DHS 105.02 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 105.03 DHS 105.03Participation by non-certified persons.
DHS 105.03(1)(1)Reimbursement for emergency services. If a resident of Wisconsin or of another state who is not certified by MA in this state provides emergency services to a Wisconsin recipient, that person shall not be reimbursed for those services by MA unless the services are covered services under ch. DHS 107 and:
DHS 105.03(1)(a) (a) The person submits to the fiscal agent a provider data form and a claim for reimbursement of emergency services on forms prescribed by the department;
DHS 105.03(1)(b) (b) The person submits to the department a statement in writing on a form prescribed by the department explaining the nature of the emergency, including a description of the recipient's condition, cause of emergency, if known, diagnosis and extent of injuries, the services which were provided and when, and the reason that the recipient could not receive services from a certified provider; and
DHS 105.03(1)(c) (c) The person possesses all licenses and other entitlements required under state and federal statutes, rules and regulations, and is qualified to provide all services for which a claim is submitted.
DHS 105.03(2) (2) Reimbursement prohibited for non-emergency services. No non-emergency services provided by a non-certified person may be reimbursed by MA.
DHS 105.03(3) (3) Reimbursement determination. Based upon the signed statement and the claim for reimbursement, the department's professional consultants shall determine whether the services are reimbursable.
DHS 105.03 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 105.04 DHS 105.04Supervision of provider assistants. Provider assistants shall be supervised. Unless otherwise specified under ss. DHS 105.05 to 105.49, supervision shall consist of at least intermittent face-to-face contact between the supervisor and the assistant and a regular review of the assistant's work by the supervisor.
DHS 105.04 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 105.05 DHS 105.05Physicians and assistants.
DHS 105.05(1)(1)Physicians. For MA certification, physicians shall be licensed to practice medicine and surgery pursuant to ss. 448.05 and 448.07, Stats., and chs. Med 1, 2, 3, 4, 5 and 14.
DHS 105.05(2) (2) Physician assistants. For MA certification, physician assistants shall be certified and registered pursuant to ss. 448.05 and 448.07, Stats., and chs. Med 8 and 14.
DHS 105.05 Note Note: For covered physician services, see s. DHS 107.06.
DHS 105.05 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 105.055 DHS 105.055Nurse anesthetists and anesthesiologist assistants.
DHS 105.055(1)(1)Certified registered nurse anesthetist. For MA certification, a nurse anesthetist shall be licensed as a registered nurse pursuant to s. 441.06, Stats., and shall meet one of the following additional requirements:
DHS 105.055(1)(a) (a) Be certified by either the council on certification of nurse anesthetists or the council on recertification of nurse anesthetists; or
DHS 105.055(1)(b) (b) Have graduated within the past 18 months from a nurse anesthesia program that meets the standards of the council on accreditation of nurse anesthesia educational programs and be awaiting initial certification.
DHS 105.055(2) (2) Anesthesiologist assistant. For MA certification, an anesthesiologist assistant shall meet the following requirements:
DHS 105.055(2)(a) (a) Have successfully completed a 6 year program for anesthesiologist assistants, 2 years of which consists of specialized academic and clinical training in anesthesia; and
DHS 105.055(2)(b) (b) Work under the direct supervision of an anesthesiologist who is physically present during provision of services.
DHS 105.055 History History: Cr. Register, September, 1991, No. 429, eff. 10-1-91.
DHS 105.06 DHS 105.06Dentists and dental hygienists.
DHS 105.06(1)(1)Dentists. For MA certification, dentists shall be licensed pursuant to ss. 447.03 and 447.04, Stats.
DHS 105.06(2) (2) Dental hygienists. For MA certification, dental hygienists shall be licensed pursuant to s. 447.04 (2), Stats.; have 2 years or 3,200 hours of active practice experience as a licensed dental hygienist; and operate within the scope of dental hygiene as defined under ss. 447.01 (3) and 447.06, Stats. Written documentation showing the required experience shall be provided to the department upon application for MA certification.
DHS 105.06 Note Note: For covered dental services, see s. DHS 107.07.
