Provision of special dietary supplements used for tube feeding or oral feeding of nursing home recipients shall be included in the nursing home daily rate pursuant to s. DHS 107.09 (2) (b)
To be included as a covered service, a non-legend drug shall be used in the treatment of a diagnosable medical condition and be a rational part of an accepted medical treatment plan. The following general categories of non-legend drugs are covered:
Non-legend drugs not within one of the categories described under subds. 1.
that previously had legend drug status and that the department has determined to be cost effective in treating the condition for which the drugs are prescribed.
Any innovator multiple–source drug is a covered service only if the prescribing provider under sub. (1)
certifies by writing the phrase “brand medically necessary" on the prescription to the pharmacist that the innovator brand drug, rather than a generic drug, is medically necessary. The prescribing provider shall document in the patient's record the reason why the innovator brand drug is medically necessary. The innovators of multiple source drug are identified in the Wisconsin medicaid drug index.
A drug produced by a manufacturer who does not meet the requirements of 42 USC 1396r-8
may be a covered service if the department determines that the drug is medically necessary and cost-effective in treating the condition for which it is prescribed.
The department may determine whether or not a drug judged by the U.S. food and drug administration to be “less than effective"shall be reimbursed under the program based on the medical appropriateness and cost-effectiveness of the drug.
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.
(4) Non-covered services.
The department may create a list of drugs or drug categories to be excluded from coverage, known as the medicaid negative drug list. These non-covered drugs may include drugs determined “less than effective" by the U.S. food and drug administration, drugs not covered by 42 USC 1396r-8
, drugs restricted under 42 USC 1396r-8
(d) (2) and experimental or other drugs which have no medically accepted indications. In addition, the following are not covered services:
Claims of a pharmacy provider for reimbursement for drugs and medical supplies included in the daily rate for nursing home recipients;
Cosmetics such as non-therapeutic skin lotions and sun screens;
Common medicine chest items such as antiseptics and band-aids;
Personal hygiene items such as tooth paste and cotton balls;
“Patent" medicines such as drugs or other medical preparations that can be bought without a prescription;
Drugs not listed in the medicaid index, including over-the-counter drugs not included in sub. (3) (h)
and legend drugs;
Drugs included in the medicaid negative drug formulary maintained by the department; and
Drugs provided for the treatment of males or females for infertility or to enhance the prospects of fertility;
Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual anatomy or characteristics;
Infant formula, except when the product and recipient's health condition meet the criteria established by the department under sub. (2) (c)
to verify medical need; and
Enteral nutritional products that do not meet the criteria established by the department under sub. (2) (c)
to verify medical need, when an alternative nutrition source is available, or that are solely for the convenience of the caregiver or the recipient.
(5) Drug review, counseling and recordkeeping.
In addition to complying with ch. Phar 7
, a pharmacist shall fulfill the requirements of 42 USC 1396r-8
(g) (2) (A) as follows:
The pharmacist shall review the drug therapy before each prescription is filled or delivered to an MA recipient. The review shall include screening for potential drug therapy problems including therapeutic duplication, drug–disease contraindications, drug–drug interactions, including serious interactions with non-legend drugs, incorrect drug dosage or duration of drug treatment, drug–allergy interactions and clinical abuse or misuse.
The pharmacist shall offer to discuss with each MA recipient, the recipient's legal representative or the recipient's caregiver who presents the prescription, matters which, in the exercise of the pharmacist's professional judgment and consistent with state statutes and rules governing provisions of this information, the pharmacist deems significant, including the following:
The route, dosage form, dosage, route of administration, and duration of drug therapy;
Specific directions and precautions for preparation, administration and use by the patient;
Common severe side effects or adverse effects or interactions and therapeutic contraindications that may be encountered, including how to avoid them, and the action required if they occur;
The pharmacist shall make a reasonable effort to obtain, record and maintain at least the following information regarding each MA recipient for whom the pharmacist dispenses drugs under the MA program:
The individual's name, address, telephone number, date of birth or age and gender;
The individual's history where significant, including any disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices; and
The pharmacist's comments relevant to the individual's drug therapy.
Nothing in this subsection shall be construed as requiring a pharmacist to provide consultation when an MA recipient, the recipient's legal representative or the recipient's caregiver refuses the consultation.
DHS 107.10 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; am. (3) (h), Register, February, 1988, No. 386
, eff. 3-1-88; emerg. am. (2) (e) and (f), (4) (k), cr. (2) (g), (3) (j) and (k), (4) (L), eff. 4-27-91; r. and recr. Register, December, 1991, No. 432
, eff. 1-1-92, r. and recr. (2) (c), am. (2) (d) and (e), cr. (2) (f) and (g), (3) (L) and (4) (n) to (t), Register, January, 1997, No. 493
, eff. 2-1-97; CR 03-033
: am. (1), (2) (d), (3) (b) to (d), (h) (intro.), (i), (4) (L) and (5) (a), r. (2) (a), cr. (3) (h) 8. Register December 2003 No. 576
, eff. 1-1-04; correction in (1) made under s. 13.92 (4) (b)7.
, Stats., Register February 2014 No. 698
“Home health aide services" means medically oriented tasks, assistance with activities of daily living and incidental household tasks required to facilitate treatment of a recipient's medical condition or to maintain the recipient's health.
