"Convalescent leave" means a resident's temporary release from an institution for mental diseases (IMD) to residency in a community setting, not more frequently than once a year and beginning on the fourth day after release, with the trial period of residence in the community lasting at least 4 days but not longer than 30 days or until the person is permanently discharged from the IMD, whichever occurs first.
Any shoe attached to a brace, not including arch supports, for prosthesis;
Mismated shoes involving a difference of a full size or more; or
Shoe modifications for a discrepancy in limb length or a rigid foot deformation.
"Cost-effectiveness" means the cost of paying premiums or purchasing health insurance for a medicaid purchase plan recipient through an employer and the associated administrative cost is likely to be less than or equal to the cost of providing medical assistance.
"Covered service" means a service, procedure, item or supplies for which MA reimbursement is available, provided to a recipient of MA by an MA-certified provider qualified to provide the particular service, procedure, item or supplies or under the supervision of a certified and qualified provider.
"Daily nursing home rate" means the amount that a nursing home is reimbursed for providing each day of routine health care services to a recipient who is a patient in the home, determined in accordance with s. 49.45 (6m) (a)
"Date of account creation" means the date the recipient establishes an independence account with a financial institution.
"Day treatment" or "day hospital" means a non-residential program in a medically supervised setting that provides case management, medical care, psychotherapy and other therapies, including recreational, physical, occupational and speech therapies, and follow-up services, to alleviate problems related to mental illness or emotional disturbances.
DHS 101.03 Note
Note: Day treatment services are provided by an interdisciplinary team on a routine, continuous basis for a scheduled portion of a 24-hour day and may include structural rehabilitative activities including training in basic living skills, interpersonal skills and problem-solving skills.
"Deeming" means a process by which income and assets are considered available to applicants or recipients for the purpose of determining financial eligibility for MA under s. 49.46 (1)
or 49.47 (4)
, Stats., and ch. DHS 103
"Department" means the department of health services.
"Department-approved occupancy rate" means a rate of nursing home occupancy established by the department and communicated to providers which is used for purposes of determining whether a bed-hold payment may be made to a nursing home.
"Developmental disability" means mental retardation or a related condition such as cerebral palsy, epilepsy, or autism, but excluding mental illness and infirmities of aging, which is:
Results in substantial functional limitations in 3 or more of the following areas of major life activity:
"Differential diagnostic examination" means an examination and assessment of a recipient's emotional and social functioning which includes one or more of the following: neurologic studies, psychological tests and psycho-social assessments.
"Direct deposit" means an electronic transfer of funds from the recipient's financial institution to the medicaid purchase plan or the department's fiscal agent, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.
"Direct, immediate, on-premises supervision" means supervision with face-to-face contact between the supervisor and the person being supervised, as necessary, with the supervisor being physically present in the same building when the service is being performed by the person being supervised.
"Direct services" mean nursing home services that benefit patient recipients on an individual basis rather than a group basis, including physician visits to patients, therapy modalities, drug dispensing, radiology or laboratory services provided by a certified radiology or laboratory unit, oral exams, and physical examinations."Direct services" are often referred to as billable services, medical services or professional services.
"Dispensary providers" means providers who dispense drugs, medical supplies or equipment upon a prescription or order from a prescriber authorized under ch. 447
, Stats., to prescribe the items.
DHS 101.03 Note
Note: Examples of dispensary providers are pharmacies, durable medical equipment suppliers and providers of vision care supplies.
"Divestment" means the disposal of any nonexempt resource for a value received which is less than the net market value.
"Division" means the department's division of health care financing.
"Drug dispensing" means the interpretation of an order for a drug or biological and the proper selection, measuring, labeling, packaging and issuance of the drug or biological for a patient or for a service unit of a hospital or other health care facility.
"Drug index" means the list of covered legend and nonlegend drugs maintained and updated by the department.
"Durable medical equipment" means equipment which can withstand repeated use, is primarily used for medical purposes, is generally not useful to a person in the absence of illness or injury and is appropriate for use in the home.
DHS 101.03 Note
Note: Examples of "durable medical equipment" are wheelchairs, hospital beds and side rails.
"Earned income" means income received in the form of wages, salary, commissions or profits from activities in which the applicant or recipient is engaged as an employee or as a self-employed person.
"Electronic funds transfer" means any electronic transfer of a recipient's financial holdings or a portion of these holdings as determined by the recipient to another account, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.
"Emergency services" means those services which are necessary to prevent the death or serious impairment of the health of the individual.
