DHS 108.02(7)(c)2. 2. Information regarding the deletion or reduction of covered services; and
DHS 108.02(7)(c)3. 3. Consumer protection information.
DHS 108.02(8) (8)Third party liability for cost of services.
DHS 108.02(8)(a)(a) The department shall make reasonable efforts to identify any third party insurer, including medicare, legally liable to contribute in whole or in part to the cost of services provided to a recipient under the MA program.
DHS 108.02(8)(b) (b) When the department has determined that medicare or any other health care plan provides health care coverage to the recipient which is primary to MA, as stated in s. 632.755 (2), Stats., the medicare or other insurance coverage shall be identified on the recipient's MA identification card by specific codes.
DHS 108.02(8)(c) (c) In the event payment for services otherwise covered by medicare or by another health care plan is unavailable, the provider may bill the department's MA fiscal agent, identifying the efforts to seek reimbursement from medicare or the other health care plan, on condition that the provider complies with the instructions issued by the department under sub. (4).
DHS 108.02(9) (9)Departmental recoupment of overpayments.
DHS 108.02(9)(a)(a) Recoupment methods. If the department finds that a provider has received an overpayment, including but not limited to erroneous, excess, duplicative and improper payments regardless of cause, under the program, the department may recover the amount of the overpayment by any of the following methods, at its discretion:
DHS 108.02(9)(a)1. 1. Offsetting or making an appropriate adjustment against other amounts owed the provider for covered services;
DHS 108.02(9)(a)2. 2. Offsetting or crediting against amounts determined to be owed the provider for subsequent services provided under the program if:
DHS 108.02(9)(a)2.a. a. The amount owed the provider at the time of the department's finding is insufficient to recover in whole the amount of the overpayment; and
DHS 108.02(9)(a)2.b. b. The provider is claiming and receiving MA reimbursement in amounts sufficient to reasonably ensure full recovery of the overpayment within a reasonable period of time; or
DHS 108.02(9)(a)3. 3. Requiring the provider to pay directly to the department the amount of the overpayment.
DHS 108.02(9)(b) (b) Written notice. No recovery by offset, adjustment or demand for payment may be made by the department under par. (a), except as provided under par. (c), unless the department gives the provider prior written notice of the department's intention to recover the amount determined to have been overpaid. The notice shall set forth the amount of the intended recovery, identify the claim or claims in question or other basis for recovery, summarize the basis for the department's finding that the provider has received amounts to which the provider is not entitled or in excess of that to which the provider is entitled, and inform the provider of a right to appeal the intended action under par. (e). Payment due the department shall be made by the provider within 30 days after the date of service of the notice of intent to recover. Final notices of intent to recover shall be sent by certified mail.
DHS 108.02(9)(c) (c) Exception. The department need not provide prior written notice under par. (b) when the overpayment was made as a result of a computer processing or clerical error, for a recoupment of a manual partial payment, or when the provider requested or authorized the recovery to be made. In any of these cases the department or its fiscal agent shall provide written notice of any payment adjustments made on the next remittance issued the provider. This notice shall specify the amount of the adjustment made and the claim or claims which were the subject of the adjustments.
DHS 108.02(9)(d) (d) Withholding of payment involving fraud or willful misrepresentation.
DHS 108.02(9)(d)1.1. The department may withhold MA payments, in whole or in part, to a provider upon receipt of reliable evidence that the circumstances giving rise to the need for withholding of payments involve fraud or willful misrepresentation under the MA program. Reliable evidence of fraud or willful misrepresentation includes, but is not limited to, the filing of criminal charges for those activities against the provider or one of its agents or employees by a prosecuting attorney. The department may withhold payments without first notifying the provider of its intention to withhold the payments. A provider is entitled to a hearing under s. DHS 106.12.
DHS 108.02(9)(d)2. 2. The department shall send written notice to the provider of the department's withholding of MA program payments within 5 days after taking that action. The notice shall generally set forth the allegations leading to the withholding, but need not disclose any specific information concerning the ongoing investigation of allegations of fraud and willful misrepresentation. The notice shall:
DHS 108.02(9)(d)2.a. a. State that payments are being withheld in accordance with this paragraph;
DHS 108.02(9)(d)2.b. b. State that the withholding action is for a temporary period, as defined under subd. 3., and cite the circumstances under which withholding will be terminated;
DHS 108.02(9)(d)2.c. c. Specify, when appropriate, to which type or types of MA claims withholding is effective; and
DHS 108.02(9)(d)2.d. d. Inform the provider that the provider has a right to submit to the department written evidence regarding the allegations of fraud and willful misrepresentation for consideration by the department.
