomy;
16.
				Procto-colonoscopy;
17.
				Tympanoplasty;
18.
				Vasectomy;
19. Vulvar cystectomy;
				and
20. Any other surgical
				procedure that the department determines shall be covered and that the
				department publishes notice of in the MA provider handbook; and
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.31 - Hospice care services

Current through June 24, 2024
(1) DEFINITIONS.
(a) "Attending physician" means a physician
				who is a doctor of medicine or osteopathy certified under s.
				DHS
				105.05 and identified by the recipient as having the
				most significant role in the determination and delivery of his or her medical
				care at the time the recipient elects to receive hospice care.
(b) "Bereavement counseling" means counseling
				services provided to the recipient's family following the recipient's
				death.
(c) "Freestanding hospice"
				means a hospice that is not a physical part of any other type of certified
				provider.
(d) "Interdisciplinary
				group" means a group of persons designated by a hospice to provide or supervise
				care and services and made up of at least a physician, a registered nurse, a
				medical worker and a pastoral counselor or other counselor, all of whom are
				employees of the hospice.
(e)
				"Medical director" means a physician who is an employee of the hospice and is
				responsible for the medical component of the hospice's patient care
				program.
(f) "Respite care" means
				services provided by a residential facility that is an alternate place for a
				terminally ill recipient to stay to temporarily relieve persons caring for the
				recipient in the recipient's home or caregiver's home from that care.
(g) "Supportive care" means services provided
				to the family and other individuals caring for a terminally ill person to meet
				their psychological, social and spiritual needs during the final stages of the
				terminal illness, and during dying and bereavement, including personal
				adjustment counseling, financial counseling, respite care and bereavement
				counseling and follow-up.
(h)
				"Terminally ill" means that the medical prognosis for the recipient is that he
				or she is likely to remain alive for no more than 6 months.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.33 - Ambulatory prenatal services for recipients with presumptive eligibility

Current through June 24, 2024
(1) COVERED SERVICES. Ambulatory prenatal
				care services are covered services. These services include treatment of
				conditions or complications that are caused by, exist or are exacerbated by a
				pregnant woman's pregnant condition.
(2) PRIOR AUTHORIZATION. An ambulatory
				prenatal service may be subject to a prior authorization requirement, when
				appropriate, as described in this chapter.
(3) OTHER LIMITATIONS.
(a) Ambulatory prenatal services shall be
				reimbursed only if the recipient has been determined to have presumptive MA
				eligibility under s.
				49.465,
				Stats., by a qualified provider under s.
				DHS
				103.11.
(b) Services under this section shall be
				provided by a provider certified under ch. DHS 105.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.34 - Prenatal care coordination services

Current through June 24, 2024
(1) COVERED
				SERVICES.
(a)
General.
1. Prenatal care coordination services
				covered by MA are services described in this section that are provided by an
				agency certified under s.
				DHS
				105.52 or by a qualified person under contract with an
				agency certified under s.
				DHS
				105.52 to help a recipient and, when appropriate, the
				recipient's family gain access to medical, social, educational and other
				services needed for a successful pregnancy outcome. Nutrition counseling and
				health education are covered services when medically necessary to ameliorate
				identified high-risk factors for the pregnancy. In this subdivision,
				"successful pregnancy outcome" means the birth of a healthy infant to a healthy
				mother.
2. Prenatal care
				coordination services are available as an MA benefit to recipients who are
				pregnant, from the beginning of the pregnancy up to the sixty-first day after
				delivery, and who are at high risk for adverse pregnancy outcomes. In this
				subdivision, "high risk for adverse pregnancy outcome" means that a pregnant
				woman requires additional prenatal care services and follow-up because of
				medical or nonmedical factors, such as psychosocial, behavioral, environmental,
				educational or nutritional factors that significantly increase her probability
				of having a low birth weight baby, a preterm birth or other negative birth
				outcome. "Low birth weight" means a birth weight less than 2500 grams or 5.5
				pounds and "preterm birth" means a birth before the gestational age of 37
				weeks. The determination of high risk for adverse pregnancy outcome shall be
				made by use of the risk assessment tool under par. (c).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.36 - School-based services

