County agencies may use their own forms in place of DMT 130 subject to the prior approval of the department. Any substitute form must be capable of fulfilling the same provisions as the current DMT 130.
A responsible party who provides full financial information and authorizations for billing all applicable insurance shall be billed on the basis of the family's ability to pay.
For each family, ability to pay shall be determined in the following manner:
The annual gross income of all family members shall be determined and totaled except that the earned income of a child who is a full-time student or a part-time student but not a full-time employee shall be excluded. Income from self-employment or rent shall be the total net income after expenses. Depreciation on farm, business or rental property and wages paid to members of the family shall not be treated as expenses for this purpose. Actual principal payments on capital equipment and depreciated property shall be allowed as an expense. The income of any family member in a residential setting is treated separately under this section.
The monthly average income shall be computed by dividing the annual gross income by 12.
Monthly payments from court ordered obligations shall be subtracted from monthly average income.
For services other than care to minors in state institutions, the department may permit a payment approval authority to add an amount based on the value of assets to monthly income. This amount may not exceed 1/6 of the assets that would be considered excess assets for the purpose of determining eligibility for the medical assistance program.
(12) Maximum monthly payment.
A family providing full financial information shall be billed at a monthly rate that does not exceed the maximum amount computed by means of the following formulas:
(a) Long-term support for adults.
For long-term support for adults in the department's community options program and similar programs, an amount not to exceed the monthly income computed according to sub. (11)
less the following:
Estimated income taxes, social security or federal retirement obligations; and
An amount determined annually by the department which is no less than current income limits for medically needy persons in the Wisconsin medical assistance program.
(b) Child day care.
For child day care, the monthly payment when income computed under sub. (11)
is less than 50% of the state median income as defined by the department shall be zero. For income at 50% of the state median income, the maximum payment shall be $5.00 per month. For income at 60% of the state median income, the payment shall be $30.00 per month. The maximum payment for income at 100% of the state median income shall be $266 per month. The department shall annually publish a schedule which prorates the day care payments for income levels for each one percent increase in income from 50% to 100% of the state median income. Parental payment limits in sub. (18) (a)
do not apply to this paragraph.
(c) Other services for children.
Except as provided in s. DHS 1.065
, for other services to children, the maximum monthly payment for a parent shall be computed as follows:
For years after calendar year 1985, the department shall update the allowances in Table DHS 1.03 (12) by the same percentage used to update family budgets in the aid to families with dependent children program.
At least $1.00 but less than $543, the maximum monthly payment is 28% of the income in excess of $1.00;
At least $543, the maximum monthly payment is $152 plus 7% of the income in excess of $543.
The department shall publish a schedule annually for agencies to compute maximum monthly payment rates under this paragraph.
DHS 1.03 Note
Note: $152 is assumed to represent a basic allowance to provide support for a child living in a family, and 7% of gross income above support is assumed to represent added support above basic needs that a family with higher income would provide for a child in the home.
(d) All other services.
For all other services, the department shall publish maximum monthly payment schedules or formulas that require payments no higher than those computed under par. (a)
(12m) Maximum monthly payment for a child in a court-ordered out-of-home placement.
The maximum monthly payment of parents for court-ordered out-of-home placements of their children under chs. 48
, Stats., shall be determined according to procedures in s. DHS 1.07
(13) Minimum payment.
The appropriate payment approval authority may establish a minimum payment rate up to $25.00 per month or 3% of gross income across-the-board for all persons or families incurring liability for a fee chargeable service whose maximum monthly payment as calculated according to subs. (2)
is less than the minimum rate. Where minimum rates are used, all persons or families shall be expected to pay the applicable minimum rate except where liability is waived according to s. DHS 1.02 (7)
or where a minimum payment exceeds the available income of the responsible party or parties. Minimum charges under this section may also be set on a per unit basis, for instance, per hour or per day, provided the charges do not accumulate to exceed $25.00 per month or 3% of monthly income.
(13m) Special payment schedules.
The department may establish special payment schedules, to be used in place of schedules determined according to sub. (12)
, for designated providers and types of services on a pilot basis for periods not to exceed 3 years. Special payment schedules shall be directed toward goals which include, but are not limited to, increasing revenue to expand or maintain service levels, improving administration of the fee system and assessing the impact of different fee approaches on service. Beyond the pilot period, the payment schedule for the designated type of service shall be established according to sub. (12)
or any other applicable provision of law. Special payment schedules shall incorporate standards for income and may incorporate standards for assets. These standards may not be more stringent than the income and assets provisions of the Wisconsin medical assistance program described in ss. DHS 103.04
. However, where income is less than the limit for medical assistance eligibility, the department may approve schedules where assets are not considered and payments for a month of service do not exceed 3% of the family's gross monthly income.