DHS 108.02(9)(d)3. 3. Withholding of the provider's payments shall be temporary. Withholding of payment may not continue after:
DHS 108.02(9)(d)3.a. a. The department determines after a preliminary investigation that there is not sufficient evidence of fraud or willful misrepresentation by the provider to require referral of the matter to an appropriate law enforcement agency pursuant to 42 CFR 455.15 and, to the extent of the department's knowledge, the matter is not already the subject of an investigation or a prosecution by a law enforcement agency or a prosecuting authority;
DHS 108.02(9)(d)3.b. b. Any law enforcement agency or prosecuting authority which has investigated or commenced prosecution of the matter determines that there is insufficient evidence of fraud or misrepresentation by the provider to pursue criminal charges or civil forfeitures; or
DHS 108.02(9)(d)3.c. c. Legal proceedings relating to the provider's alleged fraud or willful misrepresentation are completed and charges against the provider have been dismissed. In the case of a conviction of a provider for criminal or civil forfeiture offenses, those proceedings shall not be regarded as being completed until all appeals are exhausted. In the case of an acquittal in or dismissal of criminal or civil forfeiture proceedings against a provider, the proceedings shall be regarded as complete at the time of dismissal or acquittal regardless of any opportunities for appeal which the prosecuting authority may have.
DHS 108.02(9)(e) (e) Request for hearing on recovery action. If a provider chooses to contest the propriety of a proposed recovery under par. (a), the provider shall, within 20 days after receipt of the department's notice of intent to recover, request a hearing on the matter. The request shall be in writing and shall briefly identify the basis for contesting the proposed recovery. Receipt of a timely request for hearing shall prevent the department from making the proposed recovery while the hearing proceeding is pending. If a timely request for hearing is not received, the department may recover from current or future obligations of the program to the provider the amount specified in the notice of intent to recover and may take such other legal action as it deems appropriate to collect the amount specified. All hearings on recovery actions by the department shall be held in accordance with the provisions of ch. 227, Stats. The date of service of a provider's request for a hearing shall be the date on which the department of administration division of hearings and appeals receives the request.
DHS 108.02(10) (10)Estate recovery. The department shall file a claim against the estate of a recipient or client or against the estate of the surviving spouse of a recipient or client as provided in ss. 46.27 (7g), 49.496, and 49.849, Stats., to recover only the following:
DHS 108.02(10)(a) (a) The amount of medical assistance paid on or after October 1, 1991, on behalf of the recipient while the recipient resided in a nursing home;
DHS 108.02(10)(b) (b) The amount of medical assistance paid on or after July 1, 1995, on behalf of the recipient while the recipient was an inpatient in a hospital and was required to contribute to the cost of care pursuant to s. DHS 103.07 (1) (d);
DHS 108.02(10)(c) (c) The amount of medical assistance paid on or after July 1, 1995, for any of the following services provided to the recipient under the medical assistance program or any federal medical assistance waiver program under 42 USC 1396n (c) or 1396u after the recipient attained 55 years of age:
DHS 108.02(10)(c)1. 1. The following home health services:
DHS 108.02(10)(c)1.a. a. Skilled nursing services specified in s. DHS 107.11 (2) (a);
DHS 108.02(10)(c)1.b. b. Home health aide services specified in s. DHS 107.11 (2) (b); and
DHS 108.02(10)(c)1.c. c. Therapy and speech pathology services specified in s. DHS 107.11 (2) (c);
DHS 108.02(10)(c)2. 2. Private duty nursing services specified in s. DHS 107.12;
DHS 108.02(10)(c)3. 3. Home and community-based waiver services provided pursuant to a waiver authorized under 42 USC 1396n (c) or 1396u;
DHS 108.02(10)(c)4. 4. Inpatient covered hospital services specified in s. DHS 107.08 (1) (a) provided during a period of time in which the recipient was approved to have home and community-based waiver services funded pursuant to 42 USC 1396n (c) or 1396u;
DHS 108.02(10)(c)5. 5. Inpatient services which are billed separately by providers and which are listed as non-covered hospital services in s. DHS 107.08 (4) (d) provided during a period of time in which the recipient was approved to have home and community-based waiver services funded pursuant to 42 USC 1396n (c) or 1396u; and
DHS 108.02(10)(c)6. 6. Legend drugs under s. DHS 107.10 provided during a period of time in which the recipient was approved to have home and community-based waiver services funded pursuant to 42 USC 1396n (c) or 1396u; and
DHS 108.02(10)(d) (d) The amount of long-term community support services paid on or after January 1, 1996, on behalf of a client for services funded under s. 46.27 (7), Stats., after the client attained 55 years of age.