Current through June 24, 2024
(1) COVERED SERVICES.
(a)
General.
1. School-based services covered by the MA
				program are services described in this section that are provided by a school
				district or CESA.
2. The school
				district or CESA shall ensure that individuals who deliver the services,
				whether employed directly by or under contract with the school district or
				CESA, are licensed under ch. PI 34, Trans 301 or ch. 441, Stats.
3. Notwithstanding s. DHS 106.13 (intro.) and
				(1) (c), requirements under chs. DHS 101 to 108 as they relate to school-based
				services, to the extent consistent with 42 CFR ch. IV, may be waived if they
				are inconsistent with other federal education mandates.
4. Consultation, case monitoring and
				coordination related to developmental testing under the individuals with
				disabilities education act,
				20 USC
				1400 to
				1485, are included in the
				MA-covered services described in this subsection when an IEP results from the
				testing. Consultation, case monitoring and coordination for IEP services are
				also included in the covered services described in this subsection.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 108 - General Administration › Section DHS 108.01 - Safeguarded information

Current through June 24, 2024
(1) Except for
				purposes directly related to direct program administration, the department may
				not use or disclose any information concerning past or present applicants and
				recipients of MA.
(2) In this
				section, "direct program administration" means:
(a) Determining initial eligibility of the
				applicant and continuing eligibility of the recipient;
(b) Determining appropriate services to be
				covered;
(c) Providing services for
				recipients;
(d) Processing provider
				claims for reimbursement;
(e)
				Auditing provider claims for reimbursement;
(f) Investigating or prosecuting criminal or
				civil proceedings conducted in connection with program
				administration;
(g) Seeking
				third-party payment for services provided to a recipient; and
(h) Other activities determined by the
				department to be necessary for proper and efficient administration of
				MA.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter I - General Provisions › Section DHS 109.01 - Authority and purpose

Current through June 24, 2024
This chapter is promulgated under the authority of ss.
					 49.688
					 and
					 227.11(2),
					 Stats., to implement a program called SeniorCare that is designed to provide
					 prescription drug assistance for Wisconsin residents aged 65 years or older and
					 who meet the program's eligibility criteria. The chapter does all of the
					 following:
(1) Establishes the
				  application process for SeniorCare.
(2) Describes how the department will
				  determine eligibility for SeniorCare benefits and services.
(3) Identifies SeniorCare benefits, services
				  and fees.
(4) Establishes
				  requirements of SeniorCare participants and providers.
(5) Identifies the applicability of other
				  department rules.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter I - General Provisions › Section DHS 109.02 - Applicability

Current through June 24, 2024
This chapter applies to all of the following:
(1) The department.
(2) All persons applying to receive
				  SeniorCare benefits and services.
(3) All persons found eligible to receive
				  SeniorCare benefits and services.
(4) All persons prescribing or providing
				  drugs to SeniorCare participants.
(5) All drug manufacturers who sell drugs for
				  prescribed use in Wisconsin by SeniorCare participants.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter I - General Provisions › Section DHS 109.03 - Definitions

Current through June 24, 2024
Unless otherwise defined in this chapter, the definitions
					 in s. DHS 101.03 apply to this chapter. In addition, in this chapter:
(1) "Deductible benefits and services" means
				  both of the following:
(a) The prescription
				  drugs which may be purchased by a SeniorCare participant with income over 160%
				  of the poverty line for amounts no greater than the program payment
				  rate.
(b) The department's tracking
				  of prescription drug purchases by a SeniorCare participant with income over
				  160% of the poverty line so SeniorCare providers know when the participant may
				  receive the SeniorCare prescription benefit.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.11 - Application and determining eligibility

