Chapter DHS 103

DHS 103.09(4) (4) Timely notice. The agency shall give the recipient timely advance notice and explanation of the agency’s intention to terminate MA. This notice shall be in writing and shall be mailed to the recipient at least 10 calendar days before the effective date of the proposed action. The notice shall clearly state what action the agency intends to take and the specific regulation supporting that action, and shall explain the right to appeal the proposed action and the circumstances under which MA is continued if a fair hearing is requested.

DHS 103.09 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (3) (a), r. (2) (a), renum. (2) (b) to be (2) and am., r. and recr. (3) (b), cr. (3) (c), Register, March, 1993, No. 447, eff. 4-1-93; CR 21-067: am. (2), (3) Register March 2022 No 795, eff. 4-1-22, am. (2), (3) eff. the first day of the month after the emergency period, as defined in 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; CR 23-046: r. and recr. (2), r. (3) (a), renum. (3) (b) to (3) (b) (intro.) and am., cr. (3) (b) 1., 2., am. (3) (c) Register April 2024 No. 820, eff. 5-1-24; corrections in (2) (a), (c) (intro.), 1., 2. a. made under s. 35.17, Stats., Register April 2024 No. 820.

DHS 103.10 DHS 103.10 Redetermination of eligibility. The agency shall give the recipient timely advance notice of the date on which the recipient’s eligibility will be redetermined. This notice shall be in writing and mailed to the recipient at least 15 calendar days but no more than 30 calendar days before the redetermination date. The requirement for timely advance notice of eligibility redetermination does not apply to spend-down cases in which the period of certification is less than 60 days.

DHS 103.10 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 103.11 DHS 103.11 Presumptive eligibility for pregnant women and women diagnosed with breast or cervical cancer or precancerous conditions.

DHS 103.11(1) (1) Requirements for pregnant women. Pregnant women may be determined presumptively eligible for MA on the basis of a statement of pregnancy, and preliminary household and financial information provided by the applicant. That determination shall be made by providers or hospitals designated by the department who are qualified in accordance with this section.

DHS 103.11(1e) (1e) Provider requirements. A provider qualified to make determinations of presumptive eligibility for pregnant women, and women diagnosed with breast or cervical cancer or precancerous conditions shall meet the following requirements:

DHS 103.11(1e)(a) (a) Be certified as an MA provider under ch. DHS 105.

DHS 103.11(1e)(b) (b) Provide one or more of the following services:

DHS 103.11(1e)(b)1. 1. Outpatient hospital services.

DHS 103.11(1e)(b)2. 2. Rural health clinic services.

DHS 103.11(1e)(b)3. 3. Clinic services furnished by or under the direction of a physician.

DHS 103.11(1e)(c) (c) Receive funding or participate in a program under:

DHS 103.11(1e)(c)1. 1. The migrant health center or community health center programs under section 330 of the public health service act.

DHS 103.11(1e)(c)2. 2. The maternal and child health services block grant programs.

DHS 103.11(1e)(c)3. 3. The special supplemental food program for women, infants and children under section 17 of the child nutrition act of 1966, 42 USC 1786.

DHS 103.11(1e)(c)4. 4. The commodity supplemental food program under section 4 (a) of the agriculture and consumer protection act of 1973.

DHS 103.11(1e)(c)5. 5. A state prenatal program.

DHS 103.11(1e)(d) (d) Have been determined by the department to be a qualified provider under this section.

DHS 103.11(1m) (1m) Requirements for women diagnosed with breast or cervical cancer or precancerous conditions. Women may be determined presumptively eligible for MA on the basis of a diagnosis of breast or cervical cancer or precancerous conditions if they meet the requirements in s. 49.473 (2) (a) to (e), Stats.

DHS 103.11(1s) (1s) Hospital requirements. A hospital qualified to make determinations of presumptive eligibility for pregnant women, and women diagnosed with breast or cervical cancer or precancerous conditions shall meet all of the following requirements:

DHS 103.11(1s)(a) (a) Be certified for MA as a general hospital under s. DHS 105.07.

DHS 103.11(1s)(b) (b) Notify the state Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures.

DHS 103.11(1s)(c) (c) Have not been disqualified by the department for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the department.

DHS 103.11(2) (2) Duties and responsibilities.

DHS 103.11(2)(a) (a) A qualified provider or hospital shall ascertain presumptive MA eligibility for a pregnant woman or a woman diagnosed with breast or cervical cancer or precancerous conditions by:

DHS 103.11(2)(a)1. 1. Determining on the basis of preliminary information that the applicant’s household or individual information meets the applicable non-financial requirements set by the department.

DHS 103.11(2)(a)2. 2. Determining on the basis of preliminary information that the applicant’s household or individual income meets the applicable income limits set by the department.

DHS 103.11(2)(b) (b) The provider or hospital shall inform the applicant, in writing, of the determination of presumptive eligibility.

DHS 103.11(2)(bm) (bm) In the event that the provider or hospital determines that the applicant is presumptively eligible, the provider or applicant shall explain to the applicant that the presumptive eligibility is for a temporary enrollment period and to file an application for MA eligibility with the county department of social services.

DHS 103.11(2)(c) (c) Within 5 working days following the date on which the determination was made, the provider or hospital shall in writing notify the department of the applicant’s presumptive eligibility.

DHS 103.11(2)(d) (d) In the event that the provider or hospital determines that the applicant is not presumptively eligible, the provider or hospital shall inform the applicant that he or she may file an application for MA eligibility at the county department of social services.

DHS 103.11 History History: Cr. Register, February, 1988, No. 386, 3-1-88; correction in (1) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 23-046: am. (title), (1) (title), renum. (1) (intro.) to (1) and am., renum. (1) (a) to (d) to be (1e) (a) to (d) and am., cr. (1e) (intro.), (1m), (1s), am. (2) (a), (b), cr. (2) (bm), am. (2) (c), (d); correction in (title) made under s. 13.92 (4) (b) 2., Stats., corrections in (1e) (b) (intro.), (c) (intro.), 5. made under s. 35.17, Stats., and corrections in (1e) (c) 1., 3., 4., (1m) made under s. 13.92 (4) (b) 7., Stats., Register April 2024 No. 820.