DHS 107.30 Note
For more information on prior authorization, see s. DHS 107.02 (3)
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Note: Section DHS 104.04 was repealed eff. 2-1-19.
Reimbursement for ambulatory surgical center services shall include but is not limited to:
Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;
Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;
Administrative, recordkeeping and housekeeping items and services; and
Ambulatory surgical center services and items for which payment may be made under other provisions of this chapter are not covered services. These include:
X-ray and other diagnostic procedures, except those directly related to performance of the surgical procedure;
DHS 107.30 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.30 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
“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.
“Bereavement counseling" means counseling services provided to the recipient's family following the recipient's death.
“Freestanding hospice" means a hospice that is not a physical part of any other type of certified provider.
“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.
“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.
“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.
“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.
“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.
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.
(b) Conditions for coverage.
Conditions for coverage of hospice services are:
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;
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;
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:
The identification of services to be provided, including management of discomfort and symptom relief;
A description of the scope and frequency of services to the recipient and the recipient's family; and
A statement of informed consent. The hospice shall obtain the written consent of the recipient or recipient's representative for hospice care on a consent form signed by the recipient or recipient's representative that indicates that the recipient is informed about the type of care and services that may be provided to him or her by the hospice during the course of illness and the effect of the recipient's waiver of regular MA benefits.
(c) Core services.
The following services are core services which shall be provided directly by hospice employees unless the conditions of sub. (3)
Medical social services provided by a social worker under the direction of a physician. The social worker shall have at least a bachelor's degree in social work from a college or university accredited by the council of social work education; and
Counseling services, including but not limited to bereavement counseling, dietary counseling and spiritual counseling.
(d) Other services.
Other services which shall be provided as necessary are:
Short-term inpatient care for pain control, symptom management and respite purposes.
General inpatient care necessary for pain control and symptom management shall be provided by a hospital, a skilled nursing facility certified under this chapter or a hospice providing inpatient care in accordance with the conditions of participation for Medicare under 42 CFR 418.98
Inpatient care for respite purposes shall be provided by a facility under subd. 1.
or by an intermediate care facility which meets the additional certification requirements regarding staffing, patient areas and 24 hour nursing service for skilled nursing facilities under subd. 1.
An inpatient stay for respite care may not exceed 5 consecutive days at a time.
The aggregate number of inpatient days may not exceed 20% of the aggregate total number of hospice care days provided to all MA recipients enrolled in the hospice during the period beginning November 1 of any year and ending October 31 of the following year. Inpatient days for persons with acquired immune deficiency syndrome (AIDS) are not included in the calculation of aggregate inpatient days and are not subject to this limitation.
(b) Care during periods of crisis.
Care may be provided 24 hours a day during a period of crisis as long as the care is predominately nursing care provided by a registered nurse. Other care may be provided by a home health aide or homemaker during this period. “Period of crisis" means a period during which an individual requires continuous care to achieve palliation or management of acute medical symptoms.
Services required under sub. (2) (c)
shall be provided directly by the hospice unless an emergency or extraordinary circumstance exists.
A hospice may contract for services required under sub. (2) (d)
. The contract shall include identification of services to be provided, the qualifications of the contractor's personnel, the role and responsibility of each party and a stipulation that all services provided will be in accordance with applicable state and federal statutes, rules and regulations and will conform to accepted standards of professional practice.
When a resident of a skilled nursing facility or an intermediate care facility elects to receive hospice care services, the hospice shall contract with that facility to provide the recipient's room and board. Room and board includes assistance in activities of daily living and personal care, socializing activities, administration of medications, maintaining cleanliness of the recipient's room and supervising and assisting in the use of durable medical equipment and prescribed therapies.
The hospice shall be reimbursed for care of a recipient at per diem rates set by the federal health care financing administration (HCFA).
A maximum amount, or hospice cap, shall be established by the department for aggregate payments made to the hospice during a hospice cap period. A hospice cap period begins November 1 of each year and ends October 31 of the following year. Payments made to the hospice provider by the department in excess of the cap shall be repaid to the department by the hospice provider.
The hospice shall reimburse any provider with whom it has contracted for service, including a facility providing inpatient care under par. (a)
Skilled nursing facilities and intermediate care facilities providing room and board for residents who have elected to receive hospice care services shall be reimbursed for that room and board by the hospice.
Bereavement counseling and services and expenses of hospice volunteers are not reimbursable under MA.
DHS 107.31 History
Cr. Register, February, 1988, No. 386
, eff. 3-1-88; emerg. am. (2) (a) and (3) (d) 1., r. and recr. (3) (a) 3., renum. (3) (d) 2. to 4. to be 3. to 5. and cr. (3) (d) 2., eff. 7-1-88; am. (2) (a), (3) (a) 1. and (d) 1., r. and recr. (3) (a) 3., renum. (3) (d) 2. to 4. to be 3. to 5. and cr. (3) (d) 2., Register, December, 1988, No. 396
, eff. 1-1-89; corrections in (1) (a) and (2) (a) made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
Case management services covered by MA are services described in this section and provided by an agency certified under s. DHS 105.51
or by a qualified person under contract to an agency certified under s. DHS 105.51
to help a recipient, and, when appropriate, the recipient's family gain access to, coordinate or monitor necessary medical, social, educational, vocational and other services.
Case management services under pars. (b)
are provided under s. 49.45 (25)
, Stats., as benefits to those recipients in a county in which case management services are provided who are over age 64, are diagnosed as having Alzheimer's disease or other dementia, or are members of one or more of the following target populations: developmentally disabled, chronically mentally ill who are age 21 or older, alcoholic or drug dependent, physically or sensory disabled, or under the age of 21 and severely emotionally disturbed. In this subdivision, “severely emotionally disturbed"means having emotional and behavioral problems which:
Have significantly impaired the person's functioning for 6 months or more and, without treatment, are likely to continue for a year or more. Areas of functioning include: developmentally appropriate self-care; ability to build or maintain satisfactory relationships with peers and adults; self-direction, including behavioral controls, decisionmaking, judgment and value systems; capacity to live in a family or family equivalent; and learning ability, or meeting the definition of “child with exceptional educational needs" under ch. PI 1
and s. 115.76 (3)
Require the person to receive services from 2 or more of the following service systems: mental health, social services, child protective services, juvenile justice and special education; and
Include mental or emotional disturbances diagnosable under DSM-III-R. Adult diagnostic categories appropriate for children and adolescents are organic mental disorders, psychoactive substance use disorders, schizophrenia, mood disorders, schizophreniform disorders, somatoform disorders, sexual disorders, adjustment disorder, personality disorders and psychological factors affecting physical condition. Disorders usually first evident in infancy, childhood and adolescence include pervasive developmental disorders (Axis II), conduct disorder, anxiety disorders of childhood or adolescence and tic disorders.