DHS 152.03 DHS 152.03Eligibility and certification.
DHS 152.03(1) (1)Conditions. To be eligible for the CRD program, a patient shall:
DHS 152.03(1)(a) (a) Be a resident of Wisconsin;
DHS 152.03(1)(b) (b) Be diagnosed as having ESRD;
DHS 152.03(1)(c) (c) If eligible for medicare, register and pay the premium for coverage by medicare; and
DHS 152.03(1)(d) (d) Provide to the department or its designated agent full, truthful and correct information necessary for the department to determine patient eligibility and liability, including information about any change in income of more than 10%. A patient shall be denied reimbursement if he or she refuses to provide information, withholds information or provides inaccurate information. The department may verify or audit a certified patient's total family income. The department may redetermine a certified patient's estimated total family income for the current year based on change in the family's financial circumstances.
DHS 152.03(1)(e) (e) First apply for benefits under all other health care coverage programs for which the person may reasonably be eligible, including medicare, BadgerCare, medical assistance and SeniorCare.
DHS 152.03(2) (2)Patient certification.
DHS 152.03(2)(a)(a) Certification for coverage of dialysis shall be determined by the department upon the recommendation of a nephrologist from an approved dialysis unit. Certification for coverage of renal transplantation shall be determined by the department upon the recommendation of a transplant surgeon from an approved renal transplantation center.
DHS 152.03(2)(b) (b) A statewide list of certified ESRD patients shall be maintained either by the department or by another agency upon arrangement with the department. This list shall include names of all certified outpatient dialysis and kidney transplant patients in the state. Additional information deemed necessary and appropriate by the department shall be provided by the dialysis and transplant centers to determine eligibility and facilitate reimbursement.
DHS 152.03(2)(c) (c) The department or its fiscal agent shall certify an eligible patient for reimbursement upon receipt from any dialysis unit approved under ss. DHS 152.05 and 152.08 or renal transplantation center approved under ss. DHS 152.05 and 152.07 of a satisfactorily completed application for certification submitted on behalf of the patient.
DHS 152.03 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; emerg. am. (1) (c), eff. 9-1-93; r. and recr. (1), am. (2) (c), Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (1) (e) Register November 2004 No. 587, eff. 12-1-04.
DHS 152.035 DHS 152.035 Events which affect eligibility.
DHS 152.035(1) (1) Eligibility under the CRD program is terminated if any of the following events occur:
DHS 152.035(1)(a) (a) The patient dies.
DHS 152.035(1)(b) (b) The patient stops making medicare premium payments.
DHS 152.035(1)(c) (c) The patient moves out of the state of Wisconsin.
DHS 152.035(1)(d) (d) The patient no longer requires a regular course of chronic dialysis because the patient's kidneys resume function and the patient has not had a kidney transplant.
DHS 152.035(2) (2) An applicant who has died may be retroactively eligible for benefits only if the applicant had signed and completed an application prior to the date of the applicant's death.
DHS 152.035 History History: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04.
DHS 152.04 DHS 152.04Patient rights and responsibilities.
DHS 152.04(1)(1) A certified patient or, if the patient is a minor or has a guardian, the patient's parent or guardian shall inform the department within 30 days after there is any change in the patient's address, other sources of health care coverage, income of more than 10% or family size.
DHS 152.04(2)(a)(a) A patient applying for benefits or a certified patient may request an administrative hearing under subch. III of ch. 227, Stats., in the event that reimbursement is denied or certification is terminated.
DHS 152.04(2)(b) (b) A request for a hearing shall be in writing and shall be filed with the department of administration's division of hearings and appeals within 45 days after the date of notice of denial of reimbursement or termination of certification. A request for a hearing is considered filed upon its receipt by the division of hearings and appeals.
DHS 152.04 Note Note: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 152.04(3) (3) All information provided by a certified patient to the department or to a provider shall remain confidential and may not be used for any purpose other than to determine eligibility for benefits, patient liability and the types of medical services required for proper care. Statistical analyses of program data may not reveal patient identity.
DHS 152.04(4) (4) The department may not discriminate against or deny benefits to anyone on the basis of race, sex, age, national origin, marital status, creed, handicap, sexual orientation or ancestry.
DHS 152.04 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; am. (1), r. and recr. (2), Register, December, 1994, No. 468, eff. 1-1-95.
DHS 152.05 DHS 152.05Certification of renal transplantation centers, dialysis centers and dialysis facilities.
