Wisconsin Legislature: DHS 105.51(5)(c)

Alert! This chapter may be affected by an emergency rule:

DHS 105.48 Out-of-state providers.

(1) When a provider in a state that borders on Wisconsin documents to the department’s satisfaction that it is common practice for recipients in a particular area of Wisconsin to go for medical services to the provider’s locality in the neighboring state, the provider may be certified as a Wisconsin border status provider, subject to the certification requirements in this chapter and the same rules and contractual agreements that apply to Wisconsin providers, except that nursing homes are not eligible for border status.

(2) Out-of-state independent laboratories, regardless of location, may apply for certification as Wisconsin border status providers.

(2m) Out-of-state providers who meet the definition of a border-status provider as described in s. DHS 101.03 (19) and who provide services to Wisconsin members via telehealth, regardless of provider location, may apply for certification as Wisconsin border-status providers if they are licensed in Wisconsin under applicable Wisconsin statute and administrative code.

(3) Other out-of-state providers who do not meet the requirements of sub. (1) may be reimbursed for non-emergency services provided to a Wisconsin MA recipient upon approval by the department under s. DHS 107.04.

(4) The department may review border status certification of a provider annually. Border status certification may be canceled by the department if it is found to be no longer warranted by medical necessity, volume or other considerations.

(5)

(a) A provider certified in another state for services not covered in Wisconsin shall be denied border status certification for these services in the Wisconsin program.

Note: Examples of providers whose services are not covered in Wisconsin are music therapists and art therapists.

(b) A provider denied certification in another state shall be denied certification in Wisconsin, except that a provider denied certification in another state because the provider’s services are not MA-covered in that state may be eligible for Wisconsin border status certification if the provider’s services are covered in Wisconsin.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. Register, September, 1991, No. 429, eff. 10-1-91; correction in (3) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-043: cr. (2m) Register May 2023 No. 809, eff. 6-1-23.

DHS 105.49 Ambulatory surgical centers. For MA certification, an ambulatory surgical center shall be certified to participate in medicare as an ambulatory surgical center under 42 CFR 416.39.

Note: For covered ambulatory surgical center services, see s. DHS 107.30.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.50 Hospices. For MA certification, a hospice shall be certified to participate in medicare as a hospice under 42 CFR 418.50 to 418.100.

History: Cr. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.51 Case management agency providers.

(1) Agency. For MA certification, a provider of case management services shall be an agency with state statutory authority to operate one or more community human service programs. A case management agency may be a county or Indian tribal department of community programs, a department of social services, a department of human services, or a county or tribal aging unit. Each applicant agency shall specify each population eligible for case management under s. DHS 107.32 (1) (a) 2. for which it will provide case management services. Each certified agency shall offer all 3 case management components described under s. DHS 107.32 (1) so that a recipient can receive the component or components that meet his or her needs.

(2) Employed personnel.

(a) To provide case assessment or case planning services reimbursable under MA, persons employed by or under contract to the case management agency under sub. (1) shall:

1. Possess a degree in a human services-related field, possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed, and have acquired at least one year of supervised experience with the type of recipients with whom he or she will work; or

2. Possess 2 years of supervised experience or an equivalent combination of training and experience.

Note: The knowledge required in subd. 1. is typically gained through supervised experience working with persons in the target population.

(b) To provide ongoing monitoring and service coordination reimbursable under MA, personnel employed by a case management agency under sub. (1) shall possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed.

(3) Sufficiency of agency certification for employed personnel. Individuals employed by or under contract to an agency certified to provide case management services under this section may provide case management services upon the department’s issuance of certification to the agency. The agency shall maintain a list of the names of individuals employed by or under contract to the agency who are performing case management services for which reimbursement may be claimed under MA. This list shall certify the credentials possessed by the named individuals which qualify them under the standards specified in sub. (2). Upon request, an agency shall promptly advise the department in writing of the employment of persons who will be providing case management services under MA and the termination of employees who have been providing case management services under MA.

(4) Contracted personnel. Persons under contract with a certified case management agency to provide assessments or case plans shall meet the requirements of sub. (2) (a), and to provide ongoing monitoring and service coordination, shall meet the requirements of sub. (2) (b).

(5) Recordkeeping. The case manager under s. DHS 107.32 (1) (d) shall maintain a file for each recipient receiving case management services which includes the following:

(a) The assessment document;

(b) The case plan;

(d) Financial forms;

(e) Release of information forms;

(f) Case reviews;

(g) A written record of all monitoring and quality assurance activities; and

(h) All pertinent correspondence relating to the recipient’s case management.

(6) Reimbursement.

