Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 101 - Introduction And Definitions › Section DHS 101.03 - Definitions

Current through June 24, 2024
In this chapter and chs.
				  DHS
				  102 to
				  109:
(1) "Access," for purposes of BadgerCare
				Plus, means a family member living in the household has the ability to sign up
				and be covered by an employer's group health plan in the current month, or had
				the ability to sign up and be covered in any or all of the 12 months prior to
				the application or redetermination of BadgerCare Plus eligibility.
(1m) "Accredited" means approved by a
				national accrediting agency or association which has been recognized by the
				U.S. secretary of education.
(2)
				"Active treatment" means implementation and administration of a professionally
				developed and supervised individual plan of care, which is developed and
				implemented no later than 14 days after admission to the facility and is
				reasonably expected to improve the recipient's condition to the extent that
				inpatient care is no longer necessary.
Note:
The plan of care is designed to achieve
				  the recipient's discharge from inpatient status at the earliest possible
				  time.
(3) "Activities of
				daily living" means activities relating to the performance of self care, work
				and leisure or play activities, including dressing, feeding or eating,
				grooming, mobility and object manipulation.
(4) "Acute mental illness" means a mental
				illness which is not of life-long duration, which is severe in degree and
				causes a substantially diminished level of functioning in the activities of
				daily living and an inability to cope with the ordinary demands of life, and
				which may lead to an inability to maintain stable adjustment and independent
				functioning without short-term treatment.
(5) "Administrator" means the person who
				manages a health care facility.
Note:
The administrator should have a bachelor's
				  degree and either experience or specialized training in the administration of
				  health institutions or agencies; or qualifications and experience in one of the
				  professional health disciplines.
(6) "AFDC" means aid to families with
				dependent children, a public assistance program under Title IV-A of the Social
				Security Act of 1935, which was in effect until July 16, 1996, and s.
				49.19, Stats.
(8) "Agency" means the county department of
				social services, or human services, a multi-county consortium under s.
				49.78 (1m),
				Stats., a single-county consortium under s.
				49.78 (1r),
				Stats., or a tribal agency which administers income maintenance
				programs.
(9) "Ambulatory" means
				able to walk without personal assistance or mechanical aids, and without
				difficulty.
(9m) "Ambulatory
				prenatal care" means care and treatment for a pregnant woman and her fetus to
				protect and promote the woman's health and the healthy development of the
				fetus.
(10) "Ambulatory surgical
				center" means a facility that operates exclusively for the purpose of providing
				surgical services to patients not requiring hospitalization, and that meets the
				requirements of s.
				DHS
				105.49.
(11) "Ancillary cost" means an extraordinary
				and unique cost incurred by a nursing home or other qualified provider of
				services or materials furnished to a nursing home resident, which is not
				included in calculating the nursing home's daily rate but which MA reimburses
				separately under s.
				DHS 107.09 (4)
				(a).
(12) "ANSI" means American national standards
				institute.
(12m) "AODA day
				treatment" means alcohol and other drug abuse treatment services provided by a
				provider certified under s.
				DHS
				105.25 to a recipient who, in the clinical judgement
				of a qualified treatment professional, is experiencing a problem with alcohol
				or other drugs and requires intensive services of a prescribed duration, which
				may include assessment and evaluation, treatment planning, group and individual
				counseling, recipient education when necessary for effective treatment, and
				rehabilitative services, to ameliorate or remove the disability and restore
				effective functioning.
(13) "AODA
				treatment services" means alcohol and other drug abuse treatment services
				provided by a provider certified pursuant to s.
				DHS
				105.22 or
				105.23
				to assist alcoholics and drug abusers and persons affected by problems related
				to the abuse of alcohol or drugs.
Note:
Examples of AODA treatment services are
				  client evaluation, orientation and motivation, treatment planning, consultation
				  and referral, client education, individual counseling, group counseling and
				  crisis intervention.
(14)
				"Applicant" means a person who directly or through a representative makes
				application for MA.
(15)
				"Application for medical assistance" means the process of signing and
				submitting a department-approved application online, by telephone, by fax, by
				mail, or in person, by which action a person indicates to the agency authorized
				to accept the application a desire to receive MA.
(16) "Approved prescription drug products
				list" means a list prepared by the U.S. food and drug administration that
				identifies drug products approved on the basis of safety and
				effectiveness.
(17) "Asset limit"
				means that limit against which nonexempt assets under ch. DHS 103 are compared
				to determine financial eligibility for MA.
(17m) "Assistive listening device" or "ALD"
				means a personal communication unit for sound amplification. One type of
				"assistive listening device" is a hearing aid.
(17r) "BadgerCare Plus" means the MA-related
				program established under s.
				49.471, Stats.
(17t) "BadgerCare Plus fiscal test group"
				means all members of the BadgerCare Plus group and all persons who are
				financially responsible for all members of the BadgerCare Plus group.
(17w) "BadgerCare Plus group" means all
				persons listed on an application for BadgerCare Plus who meet nonfinancial
				eligibility requirements.
(17x)
				"Benefits counseling" means counseling that describes the effect of earned
				income on a person's public benefits and other support services, such as food
				stamps, housing assistance, supplemental security income, social security
				disability insurance or medical assistance.
(18) "Board" means a community mental health
				board established under s.
				51.42, Stats., a developmental
				disabilities board established under s.
				51.437, Stats., or a community
				human services board established under s.
				46.23, Stats.
(19) "Border-status provider" means a
				provider located outside of Wisconsin who regularly gives service to Wisconsin
				recipients and who is certified to participate in MA.
(20) "Budgetable income" means earned and
				unearned income that is considered available for determining financial
				eligibility for MA under subch. IV of ch. 49, Stats., and ch. DHS
				103.
(22) "Capitation fee" means a
				fee the department pays periodically to a provider for each recipient enrolled
				under a contract with the provider for the provision of medical services,
				whether or not the recipient receives services during the period covered by the
				fee.
(22g) "Caretaker relative"
				means a person listed in s.
				49.19 (1) (a) 2
				a., Stats.
(22m) "Case management"
				means activities which help MA recipients and, when appropriate, their
				families, identify their needs and manage and gain access to necessary medical,
				social, rehabilitation, vocational, educational and other services. Case
				management includes assessment, case plan development, and ongoing monitoring
				and service coordination under s.
				DHS
				107.32.
(23) "Categorically needy" means the group of
				persons who meet the nonfinancial and financial eligibility conditions to be
				eligible for MA and designated as covered groups in Wisconsin under the MA
				state plan.
(24) "Certified
				occupational therapist assistant" or "COTA" means a person who meets the
				requirements of s.
				DHS 105.28
				(2).
(24m) "CESA" means a cooperative educational
				service agency under ch. 116, Stats.
(25) "Chronic mental illness" means a mental
				illness which may be of lifelong duration, which is severe in degree and
				persistent in duration, which causes a substantially diminished level of
				functioning in the primary activities of daily living and an inability to cope
				with the ordinary demands of life, and which may lead to an inability to
				maintain stable adjustment and independent functioning without long-term
				treatment and support.
(26) "Claim"
				means a request from a provider on an approved claim form for payment for
				services to a recipient.
(27)
				"Clinical note" means a dated written notation of contact with a patient by a
				member of a health care team, which contains a description of signs and
				symptoms, treatment or drugs given, the patient's reaction and any changes in
				physical or emotional condition.
(27g) "COBRA continuation coverage" has the
				meaning under 29 CFR
				2590.701-2(2).
(27m) "Community support program" or "CSP"
				means a community-based coordinated care and treatment program operated by a
				provider certified under s.
				DHS
				105.255 to provide mental health and psychosocial
				rehabilitative services, including case management services, to MA-eligible,
				chronically mentally ill recipients residing in the community.
(28) "Compensation received" means the dollar
				value that can be attached to what is received in return for property and,
				without limitation by enumeration, that is in one or more of the following
				forms:
(a) Cash;
(b) Other assets such as accounts receivable
				and promissory notes, both of which must be valid and collectible to be of
				value, and stocks, bonds, and both land contracts and life estates;
(c) Discharge of a debt;
(d) Prepayment of a bona fide and irrevocable
				contract such as a mortgage, shelter lease or loan, or the prepayment of taxes;
				or
(e) Services, for which a
				valuation equal to the cost of purchase on the open market is assigned.
Note:
The presumption that services and
				  accommodations rendered to each other by the members of a family or other
				  relatives were gratuitous can be rebutted only by direct and positive evidence
				  of a prior express contract for payment.