DHS 107.10(4)(n) (n) Drugs provided for the treatment of males or females for infertility or to enhance the prospects of fertility;
DHS 107.10(4)(o) (o) Drugs provided for the treatment of impotence;
DHS 107.10(4)(p) (p) Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual anatomy or characteristics;
DHS 107.10(4)(q) (q) Drugs or combinations of drugs that are administered to induce abortions, when the abortions do not comply with s. 20.927, Stats., and s. DHS 107.10 (3) (L).
DHS 107.10(4)(r) (r) Food;
DHS 107.10(4)(s) (s) 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
DHS 107.10(4)(t) (t) 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.
DHS 107.10(5) (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:
DHS 107.10(5)(a) (a) 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.
DHS 107.10(5)(b) (b) 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:
DHS 107.10(5)(b)1. 1. The name and description of the medication;
DHS 107.10(5)(b)2. 2. The route, dosage form, dosage, route of administration, and duration of drug therapy;
DHS 107.10(5)(b)3. 3. Specific directions and precautions for preparation, administration and use by the patient;
DHS 107.10(5)(b)4. 4. 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;
DHS 107.10(5)(b)5. 5. Techniques for self-monitoring drug therapy;
DHS 107.10(5)(b)6. 6. Proper storage;
DHS 107.10(5)(b)7. 7. Prescription refill information; and
DHS 107.10(5)(b)8. 8. Action to be taken in the event of a missed dose.
DHS 107.10(5)(c) (c) 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:
DHS 107.10(5)(c)1. 1. The individual's name, address, telephone number, date of birth or age and gender;
DHS 107.10(5)(c)2. 2. 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
DHS 107.10(5)(c)3. 3. The pharmacist's comments relevant to the individual's drug therapy.
DHS 107.10(5)(d) (d) 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 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.
DHS 107.11 DHS 107.11Home health services.
DHS 107.11(1)(1)Definitions. In this section:
DHS 107.11(1)(a) (a) “Community-based residential facility" has the meaning prescribed in s. 50.01 (1g), Stats.
DHS 107.11(1)(b) (b) “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.
DHS 107.11(1)(c) (c) “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.
DHS 107.11(1)(d) (d) “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.
DHS 107.11(1)(e) (e) “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.
DHS 107.11(1)(f) (f) “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.
DHS 107.11(1)(g) (g) “Unlicensed caregiver" means a home health aide or personal care worker.
DHS 107.11(2) (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:
DHS 107.11(2)(a) (a) 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:
DHS 107.11(2)(a)1. 1. 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;
DHS 107.11(2)(a)2. 2. Services which, due to the recipient's medical condition, may be only safely and effectively provided by an RN or LPN;
DHS 107.11(2)(a)3. 3. Assessments performed only by a registered nurse; and
DHS 107.11(2)(a)4. 4. 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.
DHS 107.11(2)(b) (b) Home health aide services are:
DHS 107.11(2)(b)1. 1. 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;
DHS 107.11(2)(b)2. 2. 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(2)(b)3. 3. Household tasks incidental to direct care activities described in subds. 1. and 2.
DHS 107.11 Note Note: For further description of home health aide services, refer to the Wisconsin Medical Assistance Home Health Agency Provider Handbook.
DHS 107.11(2)(c)1.1. 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.
DHS 107.11(2)(c)2. 2. 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.
DHS 107.11(2)(c)3. 3. 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.
DHS 107.11(2)(c)4. 4. 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.
DHS 107.11(3) (3)Prior authorization. Prior authorization is required to review utilization of services and assess the medical necessity of continuing services for:
DHS 107.11(3)(a) (a) 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;
DHS 107.11(3)(b) (b) 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;
DHS 107.11(3)(c) (c) All medical supplies and equipment for which prior authorization is required under s. DHS 107.24;
DHS 107.11(3)(d) (d) All home health aide visits when 4 or more hours of continuous care is medically necessary; and
DHS 107.11(3)(e) (e) All subsequent skilled nursing visits.
DHS 107.11(4) (4)Other limitations.
DHS 107.11(4)(a) (a) The written plan of care shall be developed and reviewed concurrently with and in support of other health sustaining efforts for the recipient in the home.
DHS 107.11(4)(b) (b) All durable medical equipment and disposable medical supplies shall meet the requirements of s. DHS 107.24.
DHS 107.11(4)(c) (c) Services provided to a recipient who is a resident of a community-based residential facility shall be rendered according to the requirements of ch. DHS 83 and shall not duplicate services that the facility has agreed to provide.
DHS 107.11(4)(d)1.1. Except as provided in subd. 2., home health skilled nursing services provided by one or more providers are limited to less than 8 hours per day per recipient as required by the recipient's medical condition.
