HFS 107.10 Drugs. (1) COVERED SERVICES. Drugs and drug products covered by MA include legend and non–legend drugs and supplies listed in the Wisconsin medicaid drug index which are prescribed by a physician licensed under s.
448.04, Stats., by a dentist licensed under s.
447.05, Stats., by a podiatrist licensed under s.
448.04, Stats., or by an optometrist licensed under ch.
449, Stats.,
by an advanced practice nurse prescriber licensed under s. 441.16, Stats., or when a physician delegates
prescription
the prescribing 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 8.08 for physician assistants are met.
Note: The Wisconsin MAmedicaid drug index is available from the State of Wisconsin Document Sales, P.O. Box 7840, Madison, WI 53707Division of Health Care Financing, P.O. Box 309, Madison, WI 53701.
SECTION 20. HFS 107.10 (2) (a) is repealed.
SECTION 21. HFS 107.10 (2) (d), (3) (b) to (d) and (h) (intro) are amended to read:
HFS 107.10 (2) (d) Drugs which have been demonstrated to the department has determined entail substantial cost or utilization problems for the MA program, including antibiotics which cost $100 or more a day. These drugs shall be noted in the Wisconsin medicaid drug index;
(3) (b) Dispensing of non–scheduled legend drugs shall be limited to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.
(c) Generically–written prescriptions for drugs listed in the federal food and drug administration approved drug products publication shall be filled with a generic drug included in that list. Prescription orders written for brand name drugs which have a lower cost genericallycommonly available generic drug equivalent shall be filled with the lower cost drug product equivalent, unless the prescribing provider under sub. (1) writes “brand medically necessary" on the face of the prescription.
(d) Except as provided in par. (e), legend drugs shall be dispensed in the full amounts prescribed, not to exceed a 34–day supply.
(h) To be included as a covered service, an over–the–countera non-legend drug shall be used in the treatment of a diagnosable medical condition and be a rational part of an accepted medical treatment plan. Only the
The following general categories of over–the–counternon-legend drugs are covered:
SECTION 22. HFS 107.10 (3) (h) 8. is created to read:
HFS 107.10 (3) (h) 8. Non-legend drugs not within one of the categories described under subds. 1. to 7. that previously had legend drug status and that the department has determined to be cost effective in treating the condition for which the drugs are prescribed."
SECTION 23. HFS 107.10 (3) (i), (4) (L) and (5) (a) are amended to read:
HFS 107.10 (3) (i) Any innovator multiple–source drug is a covered service only if the prescribing provider under sub. (1) certifies by writing the phrase “brand medically necessary" on the prescription to the pharmacist that a specificthe innovator brand drug, rather than a generic drug, is medically necessary. The prescribing provider shall document in the patient's record the reason why the innovator brand drug is medically necessary in the patient's record. In this paragraph, “innovatorThe innovators of multiple source drug" means a multiple source drug that was originally marketed under an original new drug application approved by the U.S. food and drug administration are identified in the Wisconsin medicaid drug index.
(4) (L) Drugs included in the medicaid negative drug listformulary maintained by the department; and
(5) (a) The pharmacist shall provide for a review
ofthe drug therapy before each prescription is filled or delivered to an MA recipient. The review shall include screening for potential drug therapy problems due to including therapeutic duplication, drug–disease contraindications, drug–drug interactions, including serious interactions with non–prescription or over–the–counter
non-legend drugs, incorrect drug dosage or duration of drug treatment, drug–allergy interactions and clinical abuse or misuse.
SECTION 24. HFS 107.11 (6) (b) 5. is amended to read:
HFS 107.11 (6) (b) 5. a. Except as provided in subd. par. b., Ddrugs and treatment shall be administered by the RN or LPN only as ordered by the recipient's physician or his or her designee. The nurse shall immediately record and sign oral orders and shall obtain the physician's countersignature within 10 working days.
b. Drugs may be administered by an advanced practice nurse prescriber as authorized under ss. N 8.06 and 8.10.
SECTION 25. HFS 107.12 (1) (e) is amended to read:
HFS 107.12 (1) (e) 1. Except as provided in subd. 2.,
Drugs and treatment shall be administered by the RN or LPN only as ordered by the recipient's physician or his or her designee. The nurse shall immediately record and sign oral orders and shall obtain the physician's countersignature within 10 working days.
