DHS 101.03 Note
Note: The plan of care is designed to achieve the recipient's discharge from inpatient status at the earliest possible time.
“Activities of daily living" means activities relating to the performance of self care, work and leisure or play activities, including dressing, feeding or eating, grooming, mobility and object manipulation.
“Acute mental illness" means a mental illness which is not of life-long duration, which is severe in degree and causes a substantially diminished level of functioning in the activities of daily living and an inability to cope with the ordinary demands of life, and which may lead to an inability to maintain stable adjustment and independent functioning without short-term treatment.
“Administrator" means the person who manages a health care facility.
DHS 101.03 Note
Note: The administrator should have a bachelor's degree and either experience or specialized training in the administration of health institutions or agencies; or qualifications and experience in one of the professional health disciplines.
“AFDC" means aid to families with dependent children, a public assistance program under Title IV-A of the Social Security Act of 1935, as amended, and s. 49.19
“Agency" means the county department of social services, or human services, or a tribal agency which administers income maintenance programs.
“Ambulatory" means able to walk without personal assistance or mechanical aids, and without difficulty.
“Ambulatory prenatal care" means care and treatment for a pregnant woman and her fetus to protect and promote the woman's health and the healthy development of the fetus.
“Ambulatory surgical center" means a facility that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, and that meets the requirements of s. DHS 105.49
“Ancillary cost" means an extraordinary and unique cost incurred by a nursing home or other qualified provider of services or materials furnished to a nursing home resident, which is not included in calculating the nursing home's daily rate but which MA reimburses separately under s. DHS 107.09 (4) (a)
“ANSI" means American national standards institute.
“AODA day treatment" means alcohol and other drug abuse treatment services provided by a provider certified under s. DHS 105.25
to a recipient who, in the clinical judgement of a qualified treatment professional, is experiencing a problem with alcohol or other drugs and requires intensive services of a prescribed duration, which may include assessment and evaluation, treatment planning, group and individual counseling, recipient education when necessary for effective treatment, and rehabilitative services, to ameliorate or remove the disability and restore effective functioning.
“AODA treatment services" means alcohol and other drug abuse treatment services provided by a provider certified pursuant to s. DHS 105.22
to assist alcoholics and drug abusers and persons affected by problems related to the abuse of alcohol or drugs.
DHS 101.03 Note
Note: Examples of AODA treatment services are client evaluation, orientation and motivation, treatment planning, consultation and referral, client education, individual counseling, group counseling and crisis intervention.
“Applicant" means a person who directly or through a representative makes application for MA.
“Application for medical assistance" means the process of completing and signing a department-approved application form by which action a person indicates to the agency authorized to accept the application a desire to receive MA.
“Approved prescription drug products list" means a list prepared by the U.S. food and drug administration that identifies drug products approved on the basis of safety and effectiveness.
“Asset limit" means that limit against which nonexempt assets under ch. DHS 103
are compared to determine financial eligibility for MA.
“Assistive listening device" or “ALD" means a personal communication unit for sound amplification. One type of “assistive listening device" is a hearing aid.
“BadgerCare fiscal test group" means all members of the BadgerCare group and all persons who are financially responsible for all members of the BadgerCare group who live in the same household as the person for whom they are legally responsible and who are not SSI recipients.
“BadgerCare group" means all persons listed on an application for BadgerCare who meet nonfinancial eligibility requirements.
“Benefits counseling" means counseling that describes the effect of earned income on a person's public benefits and other support services, such as food stamps, housing assistance, supplemental security income, social security disability insurance or medical assistance.
“Board" means a community mental health board established under s. 51.42
, Stats., a developmental disabilities board established under s. 51.437
, Stats., or a community human services board established under s. 46.23
“Border-status provider" means a provider located outside of Wisconsin who regularly gives service to Wisconsin recipients and who is certified to participate in MA.
“Budgetable income" means earned and unearned income that is considered available for determining financial eligibility for MA under s. 49.46 (1)
or 49.47 (4)
, Stats., and ch. DHS 103
“Capitation fee" means a fee the department pays periodically to a provider for each recipient enrolled under a contract with the provider for the provision of medical services, whether or not the recipient receives services during the period covered by the fee.
“Case management" means activities which help MA recipients and, when appropriate, their families, identify their needs and manage and gain access to necessary medical, social, rehabilitation, vocational, educational and other services. Case management includes assessment, case plan development, and ongoing monitoring and service coordination under s. DHS 107.32
“Categorically needy" means the group of persons who meet the nonfinancial and financial eligibility conditions to be eligible for AFDC or SSI.
“CESA" means a cooperative educational service agency under ch. 116
“Chronic mental illness" means a mental illness which may be of lifelong duration, which is severe in degree and persistent in duration, which causes a substantially diminished level of functioning in the primary activities of daily living and an inability to cope with the ordinary demands of life, and which may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support.
“Claim" means a request from a provider on an approved claim form for payment for services to a recipient.
“Clinical note" means a dated written notation of contact with a patient by a member of a health care team, which contains a description of signs and symptoms, treatment or drugs given, the patient's reaction and any changes in physical or emotional condition.
“Community support program" or “CSP" means a community-based coordinated care and treatment program operated by a provider certified under s. DHS 105.255
to provide mental health and psychosocial rehabilitative services, including case management services, to MA-eligible, chronically mentally ill recipients residing in the community.
