DHS 107.28(3)(h) (h) Provide that HMO-enrolled recipients may be excluded from specific MA requirements, including but not limited to copayments, prior authorization requirements, and the second surgical opinion program; and
DHS 107.28(3)(i) (i) Provide that if a recipient who is a member of an HMO or other prepaid plan seeks medical services from a certified provider who is not participating in that plan without a referral from a provider in that plan, or in circumstances other than emergency circumstances as defined in 42 CFR 434.30, the recipient shall be liable for the entire amount charged for the service.
DHS 107.28 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (1) (c), Register, October, 2000, No. 538, eff. 11-1-00; correction in (1) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.29 DHS 107.29Rural health clinic services. Covered rural health clinic services are the following:
DHS 107.29(1) (1)Services furnished by a physician within the scope of practice of the profession under state law, if the physician performs the services in the clinic or the services are furnished away from the clinic and the physician has an agreement with the clinic providing that the physician will be paid by it for these services;
DHS 107.29(2) (2)Services furnished by a physician assistant or nurse practitioner if the services are furnished in accordance with the requirements specified in s. DHS 105.35;
DHS 107.29(3) (3)Services and supplies that are furnished incidental to professional services furnished by a physician, physician assistant or nurse practitioner;
DHS 107.29(4) (4)Part-time or intermittent visiting nurse care and related medical supplies, other than drugs and biologicals, if:
DHS 107.29(4)(a) (a) The clinic is located in an area in which there is a shortage of home health agencies;
DHS 107.29(4)(b) (b) The services are furnished by a registered nurse or licensed practical nurse employed by or otherwise compensated for the services by the clinic;
DHS 107.29(4)(c) (c) The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic, or that is established by a physician, physician assistant or nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and
DHS 107.29(4)(d) (d) The services are furnished to a homebound recipient. In this paragraph, “homebound recipient" means, for purposes of visiting nurse care, a recipient who is permanently or temporarily confined to a place of residence, other than a hospital or skilled nursing facility, because of a medical or health condition. The person may be considered homebound if the person leaves the place of residence infrequently; and
DHS 107.29(5) (5)Other ambulatory services furnished by a rural health clinic. In this subsection, “other ambulatory services" means ambulatory services other than the services in subs. (1), (2), and (3) that are otherwise included in the written plan of treatment and meet specific state plan requirements for furnishing those services. Other ambulatory services furnished by a rural health clinic are not subject to the physician supervision requirements under s. DHS 105.35.
DHS 107.29 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; corrections in (2) and (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.30 DHS 107.30Ambulatory surgical center services.
DHS 107.30(1)(1)Covered services. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulatory surgical center. The physician shall demonstrate that the recipient requires general or local anesthesia, and a postanesthesia observation time, and that the services could not be performed safely in an office setting. These services shall be performed in conformance with generally-accepted medical practice. Covered ambulatory surgical center services shall be limited to the following procedures:
DHS 107.30(1)(a) (a) Surgical procedures:
DHS 107.30(1)(a)1.1. Adenoidectomy or tonsillectomy;
DHS 107.30(1)(a)2. 2. Arthroscopy;
DHS 107.30(1)(a)3. 3. Breast biopsy;
DHS 107.30(1)(a)4. 4. Bronchoscopy;
DHS 107.30(1)(a)5. 5. Carpal tunnel;
DHS 107.30(1)(a)6. 6. Cervix biopsy or conization;
DHS 107.30(1)(a)7. 7. Circumcision;
DHS 107.30(1)(a)8. 8. Dilation and curettage;
DHS 107.30(1)(a)9. 9. Esophago-gastroduodenoscopy;
DHS 107.30(1)(a)10. 10. Ganglion resection;
DHS 107.30(1)(a)11. 11. Hernia repair;
DHS 107.30(1)(a)12. 12. Hernia — umbilical;
DHS 107.30(1)(a)13. 13. Hydrocele resection;
DHS 107.30(1)(a)14. 14. Laparoscopy, peritoneoscopy or other sterilization methods;
DHS 107.30(1)(a)15. 15. Pilonidal cystectomy;
DHS 107.30(1)(a)16. 16. Procto-colonoscopy;
DHS 107.30(1)(a)17. 17. Tympanoplasty;
DHS 107.30(1)(a)18. 18. Vasectomy;
DHS 107.30(1)(a)19. 19. Vulvar cystectomy; and
DHS 107.30(1)(a)20. 20. Any other surgical procedure that the department determines shall be covered and that the department publishes notice of in the MA provider handbook; and
DHS 107.30(1)(b) (b) Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par. (a):
DHS 107.30(1)(b)1. 1. Complete blood count (CBC);
DHS 107.30(1)(b)2. 2. Hemoglobin;
DHS 107.30(1)(b)3. 3. Hematocrit;
DHS 107.30(1)(b)4. 4. Urinalysis;
DHS 107.30(1)(b)5. 5. Blood sugar;
DHS 107.30(1)(b)6. 6. Lee white coagulant; and
DHS 107.30(1)(b)7. 7. Bleeding time.
DHS 107.30(2) (2)Services requiring prior authorization. Any surgical procedure under s. DHS 107.06 (2) requires prior authorization.
DHS 107.30 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).
DHS 107.30(3) (3)Other limitations.
