Register December 2008 No. 636
Chapter DHS 101
INTRODUCTION AND DEFINITIONS
Authority and purpose.
Ch. DHS 101 Note
Chapter HSS 101 as it existed on February 28, 1986 was repealed and a new chapter HSS 101 was created effective March 1, 1986. Chapter HSS 101 was renumbered Chapter HFS 101 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6., and 7., Stats., Register, January, 1997, No. 493
. Chapter HFS 101 was renumbered to chapter DHS 101 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 101.01 Authority and purpose.
This chapter and chs. DHS 102
are promulgated pursuant to ss. 49.45 (10)
and 49.665 (3)
, Stats., for the purpose of administering the medical assistance (MA) program in Wisconsin which finances necessary health care services for qualified persons whose financial resources are inadequate to provide for their health care needs.
DHS 101.01 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520
; emerg. am. eff. 7-1-99; am., Register, March, 2000, No. 531
, eff. 4-1-00; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 101.02 Applicability.
This chapter and chs. DHS 102
apply to all recipients of MA, all providers of MA and all persons engaged in the administration of MA.
DHS 101.02 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86;
correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
“Access," for purposes of BadgerCare, 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 18 months prior to the application or redetermination of BadgerCare eligibility.
“Accredited" means approved by a national accrediting agency or association which has been recognized by the U.S. secretary of education.
“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.
DHS 101.03 Note
Note: The plan of care is designed to achieve the recipient's discharge from inpatient status at the earliest possible time.
“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.
“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.
“Administrator" means the person who manages a health care facility.
DHS 101.03 Note
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.
“AFDC" means aid to families with dependent children, a public assistance program under Title IV-A of the Social Security Act of 1935, as amended, and s. 49.19
“Agency" means the county department of social services, or human services, or a tribal agency which administers income maintenance programs.
“Ambulatory" means able to walk without personal assistance or mechanical aids, and without difficulty.
“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.
“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
“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)
“ANSI" means American national standards institute.
“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.
“AODA treatment services" means alcohol and other drug abuse treatment services provided by a provider certified pursuant to s. DHS 105.22
to assist alcoholics and drug abusers and persons affected by problems related to the abuse of alcohol or drugs.
DHS 101.03 Note
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.
“Applicant" means a person who directly or through a representative makes application for MA.
“Application for medical assistance" means the process of completing and signing a department-approved application form by which action a person indicates to the agency authorized to accept the application a desire to receive MA.
“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.
“Asset limit" means that limit against which nonexempt assets under ch. DHS 103
are compared to determine financial eligibility for MA.
“Assistive listening device" or “ALD" means a personal communication unit for sound amplification. One type of “assistive listening device" is a hearing aid.
“BadgerCare fiscal test group" means all members of the BadgerCare group and all persons who are financially responsible for all members of the BadgerCare group who live in the same household as the person for whom they are legally responsible and who are not SSI recipients.
“BadgerCare group" means all persons listed on an application for BadgerCare who meet nonfinancial eligibility requirements.
“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.
“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
“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.
“Budgetable income" means earned and unearned income that is considered available for determining financial eligibility for MA under s. 49.46 (1)
or 49.47 (4)
, Stats., and ch. DHS 103
“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.
“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
“Categorically needy" means the group of persons who meet the nonfinancial and financial eligibility conditions to be eligible for AFDC or SSI.
“CESA" means a cooperative educational service agency under ch. 116, Stats.
“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.
“Claim" means a request from a provider on an approved claim form for payment for services to a recipient.
“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.
“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.
“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:
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;