The person securing the consent and the physician performing the sterilization shall certify by signing the consent form that:
Before the individual to be sterilized signed the consent form, they advised the individual to be sterilized that no federally funded program benefits will be withdrawn because of the decision not to be sterilized;
They explained orally the requirements for informed consent as set forth on the consent form; and
To the best of their knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.
Except in the case of premature delivery or emergency abdominal surgery, the physician shall further certify that at least 30 days have passed between the date of the individual's signature on the consent form and the date upon which the sterilization was performed, and that to the best of the physician's knowledge and belief, the individual appeared mentally competent and knowingly and voluntarily consented to be sterilized.
In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician shall certify that the sterilization was performed less than 30 days but not less than 72 hours after informed consent was obtained because of premature delivery or emergency abdominal surgery. In the case of premature delivery, the physician shall state the expected date of delivery. In the case of abdominal surgery, the physician shall describe the emergency.
If an interpreter is provided, the interpreter shall certify that the information and advice presented orally was translated, that the consent form and its contents were explained to the individual to be sterilized and that to the best of the interpreter's knowledge and belief, the individual understood what the interpreter said.
(a) Physician's visits.
A maximum of one physician's visit per month to a recipient confined to a nursing home is covered unless the recipient has an acute condition which warrants more frequent care, in which case the recipient's medical record shall document the necessity of additional visits. The attending physician of a nursing home recipient, or the physician's assistant, or a nurse practitioner under the supervision of a physician, shall reevaluate the recipient's need for nursing home care in accordance with s. DHS 107.09 (4) (m)
(b) Services of a surgical assistant.
The services of a surgical assistant are not covered for procedures which normally do not require assistance at surgery.
Certain consultations shall be covered if they are professional services furnished to a recipient by a second physician at the request of the attending physician. Consultations shall include a written report which becomes a part of the recipient's permanent medical record. The name of the attending physician shall be included on the consultant's claim for reimbursement. The following consultations are covered:
Consultation requiring limited physical examination and evaluation of a given system or systems;
Consultation requiring a history and direct patient confrontation by a psychiatrist;
Consultation requiring evaluation of frozen sections or pathological slides by a pathologist; and
Consultation involving evaluation of radiological studies or radiotherapy by a radiologist;
Services pertaining to the cleaning, trimming, and cutting of toenails, often referred to as palliative care, maintenance care, or debridement, shall be reimbursed no more than one time for each 31-day period and only if the recipient's condition is one or more of the following:
Peripheral neuropathies involving the feet, which are associated with malnutrition or vitamin deficiency, carcinoma, diabetes mellitus, drugs and toxins, multiple sclerosis, uremia or cerebral palsy.
The cutting, cleaning and trimming of toenails, corns, callouses and bunions on multiple digits shall be reimbursed at one inclusive fee for each service which includes either one or both appendages.
For multiple surgical procedures performed on the foot on the same day, the physician shall be reimbursed for the first procedure at the full rate and the second and all subsequent procedures at a reduced rate as determined by the department.
Debridement of mycotic conditions and mycotic nails shall be a covered service in accordance with utilization guidelines established and published by the department.
The application of unna boots is allowed once every 2 weeks, with a maximum of 12 applications for each 12-month period.
(e) Second opinions.
A second medical opinion is required when a selected elective surgical procedure is prescribed for a recipient. On this occasion the final decision to proceed with surgery shall remain with the recipient, regardless of the second opinion. The second opinion physician may not be reimbursed if he or she ultimately performs the surgery. The following procedures are subject to second opinion requirements:
(f) Services performed under a physician's supervision.
Services performed under the supervision of a physician shall comply with federal and state regulations relating to supervision of covered services. Specific documentation of the services shall be included in the recipient's medical record.
(g) Dental services.
Dental services performed by a physician shall be subject to all requirements for MA dental services described in s. DHS 107.07
(h) Obesity-related procedures.
Gastric bypass or gastric stapling for obesity is limited to medical emergencies, as determined by the department.
Abortions, both surgically-induced and drug-induced, are limited to those that comply with s. 20.927
Services, including drugs, directly related to non-surgical abortions shall comply with s. 20.927
, Stats., may only be prescribed by a physician, and shall comply with MA policy and procedures as described in MA provider handbooks and bulletins.
(5) Non-covered services.
The following services are not covered services:
Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, within the meaning of s. DHS 107.03 (19)
Services performed by means of a telephone call between a physician and a recipient, including those in which the physician provides advice or instructions to or on behalf of a recipient, or between or among physicians on behalf of the recipient;
As separate charges, preoperative and postoperative surgical care, including office visits for suture and cast removal, which commonly are included in the payment of the surgical procedure;
As separate charges, transportation expenses incurred by a physician, to include but not limited to mileage;
Except as provided in sub. (3) (b) 1.
, a hysterectomy if it was performed solely for the purpose of rendering an individual permanently incapable of reproducing or, if there was more than one purpose to the procedure, it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing;
Lincocin (lincomycin) injections performed on an outpatient basis;
Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;
Services directed toward the care and correction of “flat feet";
Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;
Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;
Hospital care following admission on a Friday or Saturday, except for emergencies, accident care or obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week;
Non-emergency gastric bypass or gastric stapling for obesity; and
DHS 107.06 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.06 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; cr. (2) (cm), (4) (h) and (5) (y), am. (4) (a) 3. Register, February, 1988, No. 386
, eff. 3-1-88; am. (4) (a) 1. c., p. and q., cr. (4) (a) 1. r., Register, April, 1988, No. 388
, eff. 7-1-88; r. (2) (cm) and (5) (y), r. and recr. (4) (h), Register, December, 1988, No. 396
, eff. 1-1-89; r. (2) (zh), (zk), (zo), (zp) and (4) (a), renum. (2) (zi) to (zw) to be (zh) to (zs) and am. renum. (4) (b) to (h) to be (4) (a) to (g), cr. (2) (zt), r. (4) (a), Register, September, 1991, No. 429
, eff. 10-1-91; r. and recr. (2) (h) and (5) (a), r. (2) (zb), (zc), zl), (zn), (zp), (zq) and (zs), renum. (2) (zd), (ze) to (zk), (zm), (zo), (zr) and (zt) to be(zb), (zc) to (zi), (zj), (zk), (zL) and (zm) and am.(2) (zc) and (zm), am. (5) (w) and (x), cr. (2) (zn) and (zo), (4) (h) and (i), Register, January, 1997, No. 493
, eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520
; correction in (3) (b) 3. (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
; republication of (3) (e) 5. to reinsert text inadvertently dropped in 1991, Register February 2019 No. 758
Anesthesiology services covered by the MA program are any medically necessary medical services applied to a recipient to induce the loss of sensation of pain associated with surgery, dental procedures or radiological services. These services are performed by an anesthesiologist certified under s. DHS 105.05
, or by a nurse anesthetist or an anesthesiology assistant certified under s. DHS 105.055
. Anesthesiology services shall include preoperative, intraoperative and postoperative evaluation and management of recipients as appropriate.
A nurse anesthetist shall perform services in the presence of a supervising anesthesiologist or performing physician.
An anesthesiology assistant shall perform services only in the presence of a supervising anesthesiologist.
DHS 107.065 History
Cr. Register, September, 1991, No. 429
, eff. 10-1-91; correction in (1) made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
Covered services; dentists and physicians.
Except as provided under subs. (2)
, all of the following dental services are covered services when provided by or under the supervision of a dentist or physician within the scope of practice of dentistry as defined in s. 447.01 (8)