(6) Coverage while out-of-state.
Medical assistance shall be furnished under any of the following circumstances to recipients who are Wisconsin residents but absent from the state provided that they are within the United States, Canada or Mexico:
When the health of the recipient would be endangered if the care and services were postponed until the recipient returned to Wisconsin;
When the recipient's health would be endangered if the recipient undertook travel to return to Wisconsin; or
When prior authorization has been granted for provision of a non-emergency service, except that prior authorization is not required for non-emergency services provided to Wisconsin recipients by border status providers certified by the Wisconsin MA program.
(7) Free choice of family planning method.
Recipients eligible for family planning services and supplies shall have freedom of choice of family planning method so that a recipient may choose in accordance with the dictates of conscience and shall neither be coerced nor pressured into choosing any particular method of family planning.
(8) Continuation of benefits to community care organization clients.
Recipients who were eligible for or receiving services from any of the local community care organization (CCO) projects in La Crosse county, Barron county, or Milwaukee county, in April 1976, shall be allowed to continue to receive any of the CCO services and these services shall be reimbursed under MA.
(9) Right to information concerning program policy. DHS 104.01(9)(a)(a) Program manuals.
Recipients may examine program manuals and policy issuances which affect the public, including rules and regulations governing eligibility, need and amount of assistance, recipients' rights and responsibilities and services covered under MA, at the department's state or regional offices, or an agency's offices, during regular office hours.
Except when changes in the law require automatic grant adjustments for classes of recipients, in every instance in which the department intends to discontinue, terminate, suspend or reduce a recipient's eligibility for MA or coverage of services to a general class of recipients, the department shall send a written notice to the recipient's last known address at least by the minimum time period required under 42 USC 601-613
and before the date upon which the action would become effective, informing the recipient of the following:
The circumstances under which assistance will be continued if a hearing is requested.
The department shall mail the individual written notice to be received no later than the date of intended action under any of the following circumstances:
The department receives a clear written statement signed by a recipient that states the recipient no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the recipient has indicated, in writing, that the recipient understands that the consequence of supplying the information will be termination or reduction of assistance;
The recipient has been admitted or committed to an institution and further payments to the recipient do not qualify for federal financial participation under the state plan for MA;
The recipient has been placed in skilled nursing care, intermediate care or long-term hospitalization;
The recipient's whereabouts are unknown and departmental mail directed to the recipient has been returned by the post office indicating no known forwarding address;
A recipient has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance;
A change in level of medical care is prescribed by the recipient's physician;
The recipient has received service during a period of ineligibility and the department is preparing to take recovery action, pursuant to s. DHS 108.03 (3)
(10) Right to prompt decisions and assistance.
Applicants have the right to prompt decisions on their applications. Eligibility decisions shall be made within 30 days of the date the application was signed. For individuals applying as disabled, where medical examination reports, determination of disability, and other additional medical and administrative information is necessary for the decision, eligibility decisions shall be made not more than 60 days after the date the application was signed. Health care shall be furnished promptly to eligible recipients without any delay attributable to the department's administrative process and shall be continued as needed until the individual is found ineligible.
(11) Right to request return of payments made for covered services during period of retroactive eligibility.
If a person has paid all or part of the cost of health care services received and then becomes a recipient of MA benefits with retroactive eligibility for those covered services for which the recipient has previously made payment, then the recipient has the right to notify the certified provider of the retroactive eligibility period. At that time the certified provider shall submit claims to MA for covered services provided to the recipient during the retroactive period. Upon the provider's receipt of the MA payment, the provider shall reimburse the recipient for the lesser of the amount received from MA or the amount paid by recipient or other person, minus any relevant copayment. In no case may the department reimburse the recipient directly.