2. Drugs may be administered by an advanced practice nurse prescriber as authorized under ss.
N 8.06 and
8.10.
SECTION 26. HFS 107.24 (2) (a), (3) (h) 1. (intro) and 2. and (5) (j) are amended to read:
HFS 107.24 (2) COVERED SERVICES. (a) Prescription and provision. Durable medical equipment (DME) and medical supplies are covered services only when prescribed by a physician and when provided by a certified physician, clinic, hospital outpatient department, nursing home, pharmacy, home health agency, therapist, orthotist, prosthetist, hearing aid dealerinstrument specialist or medical equipment vendor.
(3) (h) 1. A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient's physician and an audiological report from an audiologist or hearing aid dealerinstrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing aid dealerinstrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines that:
2. After a new or replacement hearing aid or other ALD has been worn for a 30-day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing aid dealerinstrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient;
(5) (j) All repairs of a hearing aid or other assistive listening device performed by a dealer within 12 months after the purchase of the hearing aid or other assistive listening device. These are included in the purchase payment and are not as separate servicesseparately reimbursable;
SECTION 27. HFS 107.36 (1) (a) 4., (b) to (i) and (2) (a) and (b) 2. are amended to read:
HFS 107.36 (1) (a) 4. Consultation, case monitoring and coordination related to developmental testing under the individuals with disabilities education act,
20 USC 1400 to
1485, are included in the MA–covered services described in this subsection when an IEP
or IFSP results from the testing. Consultation, case monitoring and coordination for IEP
or IFSP services are also included in the covered services described in this subsection.
(b)
Speech-language pathology, hearing and audiological services. Speech, languageSpeech-language pathology, hearing and audiological services for a recipient with a speech, language or hearing disorder that adversely affects the individual's functioning are covered school–based services. These services include evaluation and testing to determine the individual's need for the service, recommendations for a course of treatment and treatment. The services may be delivered to an individual or to a group of 2 to 7 individuals. The services shall be performed by or under the direction of a
speech and languagespeech-language pathologist licensed by the department of public instruction under s.
PI 3.35 or by an audiologist licensed by the department of public instruction under s.
PI 3.355, and shall
have a physician referral and be identified in the recipient's IEP
or IFSP.
(c)
Occupational therapy services. Occupational therapy services which identify, treat, or compensate for medical problems that interfere with age–appropriate functional performance are covered school–based services. These services include evaluation to determine the individual's need for occupational therapy, recommendations for a course of treatment, and rehabilitative, active or restorative treatment services. The services may be delivered to an individual or to a group of 2 to 7 individuals. The services shall be performed by or under the direction of an occupational therapist licensed by the department of public instruction under s.
PI 3.36 and shall be
prescribed by a physician and identified in the recipient's IEP
or IFSP.
(d)
Physical therapy services. Physical therapy services which identify, treat, or compensate for medical problems are covered school–based services. These services include evaluation to determine the individual's need for physical therapy, recommendations for a course of treatment, and therapeutic exercises and rehabilitative procedures. The services may be delivered to an individual or to a group of 2 to 7 individuals. The services shall be performed by or under the direction of a physical therapist licensed by the department of public instruction under s.
PI 3.37 and shall be prescribed by a physician
when required by the department of regulation and licensing and identified in the recipient's IEP
or IFSP.
(e)
Nursing services. Professional nursing services relevant to the recipient's medical needs are covered school–based services. These services include evaluation and management services, including screens and referrals for treatment of health needs; treatment; medication management; and explanations given of treatments, therapies and physical or mental conditions to family members or school district or CESA staff. The services shall be performed by a registered nurse licensed under s.
441.06, Stats., or a licensed practical nurse licensed under s.
441.10, Stats., or be delegated under nursing protocols pursuant to ch.
N 6. The services shall be prescribed or referred by a physician or an advanced practice nurse as defined under s.
N 8.02 (1) with prescribing authority granted under s.
441.16 (2), Stats., and shall be identified in the recipient's IEP
or IFSP.
(f)
Psychological counseling and social work services. Psychological counseling and social work services relevant to the recipient's mental health needs with the intent to reasonably improve the recipient's functioning are covered school–based services. These services include testing, assessment and evaluation that appraise cognitive, emotional and social functioning and self–concept; therapy or treatment that plans, manages and provides a program of psychological counseling or social work services to individuals with psychological or behavioral problems; and crisis intervention. The services may be delivered to an individual or to a group of 2 to 10 individuals. The services shall be performed by a school psychologist, school counselor or school social worker licensed by the department of public instruction under ch.