Current through June 24, 2024
(1) CONDITIONS FOR
				  ELIGIBILITY. A person who meets all of the following requirements shall be
				  eligible for SeniorCare and shall be issued a prescription drug card for use in
				  purchasing prescription drugs:
(a) The person
				  is a resident of the state of Wisconsin as defined in s.
				  27.01(10)
				  (a), Stats. The temporary absence of a
				  resident from the state shall not be grounds for denying or terminating
				  SeniorCare eligibility unless another state has determined the person is a
				  resident in the other state for purposes of medical assistance.
(b) The person is at least 65 years of
				  age.
(c) The person is not a
				  recipient of medical assistance, or as a recipient, does not receive
				  prescription drug coverage. Persons who only receive Medicare buy-in benefits
				  under s. 49.468, Stats.,
				  42 USC
				  1396a(a)(10)(E), or
				  42
				  USC 1396u-3, are not considered a medical
				  assistance recipient under this chapter.
(d) The person pays the program enrollment
				  fee specified in s.
				  DHS
				  109.16.
(e)
1.
				  Except as provided in subd. 2., the person requesting SeniorCare benefits has a
				  social security number and furnishes the number to the department.
2.
a. If an
				  applicant does not have a social security number, the applicant or a person
				  acting on behalf of the applicant shall apply to the federal social security
				  administration for a number. The department may not deny or delay services to
				  an otherwise eligible applicant pending issuance or verification of the
				  individual's social security number.
b. If the applicant or a person acting on
				  behalf of an applicant refuses to furnish a number or apply for a number, the
				  applicant shall be ineligible for SeniorCare.
(f) The person is a U.S. national or an alien
				  legally residing in the U.S. and whose status qualifies them for medical
				  assistance under
				  8
				  USC 1611 through
				  8
				  USC 1613, except that an alien whose status
				  would qualify them only for emergency medical assistance benefits under
				  42 USC
				  1396b(v)(3) is not eligible
				  for SeniorCare.
(g) The applicant,
				  participant, or person described in sub. (2) (d) who is acting on behalf of the
				  applicant or participant provides correct and truthful information as specified
				  under sub. (2) (c).
(h) The person
				  is not an inmate of a public institution as defined in
				  42 CFR
				  435.1009.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.12 - Calculation of eligible benefits and services

Current through June 24, 2024
Persons the department determines to be eligible for
					 SeniorCare benefits and services under s.
					 DHS
					 109.11 may be subject to program deductible and
					 spend-down amounts that participants must pay before the participant may
					 receive the full SeniorCare benefits and services for the remainder of a
					 benefit period. Whether and to what extent the deductibles and spend-down
					 amounts under s.
					 DHS
					 109.13 apply to a given participant depends on the
					 annual income of the participant's fiscal test group. The department shall
					 calculate income for the participant's fiscal test group as follows:
(1) SENIORCARE FISCAL TEST GROUP. The
				  SeniorCare fiscal test group shall consist solely of the applicant unless the
				  applicant is residing with a spouse. If the applicant is residing with a
				  spouse, the SeniorCare fiscal test group shall consist of the applicant and the
				  applicant's spouse, unless the spouse is an SSI recipient or the spouses are
				  living together in a nursing home.
(2) ANNUAL INCOME. The department shall
				  calculate annual income for SeniorCare applicants as follows:
(a) Income shall be based on a prospective
				  estimate of annual budgetable income under par. (c) for all persons in the
				  SeniorCare fiscal test group.
(b)
				  The annual period used as the basis for the estimate shall be the 12 calendar
				  months beginning with the month in which the SeniorCare application was
				  filed.
(c) Budgetable income shall
				  consist of gross earned and unearned income with the following exceptions:
1. Self-employment income shall be calculated
				  by deducting only estimated business expenses, losses, and depreciation from
				  gross self-employment income.
2.
				  Income from sources exempted under federal law from consideration for Medicaid
				  eligibility will also be exempt for SeniorCare.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.13 - SeniorCare benefits and services

Current through June 24, 2024
(1) CONDITIONS FOR
				  RECEIVING SENIORCARE BENEFITS AND SERVICES. A person who meets the eligibility
				  requirements under s. DHS 109.11 (1) may receive SeniorCare benefits or
				  services, subject to the conditions under this section. Except during a period
				  of program suspension under s.
				  49.688(7) (b),
				  Stats., SeniorCare benefits and services shall be available only for
				  prescription drugs prescribed for the eligible person and dispensed with a date
				  of service during the eligible person's benefit period.
(2) PRESCRIPTION BENEFIT.
(a)
Income category
				  applicability
. A person may receive the prescription benefit in par.
				  (b) under any of the following conditions:
1.
				  The person is a member of a fiscal test group with an annual income less than
				  or equal to 160% of the poverty line for a family the size of the fiscal test
				  group.
2. The person is a member of
				  a fiscal test group with an annual income greater than 160% but not in excess
				  of 240% of the poverty line for a family the size of the fiscal test group and
				  has met the deductible as described in sub. (3) (d) during the current benefit
				  period.
3. The person is a member
				  of a fiscal test group with an annual income greater than 240% of the poverty
				  line for a family the size of the fiscal test group and has met both of the
				  following thresholds during the current benefit period, in the following order:
a. The spend-down as described in sub. (4)
				  (c).
b. The deductible as described
				  in sub. (3) (d).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.14 - SeniorCare benefit period

