Transportation by SMV shall be covered only if the purpose of the trip is to receive an MA-covered service. Documentation of the name and address of the service provider shall be kept by the SMV provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first.
Charges for waiting time are covered charges. Waiting time is allowable only when a to-and-return trip is being billed. Waiting time may only be charged for one recipient when the transportation provider or driver waits for more than one recipient at one location in close proximity to where the MA-covered services are provided and no other trips are made by the vehicle or driver while the service is provided to the recipient. In this subdivision, “waiting time" means time when the transportation provider is waiting for the recipient to receive MA covered services and return to the vehicle.
Services of a second SMV transportation attendant are covered only if the recipient's condition requires the physical presence of another person for purposes of restraint or lifting. The transportation provider shall obtain a statement of the appropriateness of the second attendant from the physician, physician assistant, nurse midwife or nurse practitioner attesting to the need for the service and shall retain that statement.
A trip to a sheltered workshop or other nonmedical facility is covered only when the recipient is receiving an MA-covered service there on the dates of transportation and the medical services are of the level, intensity or extent consistent with the medical need defined in the recipient's plan of care.
Trips to school for MA-covered services shall be covered only if the recipient is receiving services on the day of the trip under the Individuals with Disabilities Education Act, 20 USC 33
, and the MA-covered services are identified in the recipient's individual education plan and are delivered at the school.
Unloaded mileage as defined in sub. (1) (c) 5.
is not reimbursed if there is any other passenger in the vehicle whether or not that passenger is an MA recipient.
When 2 or more recipients are being carried at the same time, the department may adjust the rates.
Additional charges for services at night or on weekends or holidays are not covered charges.
A recipient confined to a cot or stretcher may only be transported in an SMV if the vehicle is equipped with restraints which secure the cot or stretcher to the side and the floor of the vehicle. The recipient shall be medically stable and no monitoring or administration of non-emergency medical services or procedures may be done by SMV personnel.
Non-emergency transportation of a recipient by common carrier is subject to approval by the county or tribal agency or its designee before departure. The reimbursement shall be no more than an amount set by the department and shall be less per mile than the rates paid by the department for SMV purposes. Reimbursement for urgent transportation is subject to retroactive approval by the county or tribal agency or its designee.
The county or tribal agency or its designee shall reimburse the recipient or the vendor for transportation service only if the service is not provided directly by the county or tribal agency or its designee.
Transportation provided by a county or tribal agency or its designee shall involve the least costly means of transportation which the recipient is capable of using and which is reasonably available at the time the service is required. Reimbursement to the recipient shall be limited to mileage to the nearest MA provider who can provide the service if the recipient has reasonable access to health care of adequate quality from that provider. Reimbursement shall be made in the most cost-effective manner possible and only after sources for free transportation such as family and friends have been exhausted.
The county or tribal agency or its designee may require documentation by the service provider that an MA-covered service was received at the specific location.
No provider may be reimbursed more for transportation provided for an MA recipient than the provider's usual and customary charge. In this subdivision, “usual and customary charge" means the amount the provider charges or advertises as a charge for transportation except to county or tribal agencies or non-profit agencies.
(4) Non-covered services.
The following transportation services and charges related to transportation services are non-covered services:
Emergency transportation of a recipient who is pronounced dead by a legally authorized person before the ambulance is called;
Charges for excess mileage resulting from the use of indirect routes to and from destinations;
SMV transport of an ambulatory recipient, except an ambulatory recipient under sub. (1) (c) 1.
, to a methadone clinic or physician's clinic solely to obtain methadone or related services such as drug counseling or urinalysis;
Transportation by SMV to a pharmacy to have a prescription filled or refilled or to pick up medication or disposable medical supplies;
Transportation by SMV provided solely to compel a recipient to attend therapy, counseling or any other MA-covered appointment; and
Transportation to any location where no MA-covered service was provided either at the destination or pick-up point.
DHS 107.23 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.23 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; am. (1) (c) and (4) (5), Register, February, 1988, No. 386
, eff. 3-1-88; r. and recr., Register, November, 1994, No. 467
, eff. 12-1-94; correction in (3) (a) 4. made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
DHS 107.24 Durable medical equipment and medical supplies. DHS 107.24(1)(1)
In this chapter, “medical supplies" means disposable, consumable, expendable or nondurable medically necessary supplies which have a very limited life expectancy. Examples are plastic bed pans, catheters, electric pads, hypodermic needles, syringes, continence pads and oxygen administration circuits.
(a) Prescription and provision.
Durable medical equipment (DME) and medical supplies are covered services only when prescribed by a physician and when provided by a certified physician, clinic, hospital outpatient department, nursing home, pharmacy, home health agency, therapist, orthotist, prosthetist, hearing instrument specialist or medical equipment vendor.
(b) Items covered.
Covered services are limited to items contained in the Wisconsin durable medical equipment (DME) and medical supplies indices. Items prescribed by a physician which are not contained in one of these indices or in the listing of non-covered services in sub. (5)
require submittal of a DME additional request. Should the item be deemed covered, a prior authorization request may be required.
(c) Categories of durable medical equipment.
The following are categories of durable medical equipment covered by MA:
Occupational therapy assistive or adaptive equipment. This is medical equipment used in a recipient's home to assist a disabled person to adapt to the environment or achieve independence in performing daily personal functions. Examples are adaptive hygiene equipment, adaptive positioning equipment and adaptive eating utensils.