PI 3. The services shall be
prescribed or referred by a physician or a psychologist licensed under s. 455.04 (1), Stats., and shall be identified in the individual's IEP
or IFSP.
(g)
Developmental testing and assessments under IDEA. Developmental testing and assessments under the individuals with disabilities education act (IDEA),
20 USC 1400 to
1485, are covered school–based services when an IEP
or IFSP results. These services include evaluations, tests and related activities that are performed to determine if motor, speech, language or psychological problems exist, or to detect developmental lags for the determination of eligibility under IDEA.
The services shall be performed by a special education teacher, diagnostic teacher or other school district staff licensed by the department of public instruction under ch. PI 3. The services are also covered when performed by a therapist, psychologist, social worker, counselor or nurse licensed by the department of public instruction under ch.
PI 3, as part of their respective duties.
(h)
Transportation. Transportation services provided to individuals who require special transportation accommodations
in vehicles equipped with a ramp or lift are covered school–based services if the recipient receives a school–based service
other than transportation on the day transportation is provided. These services include transportation from the recipient's home to and from school on the same day if the school–based service is provided in the school, and transportation from school to a service site and back to school or home if the school–based service is provided at a non–school location, such as at a hospital. Transportation shall be performed by a school district, CESA or contracted provider
using vehicles equipped with a ramp or lift.
A prescription from a physician or advanced practice nurse, as defined under s. N 8.02 (1), with prescribing authority granted under s. 441.16 (2), Stats., is required to demonstrate the recipient's need for special transportation. The service shall be included in the IEP
or IFSP. The covered service that the recipient is transported to and from shall meet MA requirements for that service under ch.
HFS 105 and this chapter.
(i)
Durable medical equipment. Durable medical equipment except equipment covered in s.
HFS 107.24 is a covered service if the need for the equipment is identified in the recipient's IEP
or IFSP, the equipment is recipient-specific, the equipment is not duplicative of equipment the recipient currently owns and the equipment is for the recipient's use at school and home.
Only durable medical equipment related to speech-language pathology, physical therapy or occupational therapy will be covered under the school based services benefit. The recipient, not the school district or the CESA, shall own the equipment.
(2) LIMITATIONS. (a) Age limit. School–based services may only be provided to MA-eligible recipients underbetween 3 and 21 years of age, or for the school term during which an MA-eligible recipient becomes 21 years of age.
(b) 2. Are identified in an IEP or an IFSP;
SECTION 28. HFS 111.03 (36) is amended to read:
HFS 111.03 (36) “Provisional EMT–intermediate" means the title and temporary license level given to EMTs–intermediate licensed based on the 1989 or earlier version of the national standard curriculum as of February 1, 2002. The temporary licensing level will no longer be used after June 30, 20042006.
SECTION 29. HFS 120.02 is amended to read:
HFS 120.02 Applicability. This chapter applies to the department, the board on health care information, the independent review board, qualified vendors, health care plans, health care providers licensed in this state and persons requesting data from the department.
SECTION 30. HFS 120.03 (4m) is created to read:
HFS 120.03 (4m) “Claims data" means data stored in a health care provider's or qualified vendor's electronic billing system.
SECTION 31. HFS 120.03 (7) (note), (13), (20), (28), (29), (30) (note), (34) and (36) are amended to read:
HFS 120.03 (7) Note: A copy of the data submission manual is provided to each data submitting entity. Copies of the manual are also available at http://badger.state.wi.us/agencies/oci/ohcihttp://www.dhfs.state.wi.us/healthcareinfo or by writing to the Bureau of Health Information at P.O. Box 309, Madison, WI 53701–0309.
(13) “Freestanding ambulatory surgery center" or “center" means any distinct entity that is operated exclusively for the purpose of providing surgical services to patients not requiring hospitalization, that has an agreement with the federal
health care financing administrationcenters for medicare and medicaid services under
42 CFR 416.25 and
416.30 to participate as an ambulatory surgery center, and that meets the conditions set forth in
42 CFR 416.25 to
416.49.
(20) “Individual data elements" means items of information from or derived from a uniform patient billing form or derived from a uniform patient billing form
an electronic transaction and code set standard for health care.
