DHS 101.03(52)
(52) “Emergency services" means those services necessary to treat an emergency medical condition, including labor and delivery, that without immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, seriously impair bodily functions, or seriously disable any body part or bodily organ.
DHS 101.03(52g)
(52g) “Employed" means the person receives income for ongoing services and as a result of this income has incurred a potential tax liability. Any of the following may be used to verify employment:
DHS 101.03(52g)(f)
(f) Statements from employers. Employer statements may include those from personnel officers, supervisors or other employees of the company who have direct knowledge of the applicant's or recipient's wages. The person making the statement must provide evidence (such as employment records, business correspondence, etc.) that the applicant or recipient is or was an employee of the company during the calendar month for which the applicant or recipient requests eligibility.
DHS 101.03(52g)(g)
(g) Other agencies who receive reports of the applicant's or recipient's income directly from the employer.
DHS 101.03(52m)
(52m) “Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80% of the cost, excluding any deductibles or copayments that may be required under the plan.
DHS 101.03(52r)
(52r) “Employment barriers assessment" means an analysis that identifies a person's potential employment barriers, such as physical limitations or problems associated with the person's living situation, education or health or long term care coverage, and strategies for overcoming these potential barriers.
DHS 101.03(52s)
(52s) “Employment plan" means a plan developed by a person describing the manner in which a person shall meet the requirements of a health and employment counseling program.
DHS 101.03(53)
(53) “Enrolled recipient" means a recipient who has entered into an agreement to receive services from a provider reimbursed under the terms of a prepaid capitation contract with the department.
DHS 101.03(54)
(54) “EPSDT" means early and periodic screening, diagnosis and treatment services provided by a provider certified pursuant to s.
DHS 105.37.
DHS 101.03(55)
(55) “EPSDT case management" means those activities necessary to:
DHS 101.03(55)(b)
(b) Make arrangements and assist clients to follow through with diagnosis and treatment; and
DHS 101.03(55)(c)
(c) Refer clients, upon request, to the appropriate local agencies for transportation assistance.
DHS 101.03(56)
(56) “EPSDT provider" means a provider certified under s.
DHS 105.37 to provide EPSDT health assessment and evaluation services.
DHS 101.03(58)
(58) “Exempt assets" means assets which are not considered in the determination of financial eligibility for medical assistance.
DHS 101.03(59)
(59) “Exempt income" means income which is not considered when determining financial eligibility for medical assistance.
DHS 101.03(60)
(60) “Explanation of benefits notice" means the monthly report sent by the department to a recipient containing a summary of the department's record of MA claims paid on the recipient's behalf during that month.
DHS 101.03(61)
(61) “Eyeglasses" means lenses, including frames where necessary, and other aids to vision prescribed by a physician skilled in diseases of the eye or by a licensed optometrist.
DHS 101.03(63)
(63) “Fair market value" means the market value of the property on the date of the transaction.
DHS 101.03(64)
(64) “Fiscal agent" means the organization under contract to the department to process claims for services provided under MA.
DHS 101.03(65)
(65) “Fiscal test group" means all members of the medical assistance group and all persons who are financially responsible for members of the medical assistance group who live in the same household as the person for whom they are legally responsible and who are not SSI recipients.
DHS 101.03(66)
(66) “Functional ability" means the skill to perform activities in a normal or acceptable manner with minimal dependence on devices, persons or environment.
DHS 101.03(66m)
(66m) “Functionally equivalent” means a service provided via telehealth where the transmission of information is of sufficient quality as to be the same level of service as an in person visit. Transmission of voices, images, data, or video must be clear and understandable.
DHS 101.03(67)
(67) “Functional status" means the recipient's skill in performing activities of daily living in a normal or acceptable manner.
DHS 101.03(68)
(68) “Group occupational therapy treatment" means the delivery of occupational therapy treatment procedures in a group setting, with up to 6 patients supervised by one qualified occupational therapist and more than 6 but no more than 12 patients supervised by 2 qualified occupational therapy staff members one of whom is a registered occupational therapist.
DHS 101.03(69)
(69) “Group speech/language pathology treatment" means the delivery of speech/language pathology treatment procedures limited to the areas of expressive language, receptive language, and hearing/auditory training (auditory training, lip reading, and hearing-aid orientation), in a group setting for up to 4 MA recipients.