Current through June 24, 2024
(1) DURATION.
				  Except as provided in subs. (3) to (5), and in s.
				  DHS 109.15
				  and s.
				  49.688(7)
				  (a), Stats., the benefit period for
				  SeniorCare eligibility shall be 12 consecutive calendar months.
(2) ELIGIBILITY BEGIN DATE. Except as
				  provided in sub. (3), a person's SeniorCare eligibility begins on the first day
				  of the month after the date the department receives a complete application and
				  the person meets all of the eligibility requirements.
(3) EXCEPTION FOR MEDICAID RECIPIENTS. If the
				  department receives a complete application and determines that the person meets
				  all other eligibility requirements prior to the date medical assistance
				  eligibility ends, the person's SeniorCare eligibility begins the day after the
				  person's medical assistance eligibility ends.
(4) TERMINATION OF SENIORCARE BENEFIT PERIOD.
(a) Except as provided in sub. (5), the
				  department shall terminate the SeniorCare benefit period of a SeniorCare
				  participant who no longer meets the eligibility conditions in s.
				  DHS
				  109.11, or who requests a withdrawal from the program
				  under s.
				  DHS
				  109.11(5) (d).
(b) The department shall restore the
				  SeniorCare benefit period for a person terminated from SeniorCare without a
				  break in coverage if, within one calendar month of the effective termination
				  date, he or she does both of the following:
1. Meets all of the eligibility criteria
				  under s.
				  DHS
				  109.11.
2.
				  Notifies the department of the change in circumstances.
(c) The department shall reinstate the
				  SeniorCare benefit period for a person who has requested a withdrawal from the
				  program under s.
				  DHS
				  109.11(5) (d) if within 30 calendar
				  days of the effective date of the withdrawal both of the following occur:
1. The department receives the person's
				  request to have SeniorCare benefits restored.
2. The person meets all of the eligibility
				  criteria under s.
				  DHS
				  109.11, including a new payment of the program
				  enrollment fee specified in s.
				  DHS
				  109.16 for persons who were issued a refund under s.
				  DHS
				  109.11(5) (d) 1.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.16 - Fees

Current through June 24, 2024
For each 12-month benefit period, a program participant
					 shall pay a program enrollment fee of $30. The department shall refund the fee
					 to applicants found to be ineligible for SeniorCare.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter II - Eligibility for SeniorCare Benefits and Services › Section DHS 109.17 - Applicant appeals

Current through June 24, 2024
(1) Except as provided under sub. (2), any
				  person whose application for SeniorCare is denied or is not acted upon promptly
				  under s.
				  DHS
				  109.11(5), or who believes that the
				  benefits or services the person may receive under s.
				  DHS
				  109.13 have not been properly determined, or that his
				  or her eligibility has not been properly determined under s.
				  DHS
				  109.11(5), may file an appeal
				  pursuant to the requirements under ch. HA 3 that apply to the medical
				  assistance program.
(2)
(a) A request for a hearing concerning the
				  SeniorCare program may only be made in writing and only to the division of
				  hearings and appeals.
(b) The
				  applicant shall have 45 days from the effective date of the adverse action in
				  which to file a request for hearing.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter III - Drug Benefits › Section DHS 109.31 - Covered drugs and limitations on coverage

Current through June 24, 2024
(1) COVERED
				  SERVICES. Drugs and drug products covered under this chapter include
				  prescription drugs and insulin listed in the Wisconsin medical assistance drug
				  index that are prescribed by a physician licensed under s.
				  448.04, Stats., by a dentist
				  licensed under s. 447.04, Stats., by a podiatrist
				  licensed under s. 448.04, Stats., by an
				  optometrist licensed under ch. 449, Stats., or by a nurse prescriber under ch.
				  N 8, or when a physician delegates prescription of drugs to a nurse
				  practitioner or to a physician's assistant certified under s.
				  448.04, Stats., and the
				  requirements under s. N 6.03 for nurse practitioners and under s.
				  Med 8.07 for
				  physician assistants are met. The limitations on coverage and services in this
				  section apply to co-pay, spend-down and deductible.
(2) PRIOR AUTHORIZATION.
(a)
Drugs requiring prior
				  authorization.
The following drugs and supplies require prior
				  authorization:
1. All schedule III and IV
				  stimulant drugs.
2. Drugs that have
				  been demonstrated to entail significant expense or overuse for the medical
				  assistance program. These drugs shall be noted in the Wisconsin medical
				  assistance drug index.
3. Drugs
				  identified by the department that may be used to treat impotence, when proposed
				  to be used for the treatment of a condition not related to impotence.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter III - Drug Benefits › Section DHS 109.32 - Coverage while out-of-state