(28) “Public use data" means any form of data from the department's comprehensive discharge database, physician office visit database or facility level database that does not allow the identification of an individual from the elements released in the data files.
(29) “Qualified vendor" means an entity under contract with a health care provider that will submit data to the department according to formats the department specifies in its data submission manual. Qualified vendors may be either internal to a clinic or medical group or an external organization.
(30) Note: Examples of raw data elements are any of the following:
a. The data files hospitals and surgery centers submitted to the department each quarter.
b. The public–use data files the department produces.
c. Any custom data file produced by the department that contains individual patient data records representing hospital discharges or surgical cases. Some customers purchase this kind of data when it is more cost–effective than purchasing the complete statewide public–use data files.
d. A computer printout of the individual data elements in individual patient data records representing hospital discharges or surgical cases.
(34) “Trading partner agreement" means a signed, formal arrangement between a health care provider, the department and a qualified vendor providing the transfer of data under this chapter. The agreement specifies the acceptable data formats, the edit review and verification requirements, including procedures for processing confidential patient data and the authorized signatory for the affirmation statement.
(36) “Uniform patient billing form or electronic transaction and code set standard for health care" means a forms or standard consistent with federal data standards for health care payment transactions.
SECTION 32. HFS 120.05 (2) is amended to read:
HFS 120.05 (2) TIMING. All written communications, including documents, reports and information required to be submitted to the department shall be submitted by 1st class or registered mail, or by delivery in person or in an electronic format specified by the department. The date of submission is the daydate the written communication is postmarked, or delivered in personthe date delivery in person is made, or the date on the electronic communication.
SECTION 33. HFS 120.11 (3) (c) and (d) 1. are amended to read:
HFS 120.11 (3) (c) If the department determines data submitted by the facility to be questionable, and the department has determined that the data cannot be verified or corrected by telephone or electronic means, the department may return the questionable data to the facility or the facility's qualified vendor with information for revision and resubmission.
(d) 1. Within
3020 calendar days from the required date for data submission as specified in s.
HFS 120.12 (5) (b) 2., and (5m) (b) 2.
, and (6) (c) 2. and 120.13 (2) (a), the facility shall do all of the following:
SECTION 34. HFS 120.11 (3) (f) is repealed.
SECTION 35. HFS 120.11 (4) (e) 1. and 2. are amended to read:
HFS 120.11 (4) (e) 1. If a physician files a timely request to review data before release, the department shall make the data available to the physician as it is submitted to the department. The department's transmittalreport shall contain a “permission to change" authorization form that may be duplicated in the event of multiple problems.
2. If the physician wants to dispute the data, the physician shall describe on the formattest to the problem associated with the data on the authorization form, and an authorized representative of the facility shall indicate on the form if the facility agrees to the change.
SECTION 36. HFS 120.12 (1) (b) 2., (2) (b) 1., (c) 2. a., (3) (b) 11., (c) 1. and 3., (5) (b) 2. and 4. are amended to read:
HFS 120.12 (1) (b) 2. The department may grant an extension of a deadline specified under subd. 1. only when the hospital adequately justifies to the department the hospital's need for additional time. In this subdivision, “adequate justification" means a delay due to a strike, fire, natural disaster or delay due to catastrophic computer
failuresystem malfunction. A hospital desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days before the date the data are due. The department may grant an extension for up to 30 calendar days.
(2) (b) Data to be collected. 1. 'General hospital data.' Hospitals shall report all of the following financial data to the department in the format specified by the department, in accordance with this subsection and department instructions that are based on guidelines from the July 1998 version
2003 update of the Audits of Providers of Health Care ServicesHealth Care Organizations – AICPA Audit and Accounting Guide, published by the American institute of certified public accountants, generally accepted accounting principles and the national annual survey of hospitals conducted by the American hospital association.
(c) 2. a. Except as provided in subd. 2. b., the department may grant an extension of a deadline specified in subd. 1. only when the hospital adequately justifies to the department the hospital's need for additional time. In this subdivision, “adequate justification" means a delay due to a strike, fire, natural disaster or catastrophic computer failuresystem malfunction. A hospital desiring an extension shall submit a request in writing to the department at least 10 calendar days prior to the date that the data are due. The department may grant an extension for up to 30 calendar days.
(3) (b) 11. Swing–bed utilization, if applicable, including average number of swing beds, admissionsdischarges and days of care.