DHS 101.03(69g)
(69g) “Health and employment counseling program" means services provided within a period of eligibility, which assist a person in pursuing and maintaining employment, that are assembled into an employment plan, reviewed by a screening agency, approved by the department and include all of the following:
DHS 101.03(69m)
(69m) “Health insurance coverage" has the meaning provided in
42 USC 300gg-91(b)(1) and also includes any arrangement in which a third party agrees to pay for the health care costs of the individual.
DHS 101.03(70)
(70) “Health maintenance organization" or “HMO" means a public or private organization organized under ch.
185,
611 or
613, Stats., which makes available to enrolled participants, in consideration of predetermined periodic fixed payments, comprehensive health care services provided by providers who are selected by the organization or who have entered into a referral or contractual arrangement with the organization and which is certified under s.
DHS 105.47.
DHS 101.03(71)
(71) “Home health agency" means a public agency or private organization, or a subdivision of the agency or organization, which is primarily engaged in providing skilled nursing services and other therapeutic services to a recipient at the recipient's place of residence.
DHS 101.03(72)
(72) “Home health aide" means an individual employed by or under contract to a certified home health agency to provide home health aide services, as defined in s.
DHS 133.02 (5), under the supervision of a registered nurse.
DHS 101.03(73)
(73) “Home health service" means any covered home health service enumerated in s.
DHS 107.11 (2) and provided by a health worker on the staff of a home health agency or by a health worker under contract or another arrangement with the home health agency.
DHS 101.03(75)
(75) “Homestead" or “home" means a place of abode and lands used or operated in connection with the place of abode.
DHS 101.03 Note
Note: In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead.
DHS 101.03(75m)
(75m) “Hospice" means a public agency or private organization or a subdivision of either which primarily provides palliative care to persons experiencing the last stages of terminal illness and which provides supportive care for the family and other individuals caring for the terminally ill persons. This care is provided in a homelike environment, and includes short-term inpatient care as necessary to meet the individual's needs. Services provided by a hospital, long-term care facility, outpatient surgical center or home health agency do not constitute a hospice program of care unless that entity establishes a free-standing or distinct hospice unit, or has a distinct hospice program including staff, facility and services certified under s.
DHS 105.50 to provide hospice care.
DHS 101.03(77)
(77) “Hospital visit" means at least an overnight stay by a nursing home recipient in a certified hospital.
DHS 101.03(78)
(78) “Hysterectomy" means a medical procedure or surgery to remove the recipient's uterus.
DHS 101.03(78r)
(78r) “IFSP" means an individualized family service plan developed under s.
51.44, Stats.
DHS 101.03(78u)
(78u) “Impairment-related work expense" means a cost paid for by a medicaid purchase plan applicant or recipient to work that is all the following:
DHS 101.03(78u)(b)
(b) Not a cost that any similar worker, without a disability, would also have.
DHS 101.03(78u)(c)
(c) Not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.
DHS 101.03(78u)(d)
(d) Representative of the standard charge for the item or service in the applicant's or recipient's community.
DHS 101.03 Note
Note: Impairment-related work expenses are as described in
20 CFR 404.1576.
DHS 101.03(79)
(79) “Income disregard" means an earned or unearned income which is not considered in one or more financial tests of eligibility.
DHS 101.03(80)
(80) “Income limit" means the limit against which budgetable income is compared to determine financial eligibility.
DHS 101.03(80m)
(80m) “Independence account" means an account approved by the department that consists solely of savings, dividends and gains derived from savings and income earned from paid employment after the initial date that a person began receiving medical assistance under the medicaid purchase plan.
DHS 101.03(81)
(81) “Independent provider of service" means an individual or agency which is eligible to provide health care services to nursing home recipients, to have a provider number, and to submit claims for reimbursement under MA. “Independent provider of service" includes: a physician, dentist, chiropractor, registered physical therapist, certified occupational therapist, certified speech therapist, certified audiologist, psychiatrist, pharmacist, ambulance service agency, specialized medical vehicle service agency, psychologist, x-ray clinic and laboratory.