DHS 107.30(3)(a) (a) A sterilization is a covered service only if the procedures specified in s. DHS 107.06 (3) are followed.
DHS 107.30(3)(b) (b) A surgical procedure under sub. (1) (a) which requires a second surgical opinion, as specified in s. DHS 104.04, is a covered service only when the requirements specified by the department and published in the MA provider handbook are followed.
DHS 107.30 Note Note: Section DHS 104.04 was repealed eff. 2-1-19.
DHS 107.30(3)(c) (c) Reimbursement for ambulatory surgical center services shall include but is not limited to:
DHS 107.30(3)(c)1. 1. Nursing, technician, and related services;
DHS 107.30(3)(c)2. 2. Use of ambulatory surgical center facilities;
DHS 107.30(3)(c)3. 3. Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;
DHS 107.30(3)(c)4. 4. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;
DHS 107.30(3)(c)5. 5. Administrative, recordkeeping and housekeeping items and services; and
DHS 107.30(3)(c)6. 6. Materials for anesthesia.
DHS 107.30(4) (4)Non-covered services.
DHS 107.30(4)(a) (a) Ambulatory surgical center services and items for which payment may be made under other provisions of this chapter are not covered services. These include:
DHS 107.30(4)(a)1. 1. Physician services;
DHS 107.30(4)(a)2. 2. Laboratory services;
DHS 107.30(4)(a)3. 3. X-ray and other diagnostic procedures, except those directly related to performance of the surgical procedure;
DHS 107.30(4)(a)4. 4. Prosthetic devices;
DHS 107.30(4)(a)5. 5. Ambulance services;
DHS 107.30(4)(a)6. 6. Leg, arm, back and neck braces;
DHS 107.30(4)(a)7. 7. Artificial limbs; and
DHS 107.30(4)(a)8. 8. Durable medical equipment for use in the recipient's home.
DHS 107.30 Note Note: For more information on non-covered services, see s. DHS 107.03.
DHS 107.30 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.31 DHS 107.31Hospice care services.
DHS 107.31(1)(1)Definitions.
DHS 107.31(1)(a)(a) “Attending physician" means a physician who is a doctor of medicine or osteopathy certified under s. DHS 105.05 and identified by the recipient as having the most significant role in the determination and delivery of his or her medical care at the time the recipient elects to receive hospice care.
DHS 107.31(1)(b) (b) “Bereavement counseling" means counseling services provided to the recipient's family following the recipient's death.
DHS 107.31(1)(c) (c) “Freestanding hospice" means a hospice that is not a physical part of any other type of certified provider.
DHS 107.31(1)(d) (d) “Interdisciplinary group" means a group of persons designated by a hospice to provide or supervise care and services and made up of at least a physician, a registered nurse, a medical worker and a pastoral counselor or other counselor, all of whom are employees of the hospice.
DHS 107.31(1)(e) (e) “Medical director" means a physician who is an employee of the hospice and is responsible for the medical component of the hospice's patient care program.
DHS 107.31(1)(f) (f) “Respite care" means services provided by a residential facility that is an alternate place for a terminally ill recipient to stay to temporarily relieve persons caring for the recipient in the recipient's home or caregiver's home from that care.
DHS 107.31(1)(g) (g) “Supportive care" means services provided to the family and other individuals caring for a terminally ill person to meet their psychological, social and spiritual needs during the final stages of the terminal illness, and during dying and bereavement, including personal adjustment counseling, financial counseling, respite care and bereavement counseling and follow-up.
DHS 107.31(1)(h) (h) “Terminally ill" means that the medical prognosis for the recipient is that he or she is likely to remain alive for no more than 6 months.
DHS 107.31(2) (2)Covered services.
DHS 107.31(2)(a) (a) General. Hospice services covered by the MA program effective July 1, 1988 are, except as otherwise limited in this chapter, those services provided to an eligible recipient by a provider certified under s. DHS 105.50 which are necessary for the palliation and management of terminal illness and related conditions. These services include supportive care provided to the family and other individuals caring for the terminally ill recipient.
DHS 107.31(2)(b) (b) Conditions for coverage. Conditions for coverage of hospice services are:
DHS 107.31(2)(b)1. 1. Written certification by the hospice medical director, the physician member of the interdisciplinary team or the recipient's attending physician that the recipient is terminally ill;
DHS 107.31(2)(b)2. 2. An election statement shall be filed with the hospice by a recipient who has been certified as terminally ill under subd. 1. and who elects to receive hospice care. The election statement shall designate the effective date of the election. A recipient who files an election statement waives any MA covered services pertaining to his or her terminal illness and related conditions otherwise provided under this chapter, except those services provided by an attending physician not employed by the hospice. However, the recipient may revoke the election of hospice care at any time and thereby have all MA services reinstated. A recipient may choose to reinstate hospice care services subsequent to revocation. In that event, the requirements of this section again apply;
DHS 107.31(2)(b)3. 3. A written plan of care shall be established by the attending physician, the medical director or physician designee and the interdisciplinary team for a recipient who elects to receive hospice service prior to care being provided. The plan shall include:
DHS 107.31(2)(b)3.a. a. An assessment of the needs of the recipient;
DHS 107.31(2)(b)3.b. b. The identification of services to be provided, including management of discomfort and symptom relief;
DHS 107.31(2)(b)3.c. c. A description of the scope and frequency of services to the recipient and the recipient's family; and
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.