"Employed" means the person receives income for ongoing services and as a result of this income has incurred a potential tax liability. Any of the following may be used to verify employment:
Statements from employers. Employer statements may include those from personnel officers, supervisors or other employees of the company who have direct knowledge of the applicant's or recipient's wages. The person making the statement must provide evidence (such as employment records, business correspondence, etc.) that the applicant or recipient is or was an employee of the company during the calendar month for which the applicant or recipient requests eligibility.
Other agencies who receive reports of the applicant's or recipient's income directly from the employer.
"Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80% of the cost, excluding any deductibles or copayments that may be required under the plan.
"Employment barriers assessment" means an analysis that identifies a person's potential employment barriers, such as physical limitations or problems associated with the person's living situation, education or health or long term care coverage, and strategies for overcoming these potential barriers.
"Employment plan" means a plan developed by a person describing the manner in which a person shall meet the requirements of a health and employment counseling program.
"Enrolled recipient" means a recipient who has entered into an agreement to receive services from a provider reimbursed under the terms of a prepaid capitation contract with the department.
"EPSDT" means early and periodic screening, diagnosis and treatment services provided by a provider certified pursuant to s. DHS 105.37
"EPSDT case management" means those activities necessary to:
Make arrangements and assist clients to follow through with diagnosis and treatment; and
Refer clients, upon request, to the appropriate local agencies for transportation assistance.
"EPSDT provider" means a provider certified under s. DHS 105.37
to provide EPSDT health assessment and evaluation services.
"Exempt assets" means assets which are not considered in the determination of financial eligibility for medical assistance.
"Exempt income" means income which is not considered when determining financial eligibility for medical assistance.
"Explanation of benefits notice" means the monthly report sent by the department to a recipient containing a summary of the department's record of MA claims paid on the recipient's behalf during that month.
"Eyeglasses" means lenses, including frames where necessary, and other aids to vision prescribed by a physician skilled in diseases of the eye or by a licensed optometrist.
"Fair market value" means the market value of the property on the date of the transaction.
"Fiscal agent" means the organization under contract to the department to process claims for services provided under MA.
"Fiscal test group" means all members of the medical assistance group and all persons who are financially responsible for members of the medical assistance group who live in the same household as the person for whom they are legally responsible and who are not SSI or AFDC recipients.
"Functional ability" means the skill to perform activities in a normal or acceptable manner with minimal dependence on devices, persons or environment.
"Functional status" means the recipient's skill in performing activities of daily living in a normal or acceptable manner.
"Group occupational therapy treatment" means the delivery of occupational therapy treatment procedures in a group setting, with up to 6 patients supervised by one qualified occupational therapist and more than 6 but no more than 12 patients supervised by 2 qualified occupational therapy staff members one of whom is a registered occupational therapist.
"Group speech/language pathology treatment" means the delivery of speech/language pathology treatment procedures limited to the areas of expressive language, receptive language, and hearing/auditory training (auditory training, lip reading, and hearing-aid orientation), in a group setting for up to 4 MA recipients.
"Health and employment counseling program" means services provided within a period of eligibility, which assist a person in pursuing and maintaining employment, that are assembled into an employment plan, reviewed by a screening agency, approved by the department and include all of the following:
"Health insurance coverage" has the meaning provided in 42 USC 300gg-91
(b)(1) and also includes any arrangement in which a third party agrees to pay for the health care costs of the individual.
"Health maintenance organization" or "HMO" means a public or private organization organized under ch. 185
, Stats., which makes available to enrolled participants, in consideration of predetermined periodic fixed payments, comprehensive health care services provided by providers who are selected by the organization or who have entered into a referral or contractual arrangement with the organization and which is certified under s. DHS 105.47
"Home health agency" means a public agency or private organization, or a subdivision of the agency or organization, which is primarily engaged in providing skilled nursing services and other therapeutic services to a recipient at the recipient's place of residence.
"Home health aide" means an individual employed by or under contract to a certified home health agency to provide home health aide services, as defined in s. DHS 133.02 (5)
, under the supervision of a registered nurse.
"Home health service" means any covered home health service enumerated in s. DHS 107.11 (2)
and provided by a health worker on the staff of a home health agency or by a health worker under contract or another arrangement with the home health agency.
"Homestead" or "home" means a place of abode and lands used or operated in connection with the place of abode.
DHS 101.03 Note
Note: In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead.
"Hospice" means a public agency or private organization or a subdivision of either which primarily provides palliative care to persons experiencing the last stages of terminal illness and which provides supportive care for the family and other individuals caring for the terminally ill persons. This care is provided in a homelike environment, and includes short-term inpatient care as necessary to meet the individual's needs. Services provided by a hospital, long-term care facility, outpatient surgical center or home health agency do not constitute a hospice program of care unless that entity establishes a free-standing or distinct hospice unit, or has a distinct hospice program including staff, facility and services certified under s. DHS 105.50
to provide hospice care.