DHS 108.02(11) (11)Estate recovery adjustments.
DHS 108.02(11)(a) (a) The department may make adjustments to and settle estate claims and liens filed under s. 46.27 (7g), 49.496, or 49.849, Stats., to obtain the fullest amount practicable.
DHS 108.02(11)(b) (b) The department shall take a lien in full or partial settlement of an estate claim against the portion of an estate that is a home if either of the following apply:
DHS 108.02(11)(b)1. 1. A child of the recipient or client, regardless of age, resides in the decedent's home and that child resided in the home for at least 24 months before:
DHS 108.02(11)(b)1.a. a. The date the recipient was admitted to a nursing home, the expenses for which are subject to recovery under sub. (10) (a), and that child provided care to the recipient that delayed the recipient's admission to the nursing home;
DHS 108.02(11)(b)1.b. b. The date the recipient was admitted to a hospital, the expenses of which are subject to recovery under sub. (10) (b), and that child provided care to the recipient that delayed the recipient's admission to the hospital; or
DHS 108.02(11)(b)1.c. c. The date the recipient or client began receiving services which are subject to recovery under sub. (10) (c) 3. or (d), and that child provided care to the recipient or client that delayed the recipient's or client's receipt of the services.
DHS 108.02(11)(b)2. 2. A sibling of the recipient or client resides in the decedent's home and that sibling resided in the home for at least 12 months before:
DHS 108.02(11)(b)2.a. a. The date the recipient was admitted to a nursing home, the expenses for which are subject to recovery under sub. (10) (a);
DHS 108.02(11)(b)2.b. b. The date the recipient was admitted to a hospital, the expenses for which are subject to recovery under sub. (10) (b); or
DHS 108.02(11)(b)2.c. c. The date the recipient or client began receiving services which are subject to recovery under sub. (10) (c) 3. or (d).
DHS 108.02(11)(c) (c) Except as provided in par. (d), the lien shall be payable upon the death of the child or sibling or upon the transfer of the property, whichever comes first.
DHS 108.02(11)(d) (d) If the child or sibling sells the home against which the department has taken a lien under par. (b) and uses the proceeds of that sale to buy another home which will be used as the child's or sibling's primary residence, then the following apply:
DHS 108.02(11)(d)1. 1. If the amount of the child's or sibling's payment for or down payment on the second home is equivalent to or greater than the amount received as the proceeds from the sale of the first home, the department shall transfer the lien to the second home.
DHS 108.02(11)(d)2. 2. If the amount of the child's or sibling's payment for or down payment on the second home is less than the amount received as the proceeds from the sale of the first home, the department may recover the amount of the lien to the extent that the proceeds from the sale of the first home exceed the amount of the child's or sibling's payment or down payment on the second home. The department shall transfer any remaining portion of the lien to the second home.
DHS 108.02(12) (12)Hardship waivers under estate recovery.
DHS 108.02(12)(a)(a) Definitions. In this subsection:
DHS 108.02(12)(a)1. 1. “Beneficiary" means any person nominated in a will to receive an interest in property other than in a fiduciary capacity.
DHS 108.02(12)(a)2. 2. “Decedent" means a deceased recipient or the deceased surviving spouse of a recipient who received benefits that are subject to recovery under s. 46.27 (7g), 49.496, or 49.849, Stats.
DHS 108.02(12)(a)3. 3. “Heir" means any person who is entitled under the statutes of intestate succession, ch. 852, Stats., to an interest in property of a decedent.
DHS 108.02(12)(a)4. 4. “Recipient" means a person who received services funded by medical assistance or the long-term community support program under s. 46.27 (7), Stats.
DHS 108.02(12)(a)5. 5. “Waiver applicant" means a beneficiary or heir of a decedent who requests the department to waive an estate claim filed by the department pursuant to s. 46.27 (7g), 49.496, or 49.849, Stats.
DHS 108.02(12)(b) (b) Hardship waiver criteria.