Orthopedic or corrective shoes. These are any shoes attached to a brace for prosthesis; mismatched shoes involving a difference of a full size or more; or shoes that are modified to take into account discrepancy in limb length or a rigid foot deformation. Arch supports are not considered a brace. Examples of orthopedic or corrective shoes are supinator and pronator shoes, surgical shoes for braces, and custom-molded shoes.
Orthoses. These are devices which limit or assist motion of any segment of the human body. They are designed to stabilize a weakened part or correct a structural problem. Examples are arm braces and leg braces.
Other home health care durable medical equipment. This is medical equipment used in a recipient's home to increase the independence of a disabled person or modify certain disabling conditions. Examples are patient lifts, hospital beds and traction equipment.
Oxygen therapy equipment. This is medical equipment used in a recipient's home for the administration of oxygen or medical formulas or to assist with respiratory functions. Examples are a nebulizer, a respirator and a liquid oxygen system.
Physical therapy splinting or adaptive equipment. This is medical equipment used in a recipient's home to assist a disabled person to achieve independence in performing daily activities. Examples are splints and positioning equipment.
Prostheses. These are devices which replace all or part of a body organ to prevent or correct a physical disability or malfunction. Examples are artificial arms, artificial legs and hearing aids.
Wheelchairs. These are chairs mounted on wheels usually specially designed to accommodate individual disabilities and provide mobility. Examples are a standard weight wheelchair, a lightweight wheelchair and an electrically-powered wheelchair.
(d) Categories of medical supplies.
Only approved items within the following generic categories of medical supplies are covered:
(3) Services requiring prior authorization.
The following services require prior authorization:
Purchase of all items indicated as requiring prior authorization in the Wisconsin DME and medical supplies indices, published periodically and distributed to appropriate providers by the department;
Repair or modification of an item which exceeds the department-established maximum reimbursement without prior authorization. Reimbursement parameters are published periodically in the DME and medical supplies provider handbook;
Purchase, rental, repair or modification of any item not contained in the current DME and medical supplies indices;
Purchase of items in excess of department-established frequencies or dollar limits outlined in the current Wisconsin DME and medical supplies indices;
The second and succeeding months of rental use, with the exception that all hearing aid or other assistive listening device rentals require prior authorization;
Purchase of any item which is not covered by medicare, part b, when prescribed for a recipient who is also eligible for medicare;
Any item required by a recipient in a nursing home which meets the requirements of sub. (4) (c)
Purchase or rental of a hearing aid or other assistive listening device as follows:
A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient's physician and an audiological report from an audiologist or hearing instrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing instrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines that:
The recipient has no special need which would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist;
After a new or replacement hearing aid or other ALD has been worn for a 30-day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing instrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient;
Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization; and
Provision of services in excess of the life expectancies of equipment enumerated in the MA speech and hearing provider handbook require prior authorization, except for hearing aid or other ALD batteries and repair services.
DHS 107.24 Note
For more information on prior authorization, see s. DHS 107.02 (3)
Payment for medical supplies ordered for a patient in a medical institution is considered part of the institution's cost and may not be billed directly to the program by a provider. Durable medical equipment and medical supplies provided to a hospital inpatient to take home on the date of discharge are reimbursed as part of the inpatient hospital services. No recipient may be held responsible for charges or services in excess of MA coverage under this paragraph.
Prescriptions shall be provided in accordance with s. DHS 107.02 (2m) (b)
and may not be filled more than one year from the date the medical equipment or supply is ordered.
The services covered under this section are not covered for recipients who are nursing home residents except for:
Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters;
Durable medical equipment which is personalized in nature or custom-made for a recipient and is to be used by the recipient on an individual basis for hygienic or other reasons. These items are orthoses, prostheses including hearing aids or other assistive listening devices, orthopedic or corrective shoes, special adaptive positioning wheelchairs and electric wheelchairs. Coverage of a special adaptive positioning wheelchair or electric wheelchair shall be justified by the diagnosis and prognosis and the occupational or vocational activities of the resident recipient; and
A wheelchair prescribed by a physician if the wheelchair will contribute towards the rehabilitation of the resident recipient through maximizing his or her potential for independence, and if the recipient has a long-term or permanent disability and the wheelchair requested constitutes basic and necessary health care for the recipient consistent with a plan of health care, or the recipient is about to transfer from a nursing home to an alternate and more independent setting.
The provider shall weigh the costs and benefits of the equipment and supplies when considering purchase or rental of DME and medical supplies.
DHS 107.24 Note
Note: The program's listing of covered services and the maximum allowable reimbursement schedules are based on basic necessity. Although the program does not intend to exclude any manufacturer of equipment, reimbursement is based on the cost-benefit of equipment when comparable equipment is marketed at less cost. Several medical supply items are reimbursed according to generic pricing.
The department may determine whether an item is to be rented or purchased on behalf of a recipient. In most cases equipment shall be purchased; however, in those cases where short-term use only is needed or the recipient's prognosis is poor, only rental of equipment shall be authorized.
Orthopedic or corrective shoes or foot orthoses shall be provided only for postsurgery conditions, gross deformities, or when attached to a brace or bar. These conditions shall be described in the prior authorization request.
Provision of hearing aid accessories shall be limited as follows:
For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;
For recipients over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per recipient per year; and
For all recipients: one harness, one contralateral routing of signals (CROS) fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per recipient per year.
If a prior authorization request is approved, the person shall be eligible for MA reimbursement for the service on the date the final ear mold is taken.
(5) Non-covered services.
The following services are not covered services:
Foot orthoses or orthopedic or corrective shoes for the following conditions: