DHS 107.24(3)(h)1.c. c. 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;
DHS 107.24(3)(h)2. 2. 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;
DHS 107.24(3)(h)3. 3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization; and
DHS 107.24(3)(h)4. 4. 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 Note: For more information on prior authorization, see s. DHS 107.02 (3).
DHS 107.24(4) (4)Other limitations.
DHS 107.24(4)(a) (a) 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.
DHS 107.24(4)(b) (b) 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.
DHS 107.24(4)(c) (c) The services covered under this section are not covered for recipients who are nursing home residents except for:
DHS 107.24(4)(c)1. 1. Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters;
DHS 107.24(4)(c)2. 2. 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
DHS 107.24(4)(c)3. 3. 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.
DHS 107.24(4)(d) (d) 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.
DHS 107.24(4)(e) (e) 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.
DHS 107.24(4)(f) (f) 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.
DHS 107.24(4)(g) (g) Provision of hearing aid accessories shall be limited as follows:
DHS 107.24(4)(g)1. 1. For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;
DHS 107.24(4)(g)2. 2. 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
DHS 107.24(4)(g)3. 3. 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.
DHS 107.24(4)(h) (h) 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.
DHS 107.24(5) (5)Non-covered services. The following services are not covered services:
DHS 107.24(5)(a) (a) Foot orthoses or orthopedic or corrective shoes for the following conditions:
DHS 107.24(5)(a)1. 1. Flattened arches, regardless of the underlying pathology;
DHS 107.24(5)(a)2. 2. Incomplete dislocation or subluxation metatarsalgia with no associated deformities;
DHS 107.24(5)(a)3. 3. Arthritis with no associated deformities; and
DHS 107.24(5)(a)4. 4. Hypoallergenic conditions;
DHS 107.24(5)(b) (b) Services denied by medicare for lack of medical necessity;
DHS 107.24(5)(c) (c) Items which are not primarily medical in nature, such as dehumidifiers and air conditioners;
DHS 107.24(5)(d) (d) Items which are not appropriate for home usage, such as oscillating beds;
DHS 107.24(5)(e) (e) Items which are not generally accepted by the medical profession as being therapeutically effective, such as a heat and massage foam cushion pad;
DHS 107.24(5)(f) (f) Items which are for comfort and convenience, such as cushion lift power seats or elevators, or luxury features which do not contribute to the improvement of the recipient's medical condition;
DHS 107.24(5)(g) (g) Repair, maintenance or modification of rented durable medical equipment;
DHS 107.24(5)(h) (h) Delivery or set-up charges for equipment as a separate service;
DHS 107.24(5)(i) (i) Fitting, adapting, adjusting or modifying a prosthetic or orthotic device or corrective or orthopedic shoes as a separate service;
DHS 107.24(5)(j) (j) All repairs of a hearing aid or other assistive listening device performed by a dealer within 12 months after the purchase of the hearing aid or other assistive listening device. These are included in the purchase payment and are not separately reimbursable;
DHS 107.24(5)(k) (k) Hearing aid or other assistive listening device batteries which are provided in excess of the guidelines enumerated in the MA speech and hearing provider handbook;
DHS 107.24(5)(L) (L) Items that are provided for the purpose of enhancing the prospects of fertility in males or females;
DHS 107.24(5)(m) (m) Impotence devices, including but not limited to penile prostheses;
DHS 107.24(5)(n) (n) Testicular prosthesis;
DHS 107.24(5)(o) (o) Food; and
DHS 107.24(5)(p) (p) Infant formula and enteral nutritional products except as allowed under s. DHS 107.10 (2) (c).
DHS 107.24 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (3) (h) 1. and 2., eff. 7-1-89; am. (2) (d) 6., (3) (e), (h) 4., (4) (c) 2., (5) (j) and (k), r. and recr. (3) (h) (intro.), 1. and 2. and (4) (g), cr. (4) (h), Register, May, 1990, No. 413, eff. 6-1-90; r. and recr. (4) (a), Register, September, 1991, No. 429, eff. 10-1-91; am. (5) (j) to (k), cr. (5) (L) to (p), Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (b) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; CR 03-033: am. (2) (a), (3) (h) 1. (intro.), 2., and (5) (j) Register December 2003 No. 576, eff. 1-1-04.
DHS 107.25 DHS 107.25Diagnostic testing services.
DHS 107.25(1)(1)Covered services. Professional and technical diagnostic services covered by MA are laboratory services provided by a certified physician or under the physician's supervision, or prescribed by a physician and provided by an independent certified laboratory, and x-ray services prescribed by a physician and provided by or under the general supervision of a certified physician.