(a) Case management services shall be reimbursed when the services are provided by certified providers or their subcontractors to recipients eligible for case management.

(b) Payment shall be made to certified providers of case management services according to terms of reimbursement established by the department.

(7) County election to participate.

(a) The department may not certify a case management agency for a target population unless the county board or tribal government of the area in which the agency will operate has elected to participate in providing benefits under s. DHS 107.32 through providers operating in the county or tribal area. The county board or tribal government may terminate or modify its participation by giving a 30 day written notice to the department. This election is binding on any case management agencies providing services within the affected county or tribal area.

(b) Any case management agency provider requesting certification under this section shall provide written proof of the election of the county or tribal government to participate under this subsection.

History: Cr. Register, February, 1988, No. 386, eff. 3-1-88; corrections in (1) (a), (5) (intro.) and (7) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.52 Prenatal care coordination providers.

(1) Agency. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be:

(a) A community-based health organization;

(b) A community-based social services agency or organization;

(d) A county department of human services under s. 46.23, Stats., or social services under s. 46.215 or 46.22, Stats.;

(e) A family planning agency certified under s. DHS 105.36;

(f) A federally qualified health center (FQHC) as defined in 42 CFR 405.2401 (b);

(g) A health maintenance organization (HMO);

(h) An independent physician association (IPA);

(i) A hospital;

(j) A physician’s office or clinic;

(k) A private case management agency;

(L) A registered nurse or nurse practitioner;

(m) A rural health clinic certified under s. DHS 105.35;

(n) A tribal agency health center; or

(o) A women, infants, and children (WIC) program under 42 USC 1786.

(2) Qualified professionals.

(a) Definition. In this subsection, “qualified professional” means any of the following:

1. A nurse practitioner licensed as a registered nurse pursuant to s. 441.06, Stats., and currently certified by the American nurses’ association, the national board of pediatric nurse practitioners and associates or the nurses’ association of the American college of obstetricians and gynecologists’ certification corporation;

2. A nurse midwife certified under s. DHS 105.201;

3. A public health nurse meeting the qualifications of s. DHS 139.08;

4. A physician licensed under ch. 448, Stats., to practice medicine or osteopathy;

5. A physician assistant certified under ch. 448, Stats.;

6. A dietitian certified or eligible for registration by the commission on dietetic registration of the American dietetic association with at least 2 years of community health experience;

7. A registered nurse with at least 2 years of experience in maternity nursing or community health services or a combination of maternity nursing and community health services;

8. An employee with at least a bachelor’s degree and 2 years of experience in a health care or family services program; or

9. A health educator with a master’s degree in health education and at least 2 years of experience in community health services.

(b) Required qualified professionals. To be certified to provide prenatal care coordination services that are reimbursable under MA, the prenatal care coordination agency under sub. (1) shall:

1. Employ at least one qualified professional with at least 2 years of experience in coordinating services for at-risk or low income women;

2. Have on staff, under contract or available in a volunteer capacity a qualified professional to supervise risk assessment and ongoing care coordination and monitoring; and

3. Have on staff, under contract or available in a volunteer capacity one or more qualified professionals with the necessary expertise, based on education or at least one year of work experience, to provide health education and nutrition counseling.

(3) Sufficiency of agency certification. Individuals employed by or under contract with an agency that is certified to provide prenatal care coordination services under this section may provide prenatal care coordination services upon the department’s issuance of certification to the agency. The agency shall maintain a list of all persons who provide or supervise the provision of prenatal care coordination services. The list shall include the credentials of each named individual who is qualified to supervise risk assessment and ongoing care coordination under sub. (2) (b) 2. and to provide health education or nutrition counseling under sub. (2) (b) 3. Upon the department’s request, an agency shall promptly report to the department in writing the names of persons hired to provide prenatal care coordination services under MA and the termination of employees who have been providing prenatal care coordination services under MA.

(4) Administrative records and required documentation. To be certified to provide prenatal care coordination services reimbursable under MA, the prenatal care coordination agency under sub. (1) shall comply with s. DHS 106.02 (9) and shall submit a plan to the department documenting:

(a) That the agency is located in the area it will serve;

(b) That the agency has a variety of techniques to identify low-income pregnant women;

(c) That, at a minimum, the agency has the name, location and telephone number of the following resources in the area to be served:

1. Women, infants, and children (WIC) programs;

2. Maternal and child health services;

3. The county, city, or combined city and county public health agency;

4. Child day care services;

5. Mental health and alcohol or other drug abuse prevention and treatment agencies;

6. The county protective service agency;

7. Domestic abuse agencies;

8. Translator and interpreter services including services for the hearing-impaired;

9. Family support services;

10. Transportation services; and