Recipients of MA are liable for payment of any copayment or deductible amount established by the department pursuant to s. 49.45 (18)
, Stats., for the cost of a service, except as provided in this subsection. The recipient shall pay the copayment or deductible to the provider of service. Copayments or deductibles are not required:
From recipients who are members of a health maintenance organization or other prepaid plan for those services provided by the HMO or PHP;
For services furnished to pregnant women if the services relate to the pregnancy, or to any medical condition which may complicate the pregnancy when it can be determined from the claim submitted that the recipient was pregnant;
For emergency hospital and ambulance services and emergency services related to the relief of dental pain;
For transportation services provided through or paid for by a county social services department;
For home health services or for home nursing services if a home health agency is not available;
For outpatient psychotherapy services received over 15 hours or $500, whichever comes first, during one calendar year;
For occupational, physical or speech therapy services received exceeding 30 hours or $1,500 for any one therapy, whichever occurs first, during one calendar year;
If the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs, the monthly amount of copayment a recipient is required to pay may not exceed $5.
(b) Freedom from having to pay for services covered by MA.
Recipients may not be held liable by certified providers for covered services and items furnished under the MA program, except for copayments or deductibles under par. (a)
, if the patient identifies himself or herself as an MA recipient and shows the provider the MA identification card.
DHS 104.01 Note
Note: Recipients seeking nonemergency services from noncertified providers are liable for all charges, unless the services were authorized by the department prior to service delivery.
(c) Prior authorization of services.
When a service must be authorized by the department in order to be covered, the recipient may not be held liable by the certified provider unless the prior authorization was denied by the department and the recipient was informed of the recipient's personal liability before provision of the service. In that case the recipient may request a fair hearing. Negligence on the part of the certified provider in the prior authorization process shall not result in recipient liability.
DHS 104.01 Note
Note: For example, if a provider does not inform a recipient that a procedure or service requires prior authorization, and performs the service before submitting a prior authorization request or receiving an approval and then submits a claim for services rendered which is rejected, the recipient may not be held liable.
(d) Freedom from having to pay the difference between charges and MA payment.
Providers may not charge recipients for the amount of the difference between charge for service and MA reimbursement, except in the case of recipients wishing to be in a private room in a nursing home or hospital, in which case the provisions of s. DHS 107.09 (4) (k)
shall be met.
DHS 104.01 History
Cr. Register, December, 1979, No. 288
, eff. 2-1-80; am. Register, February, 1986, No. 362
, eff. 3-1-86; am. (4) (b), cr. (4) (f) and (g), r. (12) (a) 1. j. and k., Register, February, 1988, No. 386
, eff. 3-1-88; renum. (12) (a) 1. l. and m. under s. 13.93 (2m) (b) 1., Stats., Register, February, 1988, No. 386
; emerg. am. (1) (k), cr. (1) (l) to (q), eff. 1-1-90; am. (1) (k), cr. (1) (l) to (q), Register, September, 1990, No. 417
, eff. 10-1-90; correction in (4) (c) and (5) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, May, 1995, No. 473
; correction in (5) (d) and (12) (d) made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, April, 1999, No. 520
corrections in (4) (c) and (5) (d) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554
; corrections in (4) (f), (g), (5) (a) 1., (9) (b) 2. j., (12) (a) 1. L., m., p., q. and (d) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
; CR 20-039
: am. (3), r. (9) (b) 2. g. Register October 2021 No. 790
, eff. 11-1-21; CR 20-068: am. (2) Register December 2021 No. 792, eff. 1-1-22.
Not to seek duplication of services.
A recipient may not seek the same or similar services from more than one provider.
(2) Prior identification of eligibility.
Except in emergencies that preclude prior identification, the recipient shall, before receiving services, inform the provider that the recipient is receiving benefits under MA and shall present to the provider a current valid MA identification card.
(3) Review of benefits notice.
Recipients shall review the monthly explanation of benefits (EOB) notice sent to them by the department and shall report to the department any payments made for services not actually provided. The explanation of benefits notice may not specify confidential services, such as family planning, and may not be sent if the only service furnished is confidential.
(4) Informational cooperation with providers.
Recipients shall give providers full, correct and truthful information requested by providers and necessary for the submission of correct and complete claims for MA reimbursement. This information shall include but is not limited to:
Information concerning the recipient's eligibility status, accurate name, address and MA identification number;
Information concerning the recipient's use of MA benefits; and
Information concerning the recipient's coverage under other insurance programs.