DHS 108.02(12)(b)1.1. A beneficiary or heir of a decedent may apply to the department for a waiver of an estate claim filed by the department. The department shall review an application for a waiver under this subsection and shall determine whether the applicant meets the criterion under subd. 2. a., b. or c. If the department determines that the criterion under subd. 2. a., b. or c.. is met, the department shall waive its claim as to that applicant.
DHS 108.02(12)(b)2. 2. Any of the following situations constitutes an undue hardship on the waiver applicant:
DHS 108.02(12)(b)2.a. a. The waiver applicant would become or remain eligible for supplemental security income (SSI), food stamps under 7 USC 2011 to 2029, aid to families with dependent children (AFDC), or medical assistance if the department pursued its claim;
DHS 108.02(12)(b)2.b. b. A decedent's real property is used as part of the waiver applicant's business, which may be a working farm, and recovery by the department would affect the property and would result in the waiver applicant losing his or her means of livelihood; or
DHS 108.02(12)(b)2.c. c. The waiver applicant is receiving general relief, relief to needy Indian persons (RNIP) or veterans benefits based on need under s. 45.40 (1m), Stats.
DHS 108.02(12)(c) (c) Notice.
DHS 108.02(12)(c)1.1. The department shall provide written notice of the hardship waiver provisions to the person handling the decedent's estate, if that person can be ascertained from the probate information provided to the department, or, if that person cannot be ascertained, the department shall include the notice with the copy of the claim it files with the probate court.
DHS 108.02(12)(c)2. 2. The person handling the decedent's estate shall be responsible for notifying the decedent's beneficiaries and heirs of the hardship waiver provisions.
DHS 108.02(12)(c)3. 3. The department's notice shall include the following information:
DHS 108.02(12)(c)3.a. a. The individuals who are eligible to apply for a waiver;
DHS 108.02(12)(c)3.b. b. The criteria for granting a waiver as specified in par. (b) 2. a., b. or c.,
DHS 108.02(12)(c)3.c. c. The application and review process as specified in par. (d); and
DHS 108.02(12)(c)3.d. d. The waiver applicant's right to a hearing as specified in par. (e).
DHS 108.02(12)(d) (d) Application and review process.
DHS 108.02(12)(d)1.1. A waiver applicant shall mail his or her application for a waiver in writing to the department within 45 days after the date the department mailed its claim or affidavit pursuant to s. 49.496 or 49.849, Stats., or its notice under par. (c), whichever is later. The application shall include the following information:
DHS 108.02(12)(d)1.a. a. The relationship of the waiver applicant to the decedent and copies of documents establishing that relationship; and
DHS 108.02(12)(d)1.b. b. The criterion under par. (b) 2. a., b., or c. which is the basis for the application and documentation supporting the waiver applicant's position.
DHS 108.02(12)(d)2. 2. The department shall review each application and issue a written decision within 90 days after the application was received by the department. The department shall consider all information received within 60 days following receipt of the application. The department's decision shall be based on information received within that time-period. The department's written decision shall include information regarding the waiver applicant's right to a hearing under par. (e).
DHS 108.02(12)(e) (e) Hearing rights.
DHS 108.02(12)(e)1.1. If a waiver applicant wishes to contest the department's decision denying a waiver, the waiver applicant shall serve the department with a request for a hearing within 45 days of the date the department's decision was mailed. The hearing request shall be in writing and shall identify the basis for contesting the decision. The request shall be submitted to the department of administration's division of hearings and appeals. The date on which the division of hearings and appeals receives the request shall be the date of service.
DHS 108.02 Note Note: The mailing address of the division of hearings and appeals is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 108.02(12)(e)2. 2. If a waiver applicant wishes to introduce information at the hearing that he or she did not submit to the department under par. (d), the applicant shall provide the department with that information by mailing it to the department with a postmark of at least 7 working days prior to the hearing date.
DHS 108.02(12)(e)3. 3. The issue for hearing shall be whether the department's decision was correct based on the information submitted to the department by the waiver applicant within the time periods specified in par. (d) 2. and subd. 2. No other information may be considered by the hearing examiner unless the hearing examiner finds that the applicant did not timely provide the information to the department for good cause. The hearing decision shall be the final decision of the department. The hearing shall be held in accordance with the provisions of ch. 227, Stats.
DHS 108.02(12)(f) (f) Applicability.
DHS 108.02(12)(f)1.1. Heirs and beneficiaries may apply for a hardship waiver under this subsection from estate claims filed by the department pursuant to s. 49.496 or 49.849, Stats., in the estates of persons who die on or after April 1, 1995.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.