“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.
“Complex rehabilitation technology professional” means an individual who is certified as an assistive technology professional by the Rehabilitation Engineering and Assistive Technology Society of North America.
“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.
“Dispensary providers" means providers who dispense drugs, medical supplies or equipment upon a prescription or order from a prescriber authorized under ch. 447
, Stats., to prescribe the items.
DHS 101.03 Note
Note: Examples of dispensary providers are pharmacies, durable medical equipment suppliers and providers of vision care supplies.
“Divestment" means the disposal of any nonexempt resource for a value received which is less than the net market value.
“Division" means the department's division of health care financing.
“Drug dispensing" means the interpretation of an order for a drug or biological and the proper selection, measuring, labeling, packaging and issuance of the drug or biological for a patient or for a service unit of a hospital or other health care facility.
“Drug index" means the list of covered legend and nonlegend drugs maintained and updated by the department.
“Durable medical equipment" means equipment which can withstand repeated use, is primarily used for medical purposes, is generally not useful to a person in the absence of illness or injury and is appropriate for use in the home.
DHS 101.03 Note
Note: Examples of “durable medical equipment" are wheelchairs, hospital beds and side rails.
“Earned income" means income received in the form of wages, salary, commissions or profits from activities in which the applicant or recipient is engaged as an employee or as a self-employed person.
“Electronic funds transfer" means any electronic transfer of a recipient's financial holdings or a portion of these holdings as determined by the recipient to another account, 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.
“Emergency services" means those services which are necessary to prevent the death or serious impairment of the health of the individual.
“Employed" means the person receives income for ongoing services and as a result of this income has incurred a potential tax liability. Any of the following may be used to verify employment:
Statements from employers. Employer statements may include those from personnel officers, supervisors or other employees of the company who have direct knowledge of the applicant's or recipient's wages. The person making the statement must provide evidence (such as employment records, business correspondence, etc.) that the applicant or recipient is or was an employee of the company during the calendar month for which the applicant or recipient requests eligibility.
Other agencies who receive reports of the applicant's or recipient's income directly from the employer.
“Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80% of the cost, excluding any deductibles or copayments that may be required under the plan.
“Employment barriers assessment" means an analysis that identifies a person's potential employment barriers, such as physical limitations or problems associated with the person's living situation, education or health or long term care coverage, and strategies for overcoming these potential barriers.
“Employment plan" means a plan developed by a person describing the manner in which a person shall meet the requirements of a health and employment counseling program.
“Enrolled recipient" means a recipient who has entered into an agreement to receive services from a provider reimbursed under the terms of a prepaid capitation contract with the department.
“EPSDT" means early and periodic screening, diagnosis and treatment services provided by a provider certified pursuant to s. DHS 105.37
“EPSDT case management" means those activities necessary to:
Make arrangements and assist clients to follow through with diagnosis and treatment; and
Refer clients, upon request, to the appropriate local agencies for transportation assistance.
“EPSDT provider" means a provider certified under s. DHS 105.37
to provide EPSDT health assessment and evaluation services.
“Exempt assets" means assets which are not considered in the determination of financial eligibility for medical assistance.
“Exempt income" means income which is not considered when determining financial eligibility for medical assistance.
“Explanation of benefits notice" means the monthly report sent by the department to a recipient containing a summary of the department's record of MA claims paid on the recipient's behalf during that month.
“Eyeglasses" means lenses, including frames where necessary, and other aids to vision prescribed by a physician skilled in diseases of the eye or by a licensed optometrist.
“Fair market value" means the market value of the property on the date of the transaction.
“Fiscal agent" means the organization under contract to the department to process claims for services provided under MA.