Current through June 24, 2024
Drugs shall be covered for a SeniorCare participant only if
					 the participant is within the United States, Canada or Mexico. Drugs provided
					 by a person in another state who is not certified as a border status provider
					 shall be covered only under either of the following circumstances:
(1) As a result of an accident or sudden
				  illness, the individual needs the drug to prevent the individual's death or the
				  serious impairment of the individual's health.
(2) When the department has granted prior
				  authorization for provision of a non-emergency service, except that prior
				  authorization is not required for non-emergency services provided to Wisconsin
				  participants by border status providers certified by the Wisconsin medical
				  assistance program.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter IV - Program Integrity › Section DHS 109.41 - Annual report to legislature

Current through June 24, 2024
The department shall monitor compliance with s.
					 49.688,
					 Stats., and the provisions of this chapter by SeniorCare
					 providers.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter IV - Program Integrity › Section DHS 109.42 - Prohibition on fraud

Current through June 24, 2024
(1) No person may do any of the following:
(a) Knowingly and willfully make or cause to
				  be made any false statement or representation of a material fact in any
				  application for any SeniorCare benefit or payment.
(b) Knowingly and willfully make or cause to
				  be made any false statement or representation of a material fact for use in
				  determining rights to any SeniorCare benefit or payment.
(c) Have knowledge of the occurrence of any
				  event affecting the initial or continued right to any SeniorCare benefit or
				  payment, or the initial or continued right to any such benefit, or payment of
				  any other individual in whose behalf he or she has applied for or is receiving
				  such benefit or payment, or conceal or fail to disclose such event with an
				  intent fraudulently to secure such benefit or payment either in a greater
				  amount or quantity than is due or when no such benefit or payment is
				  authorized.
(d) Having made
				  application to receive any SeniorCare benefit or payment for the use and
				  benefit of another and having received it, knowingly and willfully convert such
				  benefit or payment or any part thereof to a use other than for the use and
				  benefit of such other person.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter V - Provider Rights and Responsibilities › Section DHS 109.51 - Provider responsibility

Current through June 24, 2024
(1) AUDIT AND
				  PROGRAM MONITORING.
(a) Providers shall comply
				  with the audit and program monitoring conditions under s. DHS 105.01 (3) (f) 1.
				  to 3.
(b) Nothing in this
				  subsection shall be construed to limit the right of a provider to appeal a
				  department recovery action brought under s. DHS 109.53 (4).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter V - Provider Rights and Responsibilities › Section DHS 109.52 - Provider certification

Current through June 24, 2024
(1) GENERAL. This section identifies the
				  terms and conditions under which SeniorCare providers of drugs are certified
				  for participation in the program.
(2) PHARMACIES.
(a) For SeniorCare certification, pharmacies
				  located in Wisconsin shall meet the requirements for registration and practice
				  under ch. 450, Stats., and chs. Phar 1 to 17. Pharmacies certified to serve
				  patients under the medical assistance program under ch. DHS 105 are required to
				  serve SeniorCare participants.
(b)
				  Pharmacies located outside of Wisconsin are exempt from the requirement under
				  par. (a), but shall be registered or licensed by the appropriate agency in the
				  state in which they are located.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter V - Provider Rights and Responsibilities › Section DHS 109.53 - Department recovery of overpayments from SeniorCare providers

Current through June 24, 2024
(1) RECOUPMENT
				  METHODS. If the department finds that a SeniorCare provider has received an
				  overpayment, including but not limited to erroneous, excess, duplicative and
				  improper payments under the program, regardless of cause, the department may
				  recover the amount of the overpayment by any of the following methods, at its
				  discretion:
(a) Offsetting or making an
				  appropriate adjustment against other amounts owed the SeniorCare provider for
				  covered services.
(b) Offsetting or
				  crediting against amounts the department determines are owed the SeniorCare
				  provider for subsequent services provided under the program if both of the
				  following conditions are met:
1. The amount
				  owed the SeniorCare provider at the time of the department's finding is
				  insufficient to recover in whole the amount of the overpayment.
2. The SeniorCare provider is claiming and
				  receiving SeniorCare reimbursement in amounts sufficient to reasonably ensure
				  full recovery of the overpayment within a reasonable period of time.
(c) Requiring the SeniorCare
				  provider to pay directly to the department the amount of the
				  overpayment.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter V - Provider Rights and Responsibilities › Section DHS 109.54 - Incorporation of Medicaid standards