(c) 1. A hospital shall submit to the department the data specified in par. (a)(b) according to a schedule specified by the department.
3. The department may grant an extension of a deadline specified in this paragraph only when the hospital adequately justifies to the department the hospital's need for additional time. In this subdivision, “adequate justification" means a delay due to a strike, fire, natural disaster or catastrophic computer failuresystem malfunction. A hospital desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days prior to the date that the data are due. The department may grant an extension for up to 30 calendar days.
(5) (b) 2. Hospitals shall send the data to the department within 3045 calendar days of the last day of each calendar quarter using the department's electronic submission system. Calendar quarters shall begin on January 1, April 1, July 1 and October 1 and shall end on March 31, June 30, September 30 and December 31.
4. The department may grant an extension of the time limits specified under subd. 2. only when the hospital adequately justifies to the department the hospital's need for additional time. In this subdivision, “adequate justification" means a delay due to a strike, fire, natural disaster or catastrophic computer failuresystem malfunction. A hospital desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days prior to the date that the data are due. The department may grant an extension for up to 30 calendar days.
SECTION 37. HFS 120.12 (5m) (a) 30. and 31. are created to read:
HFS 120.12 (5m) (a) 30. Patient race.
31. Patient ethnicity.
SECTION 38. HFS 120.12 (5m) (b) 2., 4. and 5. a. and (6) (a) and (c) 2. and 3. are amended to read:
HFS 120.12 (5m) (b) 2. Within 3045 calendar days after the last day of each calendar quarter, each hospital shall submit to the department the data specified in par. (a) using the department's electronic data submission system. Calendar quarters shall begin on January 1, April 1, July 1 and October 1 and shall end on March 31, June 30, September 30 and December 31.
4. The department may grant an extension of the deadline specified under subd. 2. only when the hospital adequately justifies to the department the hospital's need for additional time. In this subdivision, “adequate justification" means a delay due to a strike, fire, natural disaster or catastrophic computer failuresystem malfunction. A hospital desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days before the date the data are due. The department may grant an extension for up to 30 calendar days.
5. a. To ensure confidentiality, hospitals using qualified vendors to submit data shall provide an original trading partner agreement to the department that has been signed and notarized by the qualified vendor and the hospital.
(6) (a)
Definition. In this subsection “hospital–
affiliated ambulatory surgical center" means an entity that is owned by a hospital and is operated exclusively for the purpose of providing surgical services to patients not requiring hospitalization, has an agreement with the federal
health care financing administrationcenters for medicare and medicaid services under
42 CFR 416.25 and
416.30 to participate as an ambulatory surgery center, and meets the conditions set forth in
42 CFR 416.25 to
416.49.
(c) 2. Within 3045 calendar days after the end of each calendar quarter, each hospital shall submit to the department the surgical data specified in par. (a) for all ambulatory patient surgical procedures using the department's electronic submission system. The department's electronic submission system shall be described in the department's data submission manual. Calendar quarters shall begin on January 1, April 1, July 1 and October 1 and shall end on March 31, June 30, September 30 and December 31.
3. The department may grant an extension of the deadline specified under subd. 2. only when the hospital adequately justifies to the department the hospital's need for additional time. In this subdivision, “adequate justification" means a delay due to a strike, fire, natural disaster or catastrophic computer failuresystem malfunction. A hospital desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days before the date the data are due. The department may grant an extension for up to 30 calendar days.
SECTION 39. HFS 120.13 (2) (a) and (b) are amended to read:
HFS 120.13 (2) (a) Each freestanding ambulatory surgery center shall electronically submit to the department, as described in the department's data submission manual, all data elements specified in sub. (1) for all ambulatory patient surgical procedures within 3045 calendar days after the end of each calendar quarter. Calendar quarters shall begin on January 1, April 1, July 1 and October 1 and shall end on March 31, June 30, September 30 and December 31. The method of submission, data formats and coding specifications shall be defined in the department's data submission manual.
(b) The department may grant an extension of the time limits specified under par. (a) only when the center adequately justifies to the department the center's need for additional time. In this paragraph, “adequate justification" means a delay due to a strike, fire, natural disaster or catastrophic computer failuresystem malfunction. A center desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days prior to the date that the data are due. The department may grant an extension for up to 30 calendar days.
SECTION 40. HFS 120.14 (1) (b) 1. and (note), 2. to 6. (intro) and (c) 2. (intro) are amended to read:
