DHS 101.03(56)
(56) “EPSDT provider" means a provider certified under s.
DHS 105.37 to provide EPSDT health assessment and evaluation services.
DHS 101.03(58)
(58) “Exempt assets" means assets which are not considered in the determination of financial eligibility for medical assistance.
DHS 101.03(59)
(59) “Exempt income" means income which is not considered when determining financial eligibility for medical assistance.
DHS 101.03(60)
(60) “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.
DHS 101.03(61)
(61) “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.
DHS 101.03(63)
(63) “Fair market value" means the market value of the property on the date of the transaction.
DHS 101.03(64)
(64) “Fiscal agent" means the organization under contract to the department to process claims for services provided under MA.
DHS 101.03(65)
(65) “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.
DHS 101.03(66)
(66) “Functional ability" means the skill to perform activities in a normal or acceptable manner with minimal dependence on devices, persons or environment.
DHS 101.03(66m)
(66m) “Functionally equivalent” means a service provided via telehealth where the transmission of information is of sufficient quality as to be the same level of service as an in person visit. Transmission of voices, images, data, or video must be clear and understandable.
DHS 101.03(67)
(67) “Functional status" means the recipient's skill in performing activities of daily living in a normal or acceptable manner.
DHS 101.03(68)
(68) “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.
DHS 101.03(69)
(69) “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.
DHS 101.03(69g)
(69g) “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:
DHS 101.03(69m)
(69m) “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.
DHS 101.03(70)
(70) “Health maintenance organization" or “HMO" means a public or private organization organized under ch.
185,
611 or
613, 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.
DHS 101.03(71)
(71) “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.
DHS 101.03(72)
(72) “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.
DHS 101.03(73)
(73) “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.
DHS 101.03(75)
(75) “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.
DHS 101.03(75m)
(75m) “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.
DHS 101.03(77)
(77) “Hospital visit" means at least an overnight stay by a nursing home recipient in a certified hospital.
DHS 101.03(78)
(78) “Hysterectomy" means a medical procedure or surgery to remove the recipient's uterus.
DHS 101.03(78r)
(78r) “IFSP" means an individualized family service plan developed under s.
51.44, Stats.
DHS 101.03(78s)
(78s) “Incapacitation". For purposes of BadgerCare, means that there has been a finding that the individual's physical or mental incapacity to provide proper parental care. The incapacitation shall be expected to last for a period of at least 30 days. The agency director shall make the incapacitation decision or a designee based on competent medical testimony. The incapacitation shall be of such a debilitating nature as to reduce substantially or eliminate the parent's ability to support care for the child.
DHS 101.03(78u)
(78u) “Impairment-related work expense" means a cost paid for by a medicaid purchase plan applicant or recipient to work that is all the following:
DHS 101.03(78u)(b)
(b) Not a cost that any similar worker, without a disability, would also have.
DHS 101.03(78u)(c)
(c) Not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.
DHS 101.03(78u)(d)
(d) Representative of the standard charge for the item or service in the applicant's or recipient's community.
DHS 101.03 Note
Note: Impairment-related work expenses are as described in
20 CFR 404.1576.
DHS 101.03(79)
(79) “Income disregard" means an earned or unearned income which is not considered in one or more financial tests of eligibility.
DHS 101.03(80)
(80) “Income limit" means the limit against which budgetable income is compared to determine financial eligibility.
DHS 101.03(80m)
(80m) “Independence account" means an account approved by the department that consists solely of savings, dividends and gains derived from savings and income earned from paid employment after the initial date that a person began receiving medical assistance under the medicaid purchase plan.
DHS 101.03(81)
(81) “Independent provider of service" means an individual or agency which is eligible to provide health care services to nursing home recipients, to have a provider number, and to submit claims for reimbursement under MA. “Independent provider of service" includes: a physician, dentist, chiropractor, registered physical therapist, certified occupational therapist, certified speech therapist, certified audiologist, psychiatrist, pharmacist, ambulance service agency, specialized medical vehicle service agency, psychologist, x-ray clinic and laboratory.
DHS 101.03(82)
(82) “Indirect services" means nursing home services that benefit patient recipients on a group basis rather than an individual basis, including consulting, in-service training, medical direction, utilization review, and the services of unlicensed or uncertified assistants who are not under direct supervision. “Indirect services" are often referred to as nonbillable services, nonmedical services or nonprofessional services.
DHS 101.03(83)
(83) “Individual occupational therapy treatment" means delivery by one therapist to one recipient of occupational therapy treatment procedures as prescribed in the individual patient's plan of care for the purpose of restoring, improving or maintaining optimal functioning.
DHS 101.03(84)
(84) “Individual speech/language pathology treatment" means delivery by one therapist to one recipient of speech/language pathology treatment procedures, as prescribed in the individual recipient's plan of care, for the purpose of restoring, improving, or maintaining optimal speech and language functioning.
DHS 101.03(85)
(85) “Inmate of a public institution" means a person who has resided for at least a full calendar month in an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control and has received treatment or services there that are appropriate to his or her requirements.
DHS 101.03(85m)
(85m) “Institution for mental disease" or “IMD" means an institution that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services, as determined by the department or the federal health care financing administration. An institution is an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental disease.