DHS 105.06 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1994, No. 462; CR 05-033: renum. to be (1), cr. (2) Register August 2006 No. 608, eff. 9-1-06.
DHS 105.07 DHS 105.07General hospitals. For MA certification a hospital shall be approved as a general hospital under s. 50.35, Stats., and ch. DHS 124, shall meet conditions of participation for medicare and shall have a utilization review plan that meets the requirements of 42 CFR 456.101. No facility determined by the department or the federal health care financing administration to be an institution for mental disease (IMD) may be certified as a general hospital under this section. In addition:
DHS 105.07(1) (1)A hospital providing outpatient psychotherapy shall meet the requirements specified in s. DHS 105.22 (1) and (2);
DHS 105.07(2) (2)A hospital providing outpatient alcohol and other drug abuse (AODA) services shall meet the requirements specified in s. DHS 105.23;
DHS 105.07(3) (3)A hospital providing mental health day treatment services shall be certified under s. DHS 105.24;
DHS 105.07(4) (4)A hospital participating in a PRO review program shall meet the requirements of 42 CFR 456.101 and any additional requirements established under state contract with the PRO; and
DHS 105.07(5) (5)A hospital providing AODA day treatment services shall be certified under s. DHS 105.25.
DHS 105.07 Note Note: For certification of a hospital that is an institution for mental disease, see s. DHS 105.21. For covered hospital services, see s. DHS 107.08.
DHS 105.07 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (intro.), am. (1) to (4), cr. (5), Register, September, 1991, No. 429, eff. 10-1-91; correction in (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 105.075 DHS 105.075Rehabilitation hospitals. For MA certification, a rehabilitation hospital shall be approved as a general hospital under s. 50.35, Stats., and ch. DHS 124, including the requirements for rehabilitation services under s. DHS 124.21, shall meet conditions of participation for medicare and shall have a utilization review plan that meets the requirements of 42 CFR 456.101. No facility determined by the department or the federal health care financing administration to be an institution for mental disease (IMD) may be certified as a rehabilitation hospital under this section.
DHS 105.075 Note Note: For covered hospital services, see s. DHS 107.08.
DHS 105.075 History History: Cr. Register, September, 1991, No. 429, eff. 10-1-91; corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 105.08 DHS 105.08Skilled nursing facilities. For MA certification, skilled nursing facilities shall be licensed pursuant to s. 50.03, Stats., and ch. DHS 132.
DHS 105.08 Note Note: For covered nursing home services, see s. DHS 107.09.
DHS 105.08 History 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.
DHS 105.09 DHS 105.09Medicare bed requirement.
DHS 105.09(1)(1)Definition. In this section, “sufficient number of medicare-certified beds" means a supply of beds that accommodates the demand for medicare beds from both the home county and contiguous counties so that no dual eligible recipient is denied access to medicare SNF benefits because of a lack of available beds. In this subsection, “dual eligible recipient" means a person who qualifies for both medical assistance and medicare.
DHS 105.09(2) (2) Medicare bed obligation. Each county shall have a sufficient number of skilled nursing beds certified by the medicare program pursuant to ss. 49.45 (6m) (g) and 50.02 (2), Stats. The number of medicare-certified beds required in each county shall be at least 3 beds per 1000 persons 65 years of age and older in the county.
DHS 105.09(3) (3) Penalty.
DHS 105.09(3)(a)(a) If a county does not have sufficient medicare-certified beds as determined under sub. (1), each SNF within that county which does not have one or more medicare-certified beds shall be subject to a fine to be determined by the department of not less than $10 nor more than $100 for each day that the county continues to have an inadequate number of medicare-certified beds.
DHS 105.09(3)(b) (b) The department may not enforce penalty in par. (a) if the department has not given the SNF prior notification of criteria specific to its county which shall be used to determine whether or not the county has a sufficient number of medicare-certified beds.
DHS 105.09(3)(c) (c) If the number of medicare-certified beds in a county is reduced so that the county no longer has a sufficient number of medicare-certified beds under sub. (1), the department shall notify each SNF in the county of the number of additional medicare-certified beds needed in the county. The department may not enforce the penalty in par. (a) until 90 days after this notification has been provided.