DHS 107.25(2) (2)Other limitations.
DHS 107.25(2)(a) (a) All diagnostic services shall be prescribed or ordered by a physician or dentist.
DHS 107.25(2)(b) (b) Laboratory tests performed which are outside the laboratory's certified areas are not covered.
DHS 107.25(2)(c) (c) Portable x-ray services are covered only for recipients who reside in nursing homes and only when provided in a nursing home.
DHS 107.25(2)(d) (d) Reimbursement for diagnostic testing services shall be in accordance with limitations set by P.L. 98-369, Sec. 2303.
DHS 107.25 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 107.26 DHS 107.26Dialysis services. Dialysis services are covered services when provided by facilities certified pursuant to s. DHS 105.45.
DHS 107.26 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 107.27 DHS 107.27Blood. The provision of blood is a covered service when provided to a recipient by a physician certified pursuant to s. DHS 105.05, a blood bank certified pursuant to s. DHS 105.46 or a hospital certified pursuant to s. DHS 105.07.
DHS 107.27 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 107.28 DHS 107.28Health maintenance organization and prepaid health plan services.
DHS 107.28(1)(1)Covered services.
DHS 107.28(1)(a)1.1. Except as provided in subd. 2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covered services at the time the medicaid HMO contract becomes effective with the exception of the following:
DHS 107.28(1)(a)1.a. a. EPSDT outreach services;
DHS 107.28(1)(a)1.b. b. County transportation by common carrier;
DHS 107.28(1)(a)1.c. c. Dental services; and
DHS 107.28(1)(a)1.d. d. Chiropractic services.
DHS 107.28(1)(a)2. 2. The department may permit an HMO to provide less than comprehensive coverage, but only if there is adequate justification and only if commitment is expressed by the HMO to progress to comprehensive coverage.
DHS 107.28(1)(b) (b) Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.
DHS 107.28(1)(c) (c) Family care benefit . A care management organization under contract with the department to provide the family care benefit under s. DHS 10.41 shall provide those MA services specified in its contract with the department and shall meet all applicable requirements under ch. DHS 10.
DHS 107.28(2) (2)Contracts. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall:
DHS 107.28(2)(a) (a) Specify the contract period;
DHS 107.28(2)(b) (b) Specify the services provided by the contractor;
DHS 107.28(2)(c) (c) Identify the MA population covered by the contract;
DHS 107.28(2)(d) (d) Specify any procedures for enrollment or reenrollment of the recipients;
DHS 107.28(2)(e) (e) Specify the amount, duration and scope of medical services to be covered;
DHS 107.28(2)(f) (f) Provide that the department may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed under the contract;
DHS 107.28(2)(g) (g) Provide that the department may audit and inspect any of the contractor's records that pertain to services performed and the determination of amounts payable under the contract and stipulate the required record retention procedures;
DHS 107.28(2)(h) (h) Provide that the contractor safeguards recipient information;
DHS 107.28(2)(i) (i) Specify activities to be performed by the contractor that are related to third-party liability requirements; and
DHS 107.28(2)(j) (j) Specify which functions or services may be subcontracted and the requirements for subcontracts.
DHS 107.28(3) (3)Other limitations. Contracted organizations shall:
DHS 107.28(3)(a) (a) Allow each enrolled recipient to choose a health professional in the organization to the extent possible and appropriate;
DHS 107.28(3)(b)1.1. Provide that all medical services that are covered under the contract and that are required on an emergency basis are available on a 24-hour basis, 7 days a week, either in the contractor's own facilities or through arrangements, approved by the department, with another provider; and
DHS 107.28(3)(b)2. 2. Provide for prompt payment by the contractor, at levels approved by the department, for all services that are required by the contract, furnished by providers who do not have arrangements with the contractor to provide the services, and are medically necessary to avoid endangering the recipient's health or causing severe pain and discomfort that would occur if the recipient had to use the contractor's facilities;
DHS 107.28(3)(c) (c) Provide for an internal grievance procedure that:
DHS 107.28(3)(c)1. 1. Is approved in writing by the department;
DHS 107.28(3)(c)2. 2. Provides for prompt resolution of the grievance; and
DHS 107.28(3)(c)3. 3. Assures the participation of individuals with authority to require corrective action;
DHS 107.28(3)(d) (d) Provide for an internal quality assurance system that:
DHS 107.28(3)(d)1. 1. Is consistent with the utilization control requirements established by the department and set forth in the contract;
DHS 107.28(3)(d)2. 2. Provides for review by appropriate health professionals of the process followed in providing health services;
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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.