The maximum monthly payment rate calculated under sub. (12)
is adjustable in the following situations:
In cases where family members who contribute to the family income are not responsible parties for the liability being charged to the family, the maximum monthly payment rate shall not exceed the sum of the unearned and one-half the earned income of responsible party or parties, less an amount equal to that used by the Wisconsin AFDC program for work related expenses.
When payment at the maximum monthly payment rate, as calculated in sub. (12)
, would create a documentable hardship on the family, (such as the forced sale of the family residence or cessation of an education program), a lower maximum monthly payment rate may be authorized by the appropriate payment approval authority under the following provisions:
Hardship adjustments are normally restricted to situations where services extend more than one year, and sufficient relief is not afforded to the family through an extended or deferred payment plan.
Each hardship adjustment shall be documented by additional family financial information. Such documentation shall become part of the client's collection file as provided in s. DHS 1.06
Responsible parties shall be informed in writing of approval or denial with approval taking the form of a written agreement.
Hardship adjustments shall be reviewed annually and, if necessary, renegotiated.
(15) Extended payment plans.
Agencies may work out an extended payment plan with any responsible party who indicates that payment at the monthly payment rate would place a burden on the responsible party's family. This payment plan has the effect of the responsible party paying a lesser monthly amount over a longer period of time but with the total expected amount to equal the full application of the monthly payment rate under s. DHS 1.02 (6)
. Authority to approve extended payment plans may be placed at whatever staff level the payment approval authority determines is appropriate.
(16) Shortcuts to document no ability to pay for services not covered by third-party payers. DHS 1.03(16)(a)(a)
Family income information in form DMT 130 is not required where no family member receives earned income and the family is supported in full or in part by income maintenance benefits.
The financial information form (DMT 130) is not required for fee-chargeable services when zero ability to pay can be documented. The following families making application for services are automatically considered to have no ability to pay when the following financial information is documented on other forms required by the department.
When the family has no earned income and are recipients of AFDC, Medical Assistance, Food Stamps or General Relief.
Families whose income is lower than the point at which payment begins according to the maximum monthly payment rate schedule for families of similar size.
(17) Relationship to extent of services.
When full financial information is provided, the monthly payment rate established according to sub. (12)
and adjusted according to sub. (14) (a)
is the total ceiling amount that the family may be billed a month regardless of the number of family members receiving services, the number of agencies providing services, or the magnitude or extent of services received.
Parental payment limits set according to sub. (21)
shall be applied to billings to parents for each child who receives care or services in a state center for the developmentally disabled. The department may also approve parental payment limits set according to sub. (21)
which are requested by payment approval authorities for any other care or services provided to children. When parents of a child are divorced or separated, the total billed to both parents for the care of a child may not exceed the one billing limit used for the care or services received by the child. When a minor child and an adult from one family receive services, the parental payment limit may not be applied to billings for services to the adult. When used, parental payment limits shall be applied as follows:
For outpatient psychotherapy normally covered by health insurance and purchased or provided by county agencies, parents who provide full insurance information and necessary authorizations for billing all applicable insurance may not be billed a total amount per child per month greater than the monthly parental payment limit per month for each child who receives services;
For other services normally covered by health insurance, parents who provide full insurance information and necessary authorizations for billing all applicable insurance may not be billed more than the daily parental payment limit per day for each child who receives service;
For residential care not normally covered by health insurance, the following applies:
When a child is in care for less than 21 days in a calendar month, the parents may not be billed more than the daily parental payment limit per day for that child's care;
When a child is in care for more than 20 days in a calendar month, the payment approval authority shall adopt an agency policy for parental payment limits according to either the daily or monthly limit. The limit chosen shall apply uniformly to all parents;
When the daily limit is used, the agency may prorate daily billings for all families served by the agency according to their ability to pay. Under this prorating approach, the billing shall be the lesser of the daily limit or the family's monthly payment amount determined by s. DHS 1.03 (12)
multiplied by 12 and divided by 365; and
DHS 1.03 Note
Note: For example, if the maximum monthly payment for a family is $80, the daily rate would be $2.63 ($80× 12÷ 365 days = $2.63).
As an alternative to subd. 3. c.
, when the daily limit is used, an agency may bill all parents the daily limit for each day of care up to their monthly payment rate determined according to sub. (12)
The appropriate payment approval authority may bill a responsible party a minimum payment for therapeutic reasons for a fee chargeable service. The therapeutic charge may be a per month amount or a per visit or per unit of service charge and may result in a higher amount than the maximum monthly payment rate. A charge for "no-show" is considered a therapeutic charge. Therapeutic charges may not exceed the maximum monthly payment by more than $25.00 per month. Therapeutic charges and minimum charge(s) established under sub. (13)
may not total more than $25.00 per family nor may a therapeutic charge exceed the responsible party's available income.
When residential care is provided under ch. 48, Stats.
, and there is a support order under s. 49.90
, Stats., or ch. 767, Stats.
, which was in existence before the ch. 48, Stats.
, disposition, the billing amount to parents for residential care shall not be less than the previously ordered amount attributable to the child client. This provision supersedes maximum billing limitations in subs. (12)
, (18) (a)
DHS 1.03 Note
Note: Before October 1, 1984 this subsection included the following limits on the amount that parents were expected to pay each month for care or services provided or purchased for their minor children.
DHS 1.03 Note
For outpatient psychotherapy purchased or provided by county agencies, the maximum billing rate to qualified parents for outpatient psychotherapy was $4.00 per day per child client for such care from September 1, 1977 through December 31, 1979. For care from January 1, 1980 through June 30, 1980, the maximum rate for this service was $120 per month per child client. From July 1, 1980 through June 30, 1983, the maximum rate was $152 per month per child client. Since July 1, 1983 the maximum was $183 per month per child client.
DHS 1.03 Note
For all other services, the maximum billing rate for care from September 1, 1977 through June 30, 1980 was $4.00 per day per child client; from July 1, 1980 through June 30, 1983, $5.00 per day per child client; since July 1, 1983, $6.00 per day per child client. Since January 1, 1981 county departments of social services were permitted to convert the daily amounts for residential care to average monthly amounts.
(19) Redetermination of maximum monthly payment rate.
The maximum monthly payment rate established upon entry into the system shall be reviewed at least once per year. A redetermination shall be made at any time during the treatment or payment period that a significant change occurs in available income. The redetermined maximum monthly payment rate may be applied retroactively or prospectively.
(20) Payment period.
Monthly billing to responsible parties with ability to pay shall continue until:
Third-party sources have been exhausted and the responsible parties have a permanent inability or unlikely future ability to pay.
(21) Parental payment limit.
Except as provided in s. DHS 1.065
, parental payment limits shall be determined as follows:
For care in the department's centers for the developmentally disabled, the daily parental limit shall be $6.00, subject to adjustment by the department under par. (b)
. For all other care or services the department may approve daily parental payment limits at amounts which the department determines to be administratively feasible, but not higher than the cost-based fee for the service;
The daily parental payment limit for care in the department's centers for the developmentally disabled shall be adjusted upward or downward in direct proportion to movement in the Milwaukee all-urban consumer price index for food and beverages, published by the U.S. department of labor. The adjustment shall be rounded downward to the nearest whole dollar. The base date for computing the adjustments shall be the date of the last published consumer price index for Milwaukee in 1982. The base dollar amount shall be $6.00 per day. This adjustment shall be computed at the end of each calendar year and shall be effective the following July 1; and
The monthly parental payment limit shall be determined by multiplying the appropriate daily limit by 365 and dividing the product by 12.
DHS 1.03 History
Cr. Register, August, 1978, No. 272
, eff. 9-1-78; am. (2) to (6), renum. (7) to (14) to be (8), (11), (12), (14), (17) to (20) respectively and am. (8), (11), (14), (17), (18) (b) and (20), r. and recr. (18) (a), cr. (7), (9), (10), (13), (15) and (16), Register, November, 1979, No. 287
, eff. 1-1-80; emerg. am. (18) (a), eff. 7-1-80; am. (18) (a), Register, October, 1980, No. 298
, eff. 11-1-80; r. and recr. (18) (a), cr. (18) (c) and (21), Register, December, 1980, No. 300
, eff. 1-1-81; cr. (13m), Register, June, 1981, No. 306
, eff. 7-1-81; am. (8), (10), (13), (13m), (14) (a), (15) and (18) (c), r. and recr. (11) (b) 4. and (12), r. (11) (b) 5., Register, September, 1984, No. 345
, eff. 10-1-84; am. (11) (b) 1., (13) and (18) (c), r. (16) (b) 3., renum. (16) (b) 4. to be 3., r. and recr. (18) (a) and (21), Register, December, 1987, No. 384
, eff. 1-1-88; emerg. cr. (12m), eff. 1-22-97; cr. (12m), Register, August, 1997, No. 500
, eff. 9-1-97; correction in (13m) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 2001, No. 546
; CR 08-017
: am. (12) (c) (intro.) and (21) (intro.) Register June 2008 No. 630
, eff. 7-1-08; correction in (13m) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635
; CR 10-146
: r. and recr. (20) (c) Register May 2011 No. 665
, eff. 6-1-11.