Current through June 24, 2024
The following provisions applicable to the medical
					 assistance program apply to SeniorCare providers for acts and activities
					 pertaining to the SeniorCare program:
(1) GENERAL REQUIREMENTS FOR PROVISION OF
				  SERVICES. The provisions of s.
				  DHS
				  106.02 apply to the SeniorCare program.
(2) MANNER OF PREPARING AND SUBMITTING CLAIMS
				  FOR REIMBURSEMENT. With the exception of s.
				  DHS
				  106.03(2) (d), (3) (c) 3. and (5)
				  (br), the provisions of s.
				  DHS
				  106.03 apply to the SeniorCare program.
(3) PAYMENT OF CLAIMS FOR REIMBURSEMENT. With
				  the exception of s.
				  DHS 106.04(2)
				  and (3) (b) and (c), the provisions of s.
				  DHS
				  106.04 apply to the SeniorCare program.
(4) INTERMEDIATE SANCTIONS. The provisions of
				  s.
				  DHS 106.08
				  apply to the SeniorCare program.
(5) DEPARTMENTAL DISCRETION TO PURSUE
				  MONETARY RECOVERY. The provisions of s.
				  DHS
				  106.09(1) apply to the SeniorCare
				  program.
(6) WITHHOLDING PAYMENT OF
				  CLAIMS. The provisions of s.
				  DHS
				  106.10 apply to the SeniorCare program.
(7) PREPAYMENT REVIEW OF CLAIMS. The
				  provisions of s.
				  DHS
				  106.11 apply to the SeniorCare program.
(8) PROCEDURE, PLEADINGS AND PRACTICE. The
				  provisions of s.
				  DHS
				  106.12 apply to the SeniorCare program.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VI - Participant Rights and Responsibilities › Section DHS 109.61 - Participant duties

Current through June 24, 2024
(1) NOT TO SEEK DUPLICATION OF SERVICES. A
				  participant may not seek the same or similar covered drugs from more than one
				  SeniorCare provider.
(2) PRIOR
				  IDENTIFICATION OF ELIGIBILITY. Except in emergencies that preclude prior
				  identification, the participant shall, before receiving prescription drugs,
				  inform the SeniorCare provider that the participant is receiving benefits under
				  SeniorCare and shall present to the SeniorCare provider a current valid
				  SeniorCare identification card.
(3)
				  REVIEW OF BENEFITS NOTICE. Participants shall review the explanation of
				  benefits (EOB) notice sent to them by the department and shall report to the
				  department any payments made for drugs not actually provided.
(4) INFORMATIONAL COOPERATION WITH SENIORCARE
				  PROVIDERS. Participants shall give SeniorCare providers full, correct and
				  truthful information requested by SeniorCare providers and necessary for the
				  submission of correct and complete claims for SeniorCare reimbursement,
				  including information about all of the following:
(a) The participant's eligibility status,
				  accurate name, address and SeniorCare identification number.
(b) The participant's use of the SeniorCare
				  card.
(c) The participant's use of
				  SeniorCare benefits.
(d) The
				  participant's coverage under other insurance programs.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VI - Participant Rights and Responsibilities › Section DHS 109.62 - Recovery of incorrect payments from participants

Current through June 24, 2024
(1) The department
				  shall begin recovery action against any SeniorCare participant to whom or on
				  whose behalf an incorrect payment was made resulting from any of the following:
(a) A misstatement or omission of fact by the
				  person supplying information on an application, a request for a new benefit
				  period, or a review of eligibility for SeniorCare benefits.
(b) A check submitted for the program
				  enrollment fee is returned for non-sufficient funds under s.
				  DHS
				  109.11(6) (d).
(c) A recipient fails to inform the
				  department, within 10 calendar days of the change, of changes in circumstances
				  that affect eligibility.
(d) A
				  recipient received benefits while an appeal requested under s.
				  DHS 109.63
				  was pending and the contested decision is upheld.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VI - Participant Rights and Responsibilities › Section DHS 109.63 - Participant appeals

