Alert! This chapter may be affected by an emergency rule:
DHS 109.13(6)(b) (b) For underpayment errors caused by the recipient when the recipient reports the error within 45 days after the date of the initial eligibility notice, benefits will be corrected back to the beginning of the benefit period.
DHS 109.13(6)(c) (c) For underpayment errors caused by the recipient when the recipient reports the error more than 45 days after the date of the initial eligibility notice, benefits will be corrected back to the first of the month in which the error was reported.
DHS 109.13(6)(d) (d) For overpayment errors, benefits will be corrected beginning the first of the month following the issuance by the department of a timely notice of decision under s. DHS 109.11 (5) (b). Recovery of benefits issued in error shall be in accordance with s. DHS 109.62.
DHS 109.13 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (3) (c) and (d) (intro) and 2. Register October 2004 No. 586, eff. 11-1-04.
DHS 109.14 DHS 109.14SeniorCare benefit period.
DHS 109.14(1) (1)Duration. Except as provided in subs. (3) to (5), and in s. DHS 109.15 and s. 49.688 (7) (a), Stats., the benefit period for SeniorCare eligibility shall be 12 consecutive calendar months.
DHS 109.14(2) (2)Eligibility begin date. Except as provided in sub. (3), a person's SeniorCare eligibility begins on the first day of the month after the date the department receives a complete application and the person meets all of the eligibility requirements.
DHS 109.14(3) (3)Exception for medicaid recipients. If the department receives a complete application and determines that the person meets all other eligibility requirements prior to the date medical assistance eligibility ends, the person's SeniorCare eligibility begins the day after the person's medical assistance eligibility ends.
DHS 109.14(4) (4)Termination of SeniorCare benefit period.
DHS 109.14(4)(a)(a) Except as provided in sub. (5), the department shall terminate the SeniorCare benefit period of a SeniorCare participant who no longer meets the eligibility conditions in s. DHS 109.11, or who requests a withdrawal from the program under s. DHS 109.11 (5) (d).
DHS 109.14(4)(b) (b) The department shall restore the SeniorCare benefit period for a person terminated from SeniorCare without a break in coverage if, within one calendar month of the effective termination date, he or she does both of the following:
DHS 109.14(4)(b)1. 1. Meets all of the eligibility criteria under s. DHS 109.11.
DHS 109.14(4)(b)2. 2. Notifies the department of the change in circumstances.
DHS 109.14(4)(c) (c) The department shall reinstate the SeniorCare benefit period for a person who has requested a withdrawal from the program under s. DHS 109.11 (5) (d) if within 30 calendar days of the effective date of the withdrawal both of the following occur:
DHS 109.14(4)(c)1. 1. The department receives the person's request to have SeniorCare benefits restored.
DHS 109.14(4)(c)2. 2. The person meets all of the eligibility criteria under s. DHS 109.11, including a new payment of the program enrollment fee specified in s. DHS 109.16 for persons who were issued a refund under s. DHS 109.11 (5) (d) 1.
DHS 109.14(5) (5)Continuation of benefit period for medical assistance recipients. The department may not terminate the benefit period of SeniorCare participants who lose eligibility solely due to receipt of medical assistance benefits. A SeniorCare participant is not eligible for any SeniorCare benefits or services under s. DHS 109.13 for any calendar months in which he or she receives medical assistance benefits.
DHS 109.14(6) (6)Request for new benefit period. A SeniorCare participant may request a new benefit period for SeniorCare at any time. Upon receipt of a new application, the department shall determine the participant's eligibility for a new benefit period in the following manner unless the application is from the spouse of a participant and meets the conditions under s. DHS 109.15:
DHS 109.14(6)(a) (a) The person shall submit a new application as required under s. DHS 109.11.
DHS 109.14(6)(b) (b) The department shall redetermine eligibility when the request for a new benefit period is made beginning with the date a new complete application is received.
DHS 109.14(6)(c) (c) The department shall redetermine annual income for a 12-month period beginning with the date a new complete application is received.
DHS 109.14(6)(d) (d) The department shall redetermine which benefits and services under s. DHS 109.13 the applicant may receive.
DHS 109.14(6)(e) (e) The participant may withdraw the request for a new benefit period as allowed under s. DHS 109.11 (5).
DHS 109.14(6)(f) (f) Eligibility for the new benefit period shall begin on the first day of the month after the date a new complete application is received and all the eligibility requirements are met, including payment of a new enrollment fee specified in s. DHS 109.16.
DHS 109.14(6)(g) (g) Prescription drug costs that had been applied to a spend-down or deductible in a previous benefit period may not apply to the new benefit period.
DHS 109.14(6)(h) (h) Notwithstanding s. DHS 109.15, if a person eligible for SeniorCare requests a new benefit period at the same time the person's spouse applies for SeniorCare or requests a new benefit period, eligibility shall be determined under this section.