DHS 101.03(82)
(82) “Indirect services" means nursing home services that benefit patient recipients on a group basis rather than an individual basis, including consulting, in-service training, medical direction, utilization review, and the services of unlicensed or uncertified assistants who are not under direct supervision. “Indirect services" are often referred to as nonbillable services, nonmedical services or nonprofessional services.
DHS 101.03(83)
(83) “Individual occupational therapy treatment" means delivery by one therapist to one recipient of occupational therapy treatment procedures as prescribed in the individual patient's plan of care for the purpose of restoring, improving or maintaining optimal functioning.
DHS 101.03(84)
(84) “Individual speech/language pathology treatment" means delivery by one therapist to one recipient of speech/language pathology treatment procedures, as prescribed in the individual recipient's plan of care, for the purpose of restoring, improving, or maintaining optimal speech and language functioning.
DHS 101.03(85)
(85) “Inmate of a public institution" means a person who has resided for at least a full calendar month in an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control and has received treatment or services there that are appropriate to his or her requirements.
DHS 101.03(85m)
(85m) “Institution for mental disease" or “IMD" means an institution that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services, as determined by the department or the federal health care financing administration. An institution is an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental disease.
DHS 101.03(86)
(86) “Institutionalized" means being a patient in a medical institution or a resident of an intermediate care facility or skilled nursing facility.
DHS 101.03(87)
(87) “Institutionalized individual" means an individual who is:
DHS 101.03(87)(a)
(a) Involuntarily confined or detained in a rehabilitative facility, such as a psychiatric hospital or other facility for the care and treatment of mental illness, or under a civil or criminal statute in a correctional facility; or
DHS 101.03(87)(b)
(b) Confined, under a voluntary commitment, in a psychiatric hospital or other facility for the care and treatment of mental illness.
DHS 101.03(88)
(88) “Institutional provider" means a hospital, home health agency, county department operated facility, rehabilitation agency, portable x-ray provider, independent clinical laboratory, rural health clinic, skilled nursing facility, intermediate care facility, case management agency provider, personal care provider, ambulatory surgical center or hospice which is:
DHS 101.03(88)(b)
(b) Eligible to receive payment only as a certified group or organization, rather than as individuals providing services within a facility or agency; and
DHS 101.03(88)(c)
(c) Required by the department to establish that its personnel who provide services meet the applicable certification criteria contained in ch.
DHS 105, although they need not be separately certified by the department.
DHS 101.03(89)
(89) “Intermediate care facility" or “ICF" means a facility that:
DHS 101.03(89)(a)
(a) Provides, on a regular basis, health-related services to individuals who do not require hospital or skilled nursing facility care but whose mental or physical condition requires services that are above the level of room and board and that can be made available only through institutional facilities;
DHS 101.03(90)
(90) “Intermediate care services" means services provided by an intermediate care facility.
DHS 101.03(91)
(91) “Intermittent nursing services" means nursing services provided to a recipient who has a medically predictable recurring need for skilled nursing services. In most instances, this means that the recipient requires a skilled nursing visit at least once every 60 days.
DHS 101.03(92)
(92) “Laboratory" or “clinical laboratory" means a facility for the microbiological, serological, chemical, hematological, radiobiassay cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention or treatment of any disease or assessment of a medical condition.
DHS 101.03(92)(a)
(a) “Independent laboratory" means a laboratory performing diagnostic tests which is independent both of an attending or consulting physician's office and of a hospital.
DHS 101.03(92)(b)
(b) “Hospital laboratory" means a laboratory operated under the supervision of a hospital or its organized medical staff that serves hospital patients.
DHS 101.03(92)(c)
(c) “Physician's office laboratory" means a laboratory maintained by a physician for performing diagnostic tests for his or her own patients.
DHS 101.03 Note
Note: A physician's office laboratory which accepts at least 100 specimens in any category during any calendar year on referral from other physicians is considered an independent laboratory.
DHS 101.03(93)
(93) “Legally responsible" means a spouse's liability for the support of a spouse or a parent's liability for the support of a child as specified in s.
49.90, Stats.
DHS 101.03(94)
(94) “Legend drug" means, for the purposes of MA, any drug requiring a prescription under
21 USC 353 (b).