“Home health visit" or “visit" means a period of time of any duration during which home health services are provided through personal contact by agency personnel of less than 8 hours a day in the recipient's place of residence for the purpose of providing a covered home health service. The services are provided by a home health provider employed by a home health agency, by a home health provider under contract to a home health agency according to the requirements of s. DHS 133.19
or by arrangement with a home health agency. A visit begins when the home health provider enters the residence to provide a covered service and ends when the worker leaves the residence.
“Home health provider" means a person who is an RN, LPN, home health aide, physical or occupational therapist, speech pathologist, certified physical therapy assistant or certified occupational therapy assistant.
“Initial visit" means the first home health visit of any duration in a calendar day provided by a registered nurse, licensed practical nurse, home health aide, physical or occupational therapist or speech and language pathologist for the purpose of delivering a covered home health service to a recipient.
“Subsequent visit" means each additional visit of any duration following the initial visit in a calendar day provided by an RN, LPN or home health aide for the purpose of delivering a covered home health service to a recipient.
“Unlicensed caregiver" means a home health aide or personal care worker.
(2) Covered services.
Services provided by an agency certified under s. DHS 105.16
which are covered by MA are those reasonable and medically necessary services required in the home to treat the recipient's condition. Covered services are: skilled nursing services, home health aide services and medical supplies, equipment and appliances suitable for use in the recipient's home, and therapy and speech pathology services which the agency is certified to provide. These services are covered only when performed according to the requirements of s. DHS 105.16
and provided in a recipient's place of residence which is other than a hospital or nursing home. Home health skilled nursing and therapy services are covered only when provided to a recipient who, as certified in writing by the recipient's physician, is confined to a place of residence except that intermittent, medically necessary, skilled nursing or therapy services are covered if they are required by a recipient who cannot reasonably obtain these services outside the residence or from a more appropriate provider. Home health aide services may be provided to a recipient who is not confined to the home, but services shall be performed only in the recipient's home. Services are covered only when included in the written plan of care with supervision and coordination of all nursing care for the recipient provided by a registered nurse. Home health services include:
Skilled nursing services provided in a recipient's home under a plan of care which requires less than 8 hours of skilled nursing care per calendar day and specifies a level of care which the nurse is qualified to provide. These are:
Nursing services performed by a registered nurse, or by a licensed practical nurse under the supervision of a registered nurse, according to the written plan of care and accepted standards of medical and nursing practice, in accordance with ch. N 6
Services which, due to the recipient's medical condition, may be only safely and effectively provided by an RN or LPN;
Teaching and training of the recipient, the recipient's family or other caregivers requiring the skills on an RN or LPN.
DHS 107.11 Note
Note: For a further description of skilled nursing services, refer to the Wisconsin Medical Assistance Home Health Agency Provider Handbook.
Medically oriented tasks which cannot be safely delegated by an RN as determined and documented by the RN to a personal care worker who has not received special training in performing tasks for the specific individual, and which may include, but are not limited to, medically oriented activities directly supportive of skilled nursing services provided to the recipient. These may include assistance with and administration of oral, rectal and topical medications ordinarily self-administered and supervised by an RN according to 42 CFR 483.36
(d), chs. DHS 133
and N 6
, and assistance with activities directly supportive of current and active skilled therapy and speech pathology services and further described in the Wisconsin medical assistance home health agency provider handbook;
Assistance with the recipient's activities of daily living only when provided on conjunction with a medically oriented task that cannot be safely delegated to a personal care worker as determined and documented by the delegating RN. Assistance with the recipient's activities of daily living consists of medically oriented tasks when a reasonable probability exists that the recipient's medical condition will worsen during the period when assistance is provided, as documented by the delegating RN. A recipient whose medical condition has exacerbated during care activities sometime in the past 6 months is considered to have a condition which may worsen when assistance is provided. Activities of daily living include, but are not limited to, bathing, dressing, grooming and personal hygiene activities, skin, foot and ear care, eating, elimination, ambulation, and changing bed positions; and
DHS 107.11 Note
Note: For further description of home health aide services, refer to the Wisconsin Medical Assistance Home Health Agency Provider Handbook.
These are services provided in the recipient's home which can only be safely and effectively performed by a skilled therapist or speech pathologist or by a certified therapy assistant who receives supervision by the certified therapist according to 42 CFR 484.32
for a recipient confined to his or her home.
Based on the assessment by the recipient's physician of the recipient's rehabilitation potential, services provided are expected to materially improve the recipient's condition within a reasonable, predictable time period, or are necessary to establish a safe and effective maintenance program for the recipient.
In conjunction with the written plan of care, a therapy evaluation shall be conducted prior to the provision of these services by the therapist or speech pathologist who will provide the services to the recipient.
The therapist or speech pathologist shall provide a summary of activities, including goals and outcomes, to the physician at least every 62 days, and upon conclusion of therapy services.
(3) Prior authorization.
Prior authorization is required to review utilization of services and assess the medical necessity of continuing services for:
All home health visits when the total of any combination of skilled nursing, home health aide, physical and occupational therapist and speech pathologist visits by all providers exceeds 30 visits in a calendar year, including situations when the recipient's care is shared among several certified providers;
All home health aide visits when the services are provided in conjunction with private duty nursing under s. DHS 107.12
or the provision of respiratory care services under s. DHS 107.113