DHS 109.14(6)(i) (i) The department shall terminate a participant's current benefit period once the department determines eligibility for a request for a new benefit period.
DHS 109.14(7) (7)Annual eligibility review. Eligibility for a new benefit period determined under s. DHS 109.11 (6) (b) shall begin on the first day of the month immediately following the end of the previous benefit period when the department receives a complete application and all the eligibility requirements are met, including payment of a new enrollment fee specified in s. DHS 109.16, prior to the end of the 12th month of the previous benefit period.
DHS 109.14 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.
DHS 109.15 DHS 109.15Treatment of spouses. Notwithstanding ss. DHS 109.13 and 109.14, when the spouse of a SeniorCare participant files an application or review of eligibility for SeniorCare under s. DHS 109.14 (7), or requests a new benefit period, and is required under s. DHS 109.12 (1) to be in the same fiscal test group as the participant, the eligibility of the spouse for benefits and services under s. DHS 109.13 and the duration of the spouse's benefit period shall be determined in the following manner, unless both the participant and the participant's spouse jointly file a request for a new benefit period under s. DHS 109.14:
DHS 109.15(1) (1) The department shall determine the eligibility of the spouse under s. DHS 109.11, and, if eligible for SeniorCare, determine the beginning eligibility date of the spouse's benefit period according to s. DHS 109.14.
DHS 109.15(2) (2) If the department under sub. (1) determines the spouse is eligible for SeniorCare the spouse's benefit period shall end on the same date as the participant's benefit period ends.
DHS 109.15(3) (3) If the department determines the spouse is ineligible for SeniorCare, the benefits and services that the participant spouse may receive during the participant's current benefit period may not be affected.
DHS 109.15(4) (4) If the income of the spouse was not used to determine the SeniorCare benefit for the participant spouse, both of the following apply:
DHS 109.15(4)(a) (a) The department shall determine the annual income for the fiscal test group for the 12-month period beginning with the month the application request for the spouse is received.
DHS 109.15(4)(b) (b) The benefit and services under s. DHS 109.13 that the spouse may receive shall be determined as follows:
DHS 109.15(4)(b)1. 1. `Annual income exceeds 240% of poverty line.'
DHS 109.15(4)(b)1.a.a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, the spouse may receive spend-down services under s. DHS 109.13 (4) (a) 2.
DHS 109.15(4)(b)1.b. b. When determining whether the spouse meets the SeniorCare spend-down under s. DHS 109.13 (4) (c), the amount of the SeniorCare spend-down shall be prorated. The prorated amount shall be the annual spend-down amount under s. DHS 109.13 (4) (b) multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12. Only prescription drug costs of the spouse may count towards meeting the prorated spend-down.
DHS 109.15(4)(b)1.c. c. If the spouse meets the prorated spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b). When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12.
DHS 109.15(4)(b)1.d. d. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).
DHS 109.15(4)(b)2. 2. `Annual income between 160-240% of poverty line.'
DHS 109.15(4)(b)2.a.a. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b).
DHS 109.15(4)(b)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12.
DHS 109.15(4)(b)2.c. c. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).
DHS 109.15(4)(b)3. 3. `Annual income less than 160% of poverty line.'
DHS 109.15(4)(b)3.a.a. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).
DHS 109.15(5) (5) If the income of the spouse was used to determine the SeniorCare benefit for the participant, the department shall determine the benefit as follows:
DHS 109.15(5)(a) (a) Annual income exceeds 240% of poverty line.
DHS 109.15(5)(a)1.1. `Participant has not met spend-down.' If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, and the participant has not met the spend-down by the date the spouse becomes eligible for SeniorCare, the spouse may receive spend-down services under s. DHS 109.13 (4).
DHS 109.15(5)(a)2. 2. `Participant has met spend-down.'
DHS 109.15(5)(a)2.a.a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family and the participant met the spend-down before the spouse becomes eligible for SeniorCare, or the participant and spouse meet the spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).
DHS 109.15(5)(a)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12.
DHS 109.15(5)(a)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).
DHS 109.15(5)(b) (b) Annual income between 160-240% of poverty line.
DHS 109.15(5)(b)1.1. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).
DHS 109.15(5)(b)2. 2. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse's benefit period derived from subs. (1) and (2), divided by 12.
DHS 109.15(5)(b)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).
DHS 109.15(5)(c) (c) Annual income less than 160% of poverty line. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).
DHS 109.15 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (4) (b) 1. c. and 2. b. and (5) (a) 2. b. and (b) 2. Register October 2004 No. 586, eff. 11-1-04.