DHS 105.09(4) (4) Exemptions.
DHS 105.09(4)(a)(a) In this subsection, a “swing-bed hospital" means a hospital approved by the federal health care financing administration to furnish skilled nursing facility services in the medicare program.
DHS 105.09(4)(b) (b) A home or portion of a home certified as an ICF-IID is exempt from this section.
DHS 105.09(4)(c) (c) The department may grant an exemption based on but not limited to:
DHS 105.09(4)(c)1. 1. Availability of a swing-bed hospital operating within a 30 mile radius of the nursing home; or
DHS 105.09(4)(c)2. 2. Availability of an adequate number of medicare-certified beds in a facility within a 30 mile radius of the nursing home.
DHS 105.09(4)(d) (d) A skilled nursing facility located within a county determined to have an inadequate number of medicare-certified beds and which has less than 100 beds may apply to the department for partial exemption from the requirements of this section. An SNF which applies for partial exemption shall recommend to the department the number of medicare-certified beds that the SNF should have to meet the requirements of this section based on the facility's analysis of the demand for medicare-certified beds in the community. The department shall review all recommendations and issue a determination to each SNF requesting a partial exemption.
DHS 105.09 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; renum. (1), (2), (3) (a) and (b) to be (2), (3), (4) (a) and (b) and am. (2) and (4) (b), cr. (1), (4) (c) and (d), Register, February, 1988, No. 386, eff. 7-1-88; 2019 Wis. Act 1: am. (4) (b) Register May 2019 No. 761, eff. 6-1-19.
DHS 105.10 DHS 105.10SNFs and ICFs with deficiencies. If the department finds a facility deficient in meeting the standards specified in s. DHS 105.08, 105.09, 105.11 or 105.12, the department may nonetheless certify the facility for MA under the conditions specified in s. DHS 132.21 and 42 CFR 442, Subpart C.
DHS 105.10 History 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.
DHS 105.11 DHS 105.11Intermediate care facilities. For MA certification, intermediate care facilities shall be licensed pursuant to s. 50.03, Stats., and ch. DHS 132.
DHS 105.11 Note Note: For covered nursing home services, see s. DHS 107.09.
DHS 105.11 History 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.
DHS 105.12 DHS 105.12ICFs for individuals with intellectual disabilities or individuals with related conditions. For MA certification, institutions for individuals with intellectual disabilities or individuals with related conditions shall be licensed pursuant to s. 50.03, Stats., and ch. DHS 134.
DHS 105.12 Note Note: For covered ICF/IID services, see s. DHS 107.09.
DHS 105.12 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1991, No. 432; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; 2019 Wis. Act 1: am. Register May 2019 No. 761, eff. 6-1-19.
DHS 105.15 DHS 105.15Pharmacies. For MA certification, pharmacies shall meet the requirements for registration and practice under ch. 450, Stats., and chs. Phar 1 to 17.
DHS 105.15 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. Register, December, 1991, No. 432, eff. 1-1-92; correction made under s. 13.92 (4) (b) 7., Stats., Register July 2011 No. 667.
DHS 105.16 DHS 105.16Home health agencies. For MA certification, a home health agency shall be certified to participate in medicare as a home health agency, be licensed pursuant to ch. DHS 133 and meet the requirements of this section as follows:
DHS 105.16(1) (1) Home health agency services. For MA certification, a home health agency shall provide part-time, intermittent skilled nursing services performed by a registered nurse or licensed practical nurse and home health aide services and may provide physical therapy, occupational therapy, speech and language pathology services and medical supplies and equipment. Services may be provided only on visits to a recipient's home and that home may not be a hospital or nursing home. Home health services shall be provided in accordance with a written plan of care, which the physician shall review at least every 62 days or when the recipient's medical condition changes, whichever occurs first.
DHS 105.16(2) (2) Home health aides.