DHS 152.05(1) (1)Certification. For purposes of reimbursement, all ESRD units in Wisconsin that are certified under medicare shall be considered certified by the department and shall comply with the requirements of this chapter.
DHS 152.05(2) (2)Border state esrd units. A border state ESRD unit that provides medical care services to Wisconsin residents shall be considered certified by the department as a provider if it is certified under medicare. These out-of-state ESRD units shall be subject to this chapter and the same contractual agreements as Wisconsin ESRD units.
DHS 152.05 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.
DHS 152.06 DHS 152.06Provider reimbursement.
DHS 152.06(1) (1)Claim forms.
DHS 152.06(1)(a)(a) A provider shall use claim forms furnished or prescribed by the department or its fiscal agent, except that a provider may submit claims by electronic media or electronic transmission if the provider or billing service is approved by the department for electronic claims submission.
DHS 152.06(1)(b) (b) Claims shall be submitted in accordance with the claims submission requirements, claim form instruction and coding information provided by the department or its fiscal agent.
DHS 152.06(1)(c) (c) Every claim submitted shall be signed by the provider or the provider's authorized representative, certifying to the truthfulness, accuracy and completeness of the claim.
DHS 152.06(2) (2)Timeliness.
DHS 152.06(2)(a)(a) A claim shall be submitted within 24 months after the date that dialysis or transplant services were provided, except that a claim may be submitted later if the department is notified within that 24 month period that the sole reason for late submission concerns another funding source and the claim is submitted within 180 days after obtaining a decision on reimbursement from the other funding source.
DHS 152.06(2)(b) (b) A claim may not be submitted until after the patient has received the dialysis or transplant services.
DHS 152.06(3) (3)Payment.
DHS 152.06(3)(a)(a) The department shall establish allowable charges for CRD services as a basis for reimbursing providers.
DHS 152.06(3)(b) (b) Reimbursement may not be made for any portion of the cost of medical care which is payable under any other state or federal program, grant, contract or agreement.
DHS 152.06(3)(c) (c) Before submitting a claim to the CRD program, a provider shall seek payment for services provided to a certified patient from medicare, medical assistance or another health care plan if the certified patient is eligible for services under medicare, medical assistance or the other health care plan.
DHS 152.06(3)(d) (d) When benefits from medicare, medical assistance or another health care plan or other third party payer have been paid, in whole or in part to the provider, the amount of the payment from all other payers shall be indicated on or with the bill to the CRD program. The amount of the medicare, medical assistance, other health care plan or other third party payer reimbursement shall reduce the amount of the claim for CRD program payment.
DHS 152.06(3)(e) (e) If a provider receives a payment under the program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall promptly return the amount of the erroneous or excess payment to the department.
DHS 152.06(3)(f) (f) A provider may request a hearing to review a decision to deny payment or the level of payment. A request for a hearing shall be filed with the department's office of administrative hearings within 90 days after the date of the payment or decision to deny payment. A request for a hearing is considered filed upon its receipt by the office of administrative hearings. All appeals shall include written documentation and any information deemed necessary by the department. Hearings shall be conducted in accordance with subch. III of ch. 227, Stats.
DHS 152.06 Note Note: The mailing address of the Office of Administrative Hearings is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 152.06(3)(g) (g) A provider shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section.
DHS 152.06(3)(h) (h) The department shall use common methods employed by managed care programs and the medical assistance program to contain costs, including prior authorization and other limitations regarding health care utilization and reimbursement.
DHS 152.06 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; cr. (8), r. and recr. Table, Register, May, 1992, No. 437, eff. 6-1-92; emerg. r. and recr. Table cr. (6) (d), eff. 9-1-93; r. and recr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (3) (g) and (h) Register November 2004 No. 587, eff. 12-1-04.
DHS 152.065 DHS 152.065Patient liability.
DHS 152.065(1) (1)Calculation.
DHS 152.065(1)(a)(a) A certified patient's liability to contribute toward the cost of treatment shall be calculated as follows:
DHS 152.065(1)(a)1. 1. If the patient's estimated total family income for the current year exceeds 300% of the federal poverty guidelines, the patient is liable to obligate or expend a portion of that income, as specified in sub. (2), to pay the medical expenses for treatment of kidney disease before the CRD program will provide assistance in paying for treatment;
DHS 152.065(1)(a)2. 2. The patient is liable for any deductible under sub. (3);
DHS 152.065(1)(a)3. 3. The patient is liable for a coinsurance amount based on the amount reimbursable by the CRD program and family size and income in accordance with sub. (4) and Table 152.065;
DHS 152.065(1)(a)4. 4. The sum of the patient's deductibles under sub. (3) and coinsurance obligation under sub. (4) in a year may not exceed the applicable percentage of income limit in sub. (5) unless the annual deductibles under sub. (3) are greater; and
DHS 152.065(1)(a)5. 5. In addition, the patient is liable for a copayment amount under sub. (6) when the pharmacy bills the CRD program.