(5) Not to abuse or misuse the MA card or benefits.
If a recipient abuses or misuses the MA card or benefits in any manner, the department or agency, as appropriate, may limit or terminate benefits. For purposes of this subsection,“abuses or misuses" includes, but is not limited to, any of the following actions:
Permitting the use of the MA card by any unauthorized individual for the purpose of obtaining health care through MA;
Using the MA card to obtain any covered service for another individual;
Knowingly misrepresenting material facts as to medical symptoms for the purpose of obtaining any covered service;
Knowingly furnishing incorrect eligibility status or other information to a provider;
Knowingly furnishing false information to a provider in connection with health care previously rendered which the recipient has obtained and for which MA has been billed;
Knowingly obtaining health care in excess of established program limitations, or knowingly obtaining health care which is clearly not medically necessary;
Knowingly obtaining duplicate services from more than one provider for the same health care condition, excluding confirmation of diagnosis or a second opinion on surgery; or
(6) Notification of personal or financial status changes.
Recipients shall inform the agency within 10 days of any change in address, income, assets, need, or living arrangements which may affect eligibility. In addition, the department may require as a condition for continuation of MA coverage that certain recipients report each month whether there has been any change of circumstances that may affect eligibility.
(7) Financial responsibility of spouse or responsible relative.
Within the limitations provided by s. 49.90
, Stats., and this chapter, the spouse of an applicant of any age or the parent of an applicant under 18 years of age shall be charged with the cost of medical services before MA payments shall be made. However, eligibility may not be withheld, delayed or denied because a responsible relative fails or refuses to accept financial responsibility. When the agency determines that a responsible relative is able to contribute without undue hardship to self or immediate family but refuses to contribute, the agency shall exhaust all available administrative procedures to obtain that relative's contribution. If the responsible relative fails to contribute support after the agency notifies the relative of the obligation to do so, the agency shall notify the district attorney in order to commence legal action against that relative.
DHS 104.02 History
Cr. Register, December, 1979, No. 288
, eff. 2-1-80; am. Register, February, 1986, No. 362
, eff. 3-1-86; corrections in (6) and (7) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554
; CR 20-039
: am. (1) Register October 2021 No. 790
, eff. 11-1-21.
DHS 104.03(1)(a)(a) Required when program is abused.
If the department discovers that a recipient is abusing the program, including abuse under s. DHS 104.02 (5)
, the department may require the recipient to designate, in any or all categories of health care provider, a primary health care provider of the recipient's choice, except when free choice is limited under s. DHS 104.035
(b) Selection of provider.
The department shall allow a recipient to choose a primary provider from the department's current list of certified providers, except when free choice is limited under s. DHS 104.035
. The recipient's choice shall become effective only with the concurrence of the designated primary provider. The type of service and identification number of the primary provider shall be endorsed on the recipient's MA card.
(c) Failure to cooperate.
If the recipient fails to designate a primary provider after receiving a formal request from the department, the department shall designate a primary provider for the recipient in the proximity of the recipient's residence.
(2) Referral to other providers.
A primary provider may, within the scope of the provider's practice, make referrals to other providers of medical services for which reimbursement will be made if the referral can be documented as medically necessary and the services are covered by MA. This documentation shall be made by the primary provider in the recipient's medical record.
(3) Alternative primary provider.
The department may allow the designation of an alternate primary provider. When approval is given by the department to select an alternate primary provider, the recipient may designate an alternate primary provider in the same manner a primary provider is designated.
The limitations imposed in this section do not apply in the case of an emergency. Emergency health care provided by any provider to a recipient restricted under this section shall be eligible for reimbursement if the claim for reimbursement is accompanied by a full explanation of the emergency circumstances.
DHS 104.035 Prudent buyer limitations.
Free choice of a provider may be limited by the department if the department contracts for alternate service arrangements which are economical for the MA program and are within state and federal law, and if the recipient is assured of reasonable access to health care of adequate quality.