DHS 105.16(2)(a)(a) Assignment and duties. Home health aides shall be assigned to specific recipients by a registered nurse. Written instructions for patient care shall be prepared by a registered nurse, a physical or occupational therapist or a speech and language pathologist, as appropriate. Duties shall include medically oriented tasks, assistance with the recipient's activities of daily living and household tasks as specified in s. DHS 107.11 (2) (b) and further described in the Wisconsin medical assistance home health agency provider handbook.
DHS 105.16(2)(b) (b) Supervision. A registered nurse shall make supervisory visits to the recipient's home as often as necessary, but at least every 60 days, to review, monitor and evaluate the recipient's medical condition and medical needs according to the written plan of care during the period in which agency care is being provided. The RN shall evaluate the appropriateness of the relationship between the direct care giver and the recipient, assess the extent to which goals are being met, and determine if the current level of home health services provided to the recipient continues to be appropriate to treat the recipient's medical condition and if the services are medically necessary. The supervising RN shall discuss and review with the recipient the services received by the recipient and discuss the results of the supervisory visit with the LPN, home health aide or personal care worker. The results of each supervisory visit shall be documented in the recipient's medical record.
DHS 105.16(2)(c) (c) Training. Home health aides shall be trained and tested in accordance with the requirements of s. 146.40, Stats., and ch. DHS 129. Aides shall not be assigned any tasks for which they are not trained, and training and competency in all assigned tasks shall be documented and made part of the provider's records.
DHS 105.16(3) (3) Physical therapists. Physical therapists may be employed by the home health agency or by an agency under contract to the home health agency, or may be independent providers under the contract to the home health agency.
DHS 105.16(4) (4) Occupational therapists. Occupational therapists may be employed by the home health agency or by an agency under contract to the home health agency, or may be independent providers under contract to the home health agency.
DHS 105.16(5) (5) Speech and language pathologists. Speech and language pathologists may be employed by the home health agency or by an agency under contract to the home health agency, or may be independent providers under contract to the home health agency.
DHS 105.16(6) (6) Respiratory care services.
DHS 105.16(6)(a)(a) A certified home health agency may be certified to provide respiratory care services under s. DHS 107.113 if registered nurses, licensed practical nurses and respiratory therapists employed by or under contract to the agency and providing these services are certified under ch. Med 20 and:
DHS 105.16(6)(a)1. 1. Are credentialed by the national board on respiratory care; or
DHS 105.16(6)(a)2. 2. Know how to perform services under s. DHS 107.113 (1) and have the skills necessary to perform those services. Skills required to perform services listed in s. DHS 107.113 (1) (e) to (f) are required on a case-by-case basis, as appropriate. In no case may a person provide respiratory care before that person has demonstrated competence in all areas under s. DHS 107.113 (1) (a) to (d).
DHS 105.16(6)(b) (b) A registered nurse who fulfills the requirements of this subsection shall coordinate the recipient's care.
DHS 105.16(6)(c) (c) The department shall review an agency's continued compliance with this subsection.
DHS 105.16(7) (7) Private duty nursing. A home health agency may provide private duty nursing services under s. DHS 107.12 performed by a registered nurse or licensed practical nurse.
DHS 105.16(8) (8) Cost reports. The department may, when necessary, require home health agencies to report information which is supplementary to information required on medicare cost reports.
DHS 105.16(9) (9) Department review.
DHS 105.16(9)(a)(a) Record review. The department may periodically review the records described in this section and s. DHS 106.02 (9), subject only to restrictions of law. All records shall be made immediately available upon the request of an authorized department representative.
DHS 105.16(9)(b) (b) In-home visits. As part of the review under par. (a), the department may contact recipients who have received or are receiving MA services from a home health care provider. The provider shall provide any identifying information requested by the department. The department may select the recipients for visits and may visit a recipient with the approval of the recipient or recipient's guardian. The recipient to be visited has the opportunity to have any person present whom he or she chooses, during the visit by personnel of the department or other governmental investigating agency.
DHS 105.16(9)(c) (c) Investigation of complaints. The department may investigate any complaint received by it concerning the provision of MA services by a home health care provider. Following the investigation, the department may issue a preliminary final report to the home health care provider in question, except when doing so would jeopardize any other investigation by the department or other state or federal agency.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.