“Compensation received" means the dollar value that can be attached to what is received in return for property and, without limitation by enumeration, that is in one or more of the following forms:
Other assets such as accounts receivable and promissory notes, both of which must be valid and collectible to be of value, and stocks, bonds, and both land contracts and life estates;
Prepayment of a bona fide and irrevocable contract such as a mortgage, shelter lease or loan, or the prepayment of taxes; or
Services, for which a valuation equal to the cost of purchase on the open market is assigned.
DHS 101.03 Note
Note: The presumption that services and accommodations rendered to each other by the members of a family or other relatives were gratuitous can be rebutted only by direct and positive evidence of a prior express contract for payment.
“Concurrent review" means the department's informal review of a complaint on the basis of which a fair hearing has been requested, including an investigation into the facts of a recipient's request for a fair hearing, whereby the department attempts to achieve an informal resolution acceptable to the recipient before the fair hearing takes place.
DHS 101.03 Note
Note: This review does not preclude the recipient's right to a fair hearing.
“Conditional eligibility" means eligibility for MA which is conditional upon the applicant or recipient meeting the financial eligibility standards specified in 20 CFR 416.1240
within a predetermined period of time.
“Confined to a place of residence" means a recipient's physical medical condition or functional limitation in one or more of the areas listed in s. DHS 134.13 (9) (c)
, including self-care, understanding and use of language, learning, mobility, self-direction and capacity for independent learning, which:
Restricts the recipient's ability to leave his or her place of residence except with the aid of a supportive device such as crutches, a cane, a wheelchair or a walker, the assistance of another person or the use of special transportation;
Is such that leaving the residence is medically contraindicated; or
Requires a considerable and taxing effort to leave the home for medical services.
“Consultation" means communication between 2 or more providers concerning the diagnosis or treatment in a given case, which may include, but is not limited to, history-taking examination of the patient, rendering an opinion concerning diagnosis or treatment, or offering service, assistance or advice.
“Controlling interest or ownership" means that a person:
Possesses a direct or indirect interest in 5% or more of the issued shares of stock in a corporate entity;
Is the owner of an interest of 5% or more in any mortgage, deed of trust, note, or other secured obligation;
“Convalescent leave" means a resident's temporary release from an institution for mental diseases (IMD) to residency in a community setting, not more frequently than once a year and beginning on the fourth day after release, with the trial period of residence in the community lasting at least 4 days but not longer than 30 days or until the person is permanently discharged from the IMD, whichever occurs first.
Any shoe attached to a brace, not including arch supports, for prosthesis;
Mismated shoes involving a difference of a full size or more; or
Shoe modifications for a discrepancy in limb length or a rigid foot deformation.
“Cost-effectiveness" means the cost of paying premiums or purchasing health insurance for a medicaid purchase plan recipient through an employer and the associated administrative cost is likely to be less than or equal to the cost of providing medical assistance.
“Covered service" means a service, procedure, item or supplies for which MA reimbursement is available, provided to a recipient of MA by an MA-certified provider qualified to provide the particular service, procedure, item or supplies or under the supervision of a certified and qualified provider.
“Daily nursing home rate" means the amount that a nursing home is reimbursed for providing each day of routine health care services to a recipient who is a patient in the home, determined in accordance with s. 49.45 (6m) (a)
“Date of account creation" means the date the recipient establishes an independence account with a financial institution.
“Day treatment" or “day hospital" means a non-residential program in a medically supervised setting that provides case management, medical care, psychotherapy and other therapies, including recreational, physical, occupational and speech therapies, and follow-up services, to alleviate problems related to mental illness or emotional disturbances.
DHS 101.03 Note
Note: Day treatment services are provided by an interdisciplinary team on a routine, continuous basis for a scheduled portion of a 24-hour day and may include structural rehabilitative activities including training in basic living skills, interpersonal skills and problem-solving skills.
“Deeming" means a process by which income and assets are considered available to applicants or recipients for the purpose of determining financial eligibility for MA under s. 49.46 (1)
or 49.47 (4)
, Stats., and ch. DHS 103
“Department" means the department of health services.
“Department-approved occupancy rate" means a rate of nursing home occupancy established by the department and communicated to providers which is used for purposes of determining whether a bed-hold payment may be made to a nursing home.
“Developmental disability" means intellectual disability or a related condition such as cerebral palsy, epilepsy, or autism, but excluding mental illness and infirmities of aging, which is:
Results in substantial functional limitations in 3 or more of the following areas of major life activity:
“Differential diagnostic examination" means an examination and assessment of a recipient's emotional and social functioning which includes one or more of the following: neurologic studies, psychological tests and psycho-social assessments.
“Direct deposit" means an electronic transfer of funds from the recipient's financial institution to the medicaid purchase plan or the department's fiscal agent, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.
“Direct, immediate, on-premises supervision" means supervision with face-to-face contact between the supervisor and the person being supervised, as necessary, with the supervisor being physically present in the same building when the service is being performed by the person being supervised.
“Direct services" mean nursing home services that benefit patient recipients on an individual basis rather than a group basis, including physician visits to patients, therapy modalities, drug dispensing, radiology or laboratory services provided by a certified radiology or laboratory unit, oral exams, and physical examinations.“Direct services" are often referred to as billable services, medical services or professional services.