Fee establishment, calculation and approval. DHS 1.04(1)(1)
With respect to client services for which responsible parties incur liability and may be billed, each facility operated by the department, a county department of social services, county department established under s. 46.23
, Stats., or an agency providing services pursuant to a contract with the department, a county department of social services or a county department established under s. 46.23
, Stats., shall establish a fee or set of fees as follows if required by the appropriate fee approval authority in par. (g)
(a) Facility fee or service fee.
The division, county department of social services, board established under s. 51.42
, Stats., or private firm in charge of the facility shall establish a uniform facility fee, except that if the facility provides 2 or more services of a disparate nature with associated wide differences in per-service cost, separate per-service fees shall be established.
(b) Fee calculation.
Fees shall be determined in advance for each calendar year, except that divisions may determine fees in advance for each fiscal year. For purchased services, the contract rate and billable units to the purchaser should be identical to the fee and billable units to the responsible party or parties, wherever possible. Fees shall be determined by dividing either the number of patient days projected by the year in question, or, if the facility or service provides less than 24 hour care, the number of hours of billable client service projected for the year in question, into allowable anticipated facility or service-related expenditures for the year in question. For purchased services not easily converted to time units and where the contract or agreement specifies purchase units other than time, fees shall be set using the contract unit.
Expenditures mean ordinary and necessary budgeted non-capital expenses and depreciation on capital equipment. Cost standards that govern purchase of care and services under s. 46.036
, Stats., shall apply to expenditures for calculating the fee. Outlays associated with non-client-specific community service and with client services exempted under s. DHS 1.01 (4)
plus a pro-rata share of depreciation and associated administration or indirect costs are excluded. Where the facility establishes separate per-service fees, expenditures mean ordinary and necessary per-service expenses plus a pro-rata share of depreciation and indirect or administration costs.
(d) Calculating fees.
A division, a county department of social services, a county department established under s. 46.23
, Stats., or a private firm under contract to a division or county department responsible for the calculation of the facility or service fees may use forms provided by the department for the calculation of unit rates. Budgeted costs shall be segregated among cost centers based on groupings of programs which have significantly different costs. A single facility fee may be used if the facility does not provide services of a disparate nature with associated wide discrepancies in cost. Multi-service facilities providing services which are not covered by the uniform fee system may not include costs for those services in their calculations of fees.
DHS 1.04 Note
Note: An example of services of a disparate nature is services provided by psychiatrists in comparison with services provided by social workers.
DHS 1.04 Note
Note: A form that may be used to calculate unit rates is DMT 143, Uniform Fee Application, which is available along with instructions for filling it out from the Bureau of Fiscal Services, P.O. Box 7853, Madison, Wisconsin 53707-7853.
(e) Multiple therapist fees.
Where fees are computed according to professional disciplines (i.e. psychiatrist, psychologist, social worker, nurse, etc.), a fee for an hour of service provided by 2 or more professionals would be the sum of the hourly rates for each professional.
DHS 1.04 Note
Note: Example: The fee for an hour of service provided by a psychologist and social worker would be the sum of the hourly rate computed for each discipline.
(f) Group therapy fees.
Group therapy fees shall be computed by dividing the fee calculated according to par. (d)
by the projected number of non-family-related clients per group.
DHS 1.04 Note
DHS 1.04 Note
For group sessions conducted by one therapist with an average size of 7.
DHS 1.04 Note
Group fee = Therapist fee÷ 7
DHS 1.04 Note
For group sessions conducted by more than one therapist with an average group size of 10.
DHS 1.04 Note
Group fee = (Therapist 1 + Therapist 2 etc.) ÷ 10
Divisions, county departments of social services, and county departments established under s. 51.42
, Stats., shall approve rates for facilities they operate. This subdivision does not apply where another form of approval is set by law.
The administrative unit of a purchasing agency authorized to enter into contracts or agreements for purchased services may approve the fee or fees for purchased services. Any fee approval shall occur before execution of the contract or agreement and the approved fee or fees shall be part of the contract. If the purchaser chooses not to approve fees under this subdivision, fees shall be established in accordance with sub. (2) (a)
Where 2 or more agencies purchase the same service(s) from the same provider, the agency with the largest dollar contract shall have final approval of the facility fee or service fee(s) in question.
(h) Effective date of fee.
Fees in effect at any time shall remain in effect until new fees are determined and approved pursuant to these rules. No fees shall be modified without the prior consent of the fee-approving authority.