DHS 109.16 DHS 109.16Fees. For each 12-month benefit period, a program participant shall pay a program enrollment fee of $30. The department shall refund the fee to applicants found to be ineligible for SeniorCare.
DHS 109.16 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. Register October 2004 No. 586, eff. 11-1-04.
DHS 109.17 DHS 109.17Applicant appeals.
DHS 109.17(1) (1) Except as provided under sub. (2), any person whose application for SeniorCare is denied or is not acted upon promptly under s. DHS 109.11 (5), or who believes that the benefits or services the person may receive under s. DHS 109.13 have not been properly determined, or that his or her eligibility has not been properly determined under s. DHS 109.11 (5), may file an appeal pursuant to the requirements under ch. HA 3 that apply to the medical assistance program.
DHS 109.17(2)(a)(a) A request for a hearing concerning the SeniorCare program may only be made in writing and only to the division of hearings and appeals.
DHS 109.17(2)(b) (b) The applicant shall have 45 days from the effective date of the adverse action in which to file a request for hearing.
DHS 109.17 Note Note: A hearing request should be mailed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI, 53707-7875. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or transmitted by facsimile machine to 608-264-9885.
DHS 109.17 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.
subch. III of ch. DHS 109 Subchapter III — Drug Benefits
DHS 109.31 DHS 109.31Covered drugs and limitations on coverage.
DHS 109.31(1)(1)Covered services. Drugs and drug products covered under this chapter include prescription drugs and insulin listed in the Wisconsin medical assistance drug index that are prescribed by a physician licensed under s. 448.04, Stats., by a dentist licensed under s. 447.04, Stats., by a podiatrist licensed under s. 448.04, Stats., by an optometrist licensed under ch. 449, Stats., or by a nurse prescriber under ch. N 8, or when a physician delegates prescription of drugs to a nurse practitioner or to a physician's assistant certified under s. 448.04, Stats., and the requirements under s. N 6.03 for nurse practitioners and under s. Med 8.07 for physician assistants are met. The limitations on coverage and services in this section apply to co-pay, spend-down and deductible.
DHS 109.31(2) (2)Prior authorization.
DHS 109.31(2)(a)(a) Drugs requiring prior authorization. The following drugs and supplies require prior authorization:
DHS 109.31(2)(a)1. 1. All schedule III and IV stimulant drugs.
DHS 109.31(2)(a)2. 2. Drugs that have been demonstrated to entail significant expense or overuse for the medical assistance program. These drugs shall be noted in the Wisconsin medical assistance drug index.
DHS 109.31(2)(a)3. 3. Drugs identified by the department that may be used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.
DHS 109.31(2)(b) (b) Request for prior authorization.
DHS 109.31(2)(b)1.1. In considering a prior authorization request under this chapter made by a provider under sub. (1), the department shall require the information required in s. DHS 107.02 (3) (d) and apply the review criteria in s. DHS 107.02 (3) (e).
DHS 109.31(2)(b)2.a.a. If a SeniorCare provider under sub. (1) does not request and obtain prior authorization before providing a prescription drug requiring prior authorization, the department may not provide reimbursement except in an emergency.
DHS 109.31(2)(b)2.b. b. Except in an emergency case as specified under subd. 2. a., the department may not cover a prescription drug or apply a participant's purchase to the deductible or spend-down if the department has not prior authorized a drug requiring prior authorization. A certified provider may not hold a recipient liable for payment for a covered service requiring prior authorization by the department unless the department denies the prior authorization request and the provider informs the recipient of the recipient's personal liability before provision of the service. If the department denies the recipient's prior authorization request, the recipient may request a fair hearing under s. DHS 109.63. SeniorCare providers are required to request prior authorization for all SeniorCare participants.
DHS 109.31(3) (3)Other limitations.
DHS 109.31(3)(a)(a) SeniorCare providers shall limit dispensing of schedule III, IV and V drugs to the original dispensing plus 5 refills, or 6 months from the date of the original prescription, whichever comes first.
DHS 109.31(3)(b) (b) SeniorCare providers shall limit dispensing of non-scheduled legend drugs and insulin to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.
DHS 109.31(3)(c) (c) SeniorCare providers shall fill:
DHS 109.31(3)(c)1. 1. Generically-written prescriptions for drugs listed in the federal food and drug administration approved drug products publication with a generic drug included in that list.
DHS 109.31(3)(c)2. 2. Prescription orders written for brand name drugs that have a lower cost generically available drug with the lower cost drug product, unless the prescribing provider under sub. (1) writes “brand medically necessary" on the face of the prescription. The prescribing provider shall document in the patient's record the reason why the drug is medically necessary.
DHS 109.31(3)(d) (d) Except as provided in par. (e), SeniorCare providers shall dispense prescription drugs in amounts not to exceed a 34-day supply.
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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.