Current through June 24, 2024
(1) Except as provided under sub. (2), any
				  participant who is aggrieved by the department's action or inaction may file an
				  appeal pursuant to the requirements under ch. HA 3 that apply to the medical
				  assistance program.
(2)
(a) A request for a hearing concerning the
				  SeniorCare program may only be made in writing and only to the division of
				  hearings and appeals.
(b) The
				  participant shall have 45 days from the effective date of the adverse action in
				  which to file a request for hearing.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VII - Program Administration › Section DHS 109.71 - Rebate agreement

Current through June 24, 2024
The department shall provide to a drug manufacturer that
					 sells drugs for prescribed use in this state documents designed for use by the
					 manufacturer in entering into a rebate agreement with the department. The
					 manufacturer shall make rebate payments for each prescription drug of the
					 manufacturer that is prescribed for and purchased by persons under s.
					 DHS 109.13(2) (b)
					 and (3) (b), to the state treasurer to be
					 credited to the appropriation account under s.
					 20.435(4)
					 (j), Stats., each calendar quarter or
					 according to a schedule established by the department.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VII - Program Administration › Section DHS 109.72 - Payment for drugs

Current through June 24, 2024
The department shall provide to SeniorCare providers
					 payments for prescription drugs sold by the SeniorCare providers to eligible
					 persons under s.
					 DHS 109.13(2)
					 (b). The payment for each prescription drug
					 under this subsection shall be no more than the program payment rate, minus any
					 copayment paid by the person under s.
					 DHS 109.13(2)
					 (b).
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VII - Program Administration › Section DHS 109.73 - Program suspension

Current through June 24, 2024
During any period in which funding under s.
					 20.435(4) (bv),
					 Stats., is completely expended for the payments to SeniorCare providers, the
					 requirements of ss. DHS 109.71 and 109.72 do not apply to prescription drugs
					 purchased during that period. However, the department shall continue to accept
					 applications and determine eligibility under subchapter II and shall indicate
					 to applicants that the eligibility of program participants to purchase
					 prescription drugs as specified in this chapter, under the requirements of s.
					 DHS 109.72, is conditioned on the availability of funding under s.
					 20.435(4) (bv),
					 Stats.
Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 109 - Senior Care › Subchapter VII - Program Administration › Section DHS 109.74 - Safeguarded information

Current through June 24, 2024
(1) Except for
				  purposes directly related to direct program administration, the department may
				  not use or disclose any information concerning past or present applicants and
				  participants in SeniorCare.
(2) For
				  purposes of direct program administration, the department may permit disclosure
				  to, or use of safeguarded information by, legally qualified persons or agency
				  representatives outside the department. Governmental authorities, the courts,
				  and law enforcement officers are persons outside the department who shall
				  comply with sub. (3).
(3) Persons
				  or agency representatives outside the department to whom the department may
				  disclose or permit use of safeguarded information shall meet all of the
				  following qualifications:
(a) The persons' or
				  agency representatives' purpose for use or disclosure shall involve direct
				  program administration.
(b) The
				  person or agency shall be bound by law or other legally enforceable obligation
				  to observe confidentiality standards comparable to those observed by the
				  department.
Wisconsin Administrative Code › Department of Health Services › DHS 110-199 - Health › Chapter DHS 110 - Emergency Medical Services Licensing, Certification, And Training Requirements › Subchapter I - General Provisions › Section DHS 110.01 - Authority and purpose

Current through June 24, 2024
This chapter is promulgated under the authority of ss.
					 256.08(4)
					 and
					 256.15(13),
					 Stats., to establish standards for all of the following:
(1) Certifying, training, and credentialing
				  emergency medical responders.
(2)
				  Licensing, training, and credentialing emergency medical services
				  practitioners.
(3) Licensing
				  emergency medical services providers.
(4) Certifying emergency medical services
				  training centers.
(5) Certifying
				  EMS instructors.
(6) Approving
				  medical directors.
(7) Approving
				  providers of CPR and AED training.
Wisconsin Administrative Code › Department of Health Services › DHS 110-199 - Health › Chapter DHS 110 - Emergency Medical Services Licensing, Certification, And Training Requirements › Subchapter I - General Provisions › Section DHS 110.02 - Applicability

