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 105.04 Supervision 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(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 105.055 Nurse 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 105.06 Dentists and dental hygienists. 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 105.07 General 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(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 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 105.075 Rehabilitation 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 Note
Note: Section DHS 124.21 has been repealed.
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 105.08 Skilled 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(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)(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)(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 105.10 SNFs 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 105.11 Intermediate 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 105.12 ICFs 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 105.14(1)(a)(a)
Introduction. In accordance with s.
49.45 (2) (a) 11. and
(47) (a) and
(b), Stats., this section is promulgated to establish regulations and standards for the care, treatment or services, and health, safety, rights, well-being and welfare of participants in certified adult day care centers (ADCCs). This section is promulgated to ensure that each ADCC provides a supportive environment in a community-based group setting that is the least restrictive of each participant's freedom, and that care and services are provided in a manner that protects the rights and dignity of each participant.
DHS 105.14(1)(b)2.
2. “Accessible” means barriers are not present that prevent a person from entering, leaving, or functioning within an ADCC without physical help.
DHS 105.14(1)(b)3.
3. “Activities of daily living” or “ADL” means bathing, eating, oral hygiene, dressing, toileting, incontinence care, mobility and transferring from one surface to another such as from a bed to a chair.
DHS 105.14(1)(b)5.
5. “Adult day care center” or “ADCC” means an entity that provides services for part of a day in a group setting to adults who need an enriched health, supportive or social experience, and who may need assistance with activities of daily living, supervision, or protection.
DHS 105.14(1)(b)7.
7. “Assessment” means gathering and analyzing information about a prospective or existing participant's needs and abilities as provided in sub.
(7) (a).
DHS 105.14(1)(b)9.
9. “Chemical restraint” means a psychotropic medication used for discipline or convenience, and not required to treat medical symptoms.
DHS 105.14(1)(b)11.a.
a. The health care agent under an activated power of attorney for health care under ch.
155, Stats.
DHS 105.14(1)(b)12.
12. “Medication administration” means the direct injection, ingestion or other application of a prescription or over-the-counter drug or device to a participant, but does not include reminders to take the medication. Medication administration can be performed by any of the following:
DHS 105.14(1)(b)15.
15. “Nursing care” means nursing procedures, other than personal or supportive care, that a registered nurse or a licensed practical nurse performs directly on or to a participant.