DHS 152.065(1)(b) (b) If there are 2 or more certified patients in the same family, the family's liability shall be limited to the liability of one member of the family.
DHS 152.065(2) (2)Income deductible. A certified patient whose estimated total family income in the current year is at or above 200% of the federal poverty guidelines shall obligate or expend the following percentage of that income to pay the cost of medical treatment for the chronic renal disease before the CRD program will provide assistance in paying for the cost of treatment:
DHS 152.065(2)(a) (a) When total family income is from 200% to 250% of the federal poverty guidelines, 0.50% of that income.
DHS 152.065(2)(b) (b) When total family income is more than 250% but not more than 275% of the federal poverty guidelines, 0.75% of that income.
DHS 152.065(2)(c) (c) When total family income is more than 275% but not more than 300% of the federal poverty guidelines, 1.0% of that income.
DHS 152.065(2)(d) (d) When total family income is more than 300% but not more than 325% of the federal poverty guidelines, 1.25% of that income.
DHS 152.065(2)(e) (e) When total family income is more than 325% but not more than 350% of the federal poverty guidelines, 2.0% of that income.
DHS 152.065(2)(f) (f) When total family income is more than 350% but not more than 375% of the federal poverty guidelines, 2.75% of that income.
DHS 152.065(2)(g) (g) When total family income is more than 375% but not more than 400% of the federal poverty guidelines, 3.5% of that income.
DHS 152.065(2)(h) (h) When total family income is more than 400% of the federal poverty guidelines, 4.5% of that income.
DHS 152.065(3) (3)Medicare-equivalent deductibles.
DHS 152.065(3)(a)(a) An amount equal to the medicare part A deductible, as defined under 42 USC 1395e and 42 CFR 409.82, shall be assessed all certified patients for the first inpatient hospital stay in a 12-month period.
DHS 152.065(3)(b) (b) An amount equal to the medicare part B deductible, as defined under 42 USC 1395L (b), shall be assessed all certified patients for the first outpatient visit in a 12-month period.
DHS 152.065(4) (4)Patient coinsurance.
DHS 152.065(4)(a)(a) The coinsurance amount which a patient pays to the provider as part of the cost of treatment of the patient's chronic renal disease shall be based on the amount reimbursable by the program.
DHS 152.065(4)(b) (b) A patient's coinsurance amount shall be determined at the time the patient is certified for coverage and redetermined annually thereafter.
DHS 152.065(4)(c) (c) The amount of a patient's coinsurance shall be related to family size and income, rounded to the nearest whole dollar, and expressed as a percentage of the charges for treatment in accordance with the schedule in Table 152.065.
DHS 152.065(5) (5)Limit on liability.
DHS 152.065(5)(a)(a) Each patient's liability in a year for medicare-equivalent deductibles under sub. (3) and coinsurance under sub. (4) may not exceed the following applicable percentage of the family's income, rounded to the nearest whole dollar, unless the annual deductibles under sub. (3) are greater:
DHS 152.065(5)(a)1. 1. For an income of up to $10,000, 3%;
DHS 152.065(5)(a)2. 2. For an income of $10,001, to $20,000, 4%;
DHS 152.065(5)(a)3. 3. For an income of $20,001 to $40,000, 5%;
DHS 152.065(5)(a)4. 4. For an income of $40,001 to $60,000, 6%;
DHS 152.065(5)(a)5. 5. For an income of $60,001 to $80,001, 7%;
DHS 152.065(5)(a)6. 6. For an income of $80,001 to $100,000, 9%; and
DHS 152.065(5)(a)7. 7. For an income of $100,001 and over, 10%.
DHS 152.065(5)(b) (b) The limit on liability under par. (a) does not include the income deductible under sub. (2).
DHS 152.065(6) (6)Patient copayment. When a pharmacy directly bills the chronic renal disease program for a prescription received by an ESRD patient, the patient is responsible for a $7.50 copayment amount for each generic drug and a $15.00 copayment amount for each brand name drug.
DHS 152.065(7) (7)Estate recovery.
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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.