Current through June 24, 2024
This chapter applies to all of the following:
(1) Emergency medical responders.
(2) Emergency medical technicians.
(3) Advanced emergency medical
				  technicians.
(4) Emergency medical
				  technicians - intermediate.
(5)
				  Paramedics.
(6) Emergency medical
				  services training centers.
(7)
				  Emergency medical services providers.
(8) Medical directors.
(9) Program directors.
(10) EMS instructors.
(11) CPR and AED training
				  providers.
Wisconsin Administrative Code › Department of Health Services › DHS 110-199 - Health › Chapter DHS 110 - Emergency Medical Services Licensing, Certification, And Training Requirements › Subchapter I - General Provisions › Section DHS 110.03 - Waivers

Current through June 24, 2024
The department may waive any non-statutory requirement
					 under this chapter, upon written request, if the department finds that strict
					 enforcement of the requirement will create an unreasonable hardship for the
					 emergency medical services provider or the public in meeting the emergency
					 medical service needs of the provider's primary service area and that waiver of
					 the requirement will not adversely affect the health, safety or welfare of
					 patients or the general public. The department's denial of a request for a
					 waiver shall constitute the final decision of the department and is not subject
					 to a hearing under s.
					 DHS
					 110.59.
Wisconsin Administrative Code › Department of Health Services › DHS 110-199 - Health › Chapter DHS 110 - Emergency Medical Services Licensing, Certification, And Training Requirements › Subchapter II - Emergency Medical Professionals; Licensing; Certification; Training; Credential; Fees › Section DHS 110.05 - License or certificate and credential required

Current through June 24, 2024
(1) Before an
				  individual may perform emergency medical care or advertise for the provision of
				  emergency medical care as an EMS professional, the individual shall be
				  certified as an emergency medical responder or licensed as an EMS practitioner
				  by the department and shall be credentialed by each emergency medical service
				  provider with which the individual serves, except under the following
				  conditions:
(a) The individual provides
				  emergency medical care as a volunteer practitioner under s.
				  257.03,
				  Stats.
(b) The individual provides
				  emergency medical care as a trainee under s.
				  DHS
				  110.15, while under supervision of a
				  preceptor.
(c) The individual is a
				  certified emergency medical responder in another state who provides emergency
				  medical care to 10 or fewer patients in this state under s.
				  256.15(2)
				  (b), Stats.
(d) The individual is a licensed emergency
				  medical services practitioner in another state or holds a training permit from
				  another state who is involved 10 or fewer patient transports per year that
				  originate and terminate in this state under s.
				  256.15(2)
				  (b), Stats.
(e) The individual holds a valid certificate,
				  license or training permit allowing the individual to act as an emergency
				  medical responder or emergency medical services practitioner in another state
				  and is acting in response from that state to a request for mutual aid under s.
				  256.15(2)
				  (c), Stats.
Wisconsin Administrative Code › Department of Health Services › DHS 110-199 - Health › Chapter DHS 110 - Emergency Medical Services Licensing, Certification, And Training Requirements › Subchapter II - Emergency Medical Professionals; Licensing; Certification; Training; Credential; Fees › Section DHS 110.08 - Practice level upgrades; downgrades

Current through June 24, 2024
(1) UPGRADING
				  EMERGENCY MEDICAL SERVICES PRACTITIONER PRACTICE LEVELS. To upgrade an
				  emergency medical services practitioner practice level, the emergency medical
				  services practitioner shall complete the application requirements under s.
				  DHS
				  110.06 for the desired emergency medical services
				  practitioner practice level.
(2)
				  DOWNGRADING EMERGENCY MEDICAL SERVICES PRACTITIONER PRACTICE LEVELS. To
				  downgrade an emergency medical services practitioner practice level, the
				  emergency medical services practitioner shall complete the application
				  requirements under s.
				  DHS
				  110.06 for the practice level to which the emergency
				  medical services practitioner wishes to downgrade. When the downgrade occurs at
				  renewal, the individual shall submit proof of refresher training at the
				  downgraded level or the previous license level.
(3) UPGRADING TO THE EMT PRACTICE LEVEL. To
				  upgrade from emergency medical responder certification to EMT licensure, the
				  emergency medical responder shall complete the application requirements under
				  s.
				  DHS
				  110.06 for the EMT license level.