DHS 101.03(86)
(86) “Institutionalized" means being a patient in a medical institution or a resident of an intermediate care facility or skilled nursing facility.
DHS 101.03(87)
(87) “Institutionalized individual" means an individual who is:
DHS 101.03(87)(a)
(a) Involuntarily confined or detained in a rehabilitative facility, such as a psychiatric hospital or other facility for the care and treatment of mental illness, or under a civil or criminal statute in a correctional facility; or
DHS 101.03(87)(b)
(b) Confined, under a voluntary commitment, in a psychiatric hospital or other facility for the care and treatment of mental illness.
DHS 101.03(88)
(88) “Institutional provider" means a hospital, home health agency, county department operated facility, rehabilitation agency, portable x-ray provider, independent clinical laboratory, rural health clinic, skilled nursing facility, intermediate care facility, case management agency provider, personal care provider, ambulatory surgical center or hospice which is:
DHS 101.03(88)(b)
(b) Eligible to receive payment only as a certified group or organization, rather than as individuals providing services within a facility or agency; and
DHS 101.03(88)(c)
(c) Required by the department to establish that its personnel who provide services meet the applicable certification criteria contained in ch.
DHS 105, although they need not be separately certified by the department.
DHS 101.03(89)
(89) “Intermediate care facility" or “ICF" means a facility that:
DHS 101.03(89)(a)
(a) Provides, on a regular basis, health-related services to individuals who do not require hospital or skilled nursing facility care but whose mental or physical condition requires services that are above the level of room and board and that can be made available only through institutional facilities;
DHS 101.03(90)
(90) “Intermediate care services" means services provided by an intermediate care facility.
DHS 101.03(91)
(91) “Intermittent nursing services" means nursing services provided to a recipient who has a medically predictable recurring need for skilled nursing services. In most instances, this means that the recipient requires a skilled nursing visit at least once every 60 days.
DHS 101.03(92)
(92) “Laboratory" or “clinical laboratory" means a facility for the microbiological, serological, chemical, hematological, radiobiassay cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention or treatment of any disease or assessment of a medical condition.
DHS 101.03(92)(a)
(a) “Independent laboratory" means a laboratory performing diagnostic tests which is independent both of an attending or consulting physician's office and of a hospital.
DHS 101.03(92)(b)
(b) “Hospital laboratory" means a laboratory operated under the supervision of a hospital or its organized medical staff that serves hospital patients.
DHS 101.03(92)(c)
(c) “Physician's office laboratory" means a laboratory maintained by a physician for performing diagnostic tests for his or her own patients.
DHS 101.03 Note
Note: A physician's office laboratory which accepts at least 100 specimens in any category during any calendar year on referral from other physicians is considered an independent laboratory.
DHS 101.03(93)
(93) “Legally responsible" means a spouse's liability for the support of a spouse or a parent's liability for the support of a child as specified in s.
49.90, Stats.
DHS 101.03(94)
(94) “Legend drug" means, for the purposes of MA, any drug requiring a prescription under
21 USC 353 (b).
DHS 101.03(94p)
(94p) “Medicaid review period" is the calendar month of a medical assistance recipient's application plus 11 calendar months or the medicaid eligibility review calendar month plus 11 calendar months.
DHS 101.03(94r)
(94r) “Medical expense" means a cost paid by a medicaid purchase plan recipient for goods or services that have been prescribed or provided by a medical practitioner licensed in Wisconsin or another state. The cost is not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.
DHS 101.03(95)
(95) “Medical assistance" or “MA" means the assistance program operated by the department under ss.
49.43 to
49.497 and
49.665, Stats., any services or items under ss.
49.45 to
49.497, Stats., and this chapter and chs.
DHS 102 to
108, or any payment or reimbursement made for these services or items.
DHS 101.03(96)
(96) “Medical assistance group" or “MA group" means all persons listed on an application for MA who meet nonfinancial eligibility requirements, except that each AFDC recipient, SSI recipient, and each child with no legally responsible relative comprises a separate MA group.
DHS 101.03(96m)(a)
(a) Required to prevent, identify or treat a recipient's illness, injury or disability; and
DHS 101.03(96m)(b)1.
1. Is consistent with the recipient's symptoms or with prevention, diagnosis or treatment of the recipient's illness, injury or disability;
DHS 101.03(96m)(b)2.
2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;
DHS 101.03(96m)(b)3.
3. Is appropriate with regard to generally accepted standards of medical practice;
DHS 101.03(96m)(b)4.
4. Is not medically contraindicated with regard to the recipient's diagnoses, the recipient's symptoms or other medically necessary services being provided to the recipient;
DHS 101.03(96m)(b)6.
6. Is not duplicative with respect to other services being provided to the recipient;
DHS 101.03(96m)(b)7.
7. Is not solely for the convenience of the recipient, the recipient's family or a provider;
DHS 101.03(96m)(b)8.
8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and
DHS 101.03(96m)(b)9.
9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.
DHS 101.03(97)
(97) “Medically needy" means the group of persons who meet the non-financial eligibility conditions for AFDC or SSI, but whose income exceeds the financial eligibility limits for those programs.