DHS 107.11(4)(d)2. 2. If the recipient's medical condition worsens so that 8 or more hours of direct, skilled nursing services are required in a calendar day, a maximum of 30 calendar days of skilled nursing care may continue to be reimbursed as home health services, beginning on the day 8 hours or more of skilled nursing services became necessary. To continue medically necessary services after 30 days, prior authorization for private duty nursing is required under s. DHS 107.12 (2).
DHS 107.11(4)(e) (e) An intake evaluation is a covered home health skilled nursing service only if, during the course of the initial visit to the recipient, the recipient is admitted into the agency's care and covered skilled nursing services are performed according to the written physician's orders during the visit.
DHS 107.11(4)(f) (f) A skilled nursing ongoing assessment for a recipient is a covered service:
DHS 107.11(4)(f)1. 1. When the recipient's medical condition is stable, the recipient has not received a covered skilled nursing service, covered personal care service, or covered home visit by a physician service within the past 62 days, and a skilled assessment is required to re-evaluate the continuing appropriateness of the plan of care. In this paragraph, “medically stable" means the recipient's physical condition is non-acute, without substantial change or fluctuation at the current time.
DHS 107.11(4)(f)2. 2. When the recipient's medical condition requires skilled nursing personnel to identify and evaluate the need for possible modification of treatment;
DHS 107.11(4)(f)3. 3. When the recipient's medical condition requires skilled nursing personnel to initiate additional medical procedures until the recipient's treatment regimen stabilizes, but is not part of a longstanding pattern of care; or
DHS 107.11(4)(f)4. 4. If there is a likelihood of complications or an acute episode.
DHS 107.11(4)(g) (g) Teaching and training activities are covered services only when provided to the recipient, recipient's family or other caregiver in conjunction with other covered skilled nursing care provided to the recipient.
DHS 107.11(4)(h) (h) A licensed nurse shall administer medications to a minor child or to an adult who is not self-directing, as determined by the physician, to direct or administer his or her own medications, when a responsible adult is not present to direct the recipient's medication program.
DHS 107.11(4)(i) (i) Services provided by an LPN which are not delegated by an RN under s. N 6.03 are not covered services.
DHS 107.11(4)(j) (j) Skilled physical and occupational therapy and speech pathology services are not to include activities provided for the general welfare of the recipient or activities to provide diversion for the recipient or to motivate the recipient.
DHS 107.11(4)(k) (k) Skilled nursing services may be provided for a recipient by one or more home health agencies or by an agency contracting with a nurse or nurses only if the agencies meet the requirements of ch. DHS 133 and are approved by the department.
DHS 107.11(4)(L) (L) RN supervision and administrative costs associated with the provision of services under this section are not separately reimbursable MA services.
DHS 107.11(4)(m) (m) Home health aide service limitations are the following:
DHS 107.11(4)(m)1. 1. A home health aide may provide assistance with a recipient's medications only if the written plan of care documents the name of the delegating registered nurse and the recipient is aged 18 or more;
DHS 107.11(4)(m)2. 2. Home health aide services are primarily medically oriented tasks, as determined by the delegating RN, when the instability of the recipient's condition as documented in the medical record is such that the recipient's care cannot be safely delegated to a personal care worker under s. DHS 107.112;
DHS 107.11(4)(m)3. 3. A home health aide visit which is a covered service shall include at least one medically oriented task performed during a visit which cannot, in the judgment of the delegating RN, be safely delegated to a personal care worker; and
DHS 107.11(4)(m)4. 4. A home health aide, rather than a personal care worker, shall always provide medically oriented services for recipients who are under age 18.
DHS 107.11(5) (5)Non-covered services. The following services are not covered home health services:
DHS 107.11(5)(a) (a) Services that are not medically necessary;
DHS 107.11(5)(b) (b) Skilled nursing services provided for 8 or more hours per recipient per day;
DHS 107.11(5)(c) (c) More than one initial visit per day by a home health skilled nurse, home health aide, physical or occupational therapist or speech and language pathologist;
DHS 107.11(5)(d) (d) Private duty nursing services under s. DHS 107.12, unless the requirements of sub. (4) (d) 2. apply;
DHS 107.11(5)(e) (e) Services requiring prior authorization that are provided without prior authorization;
DHS 107.11(5)(f) (f) Supervision of the recipient when supervision is the only service provided at the time;
DHS 107.11(5)(g) (g) Hospice care provided under s. DHS 107.31;
DHS 107.11(5)(h) (h) Mental health and alcohol or other drug abuse services provided under s. DHS 107.13 (2), (3), (3m), (4) and (6);
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.