DHS 107.19(3)(e)4.
4. The evaluation indicates that the recipient's abilities are functional for the person's present way of life;
DHS 107.19(3)(e)5.
5. The recipient shows no motivation, interest, or desire to participate in therapy, which may be for reasons of an overriding severe emotional disturbance;
DHS 107.19(3)(e)6.
6. Other therapies are providing sufficient services to meet the recipient's functioning needs; or
DHS 107.19(3)(e)7.
7. The procedures requested are not medical in nature or are not covered services. Inappropriate diagnoses for therapy services and procedures of questionable medical necessity may not receive departmental authorization, depending upon the individual circumstances.
DHS 107.19(4)
(4)
Non-covered services. The following services are not covered services:
DHS 107.19(4)(a)
(a) Activities such as end-of-the-day clean-up time, transportation time, consultations and required paper reports. These are considered components of the provider's overhead costs and are not covered as separately reimbursable items; and
DHS 107.19 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.19 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (b), (c) and (h), (2) (a) 1. and 3.,
Register, May, 1990, No. 413, eff. 6-1-90; corrections in (1) (intro.) and (4) (b) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.20(1)(1)
Covered services. Covered vision care services are eyeglasses and those medically necessary services provided by licensed optometrists within the scope of practice of the profession of optometry as defined in s.
449.01, Stats., who are certified under s.
DHS 105.32, and by opticians certified under s.
DHS 105.33 and physicians certified under s.
DHS 105.05.
DHS 107.20(2)
(2)
Services requiring prior authorization. The following covered services require prior authorization by the department:
DHS 107.20(2)(a)
(a) Vision training, which shall only be approved for patients with one or more of the following conditions:
DHS 107.20(2)(b)
(b) Aniseikonic services for recipients whose eyes have unequal refractive power;
DHS 107.20(2)(c)
(c) Tinted eyeglass lenses, occupational frames, high index glass, blanks (55 mm. size and over) and photochromic lens;
DHS 107.20(2)(d)
(d) Eyeglass frames and all other vision materials which are not obtained through the MA vision care volume purchase plan;
DHS 107.20 Note
Note: Under the department's vision care volume purchase plan, MA-certified vision care providers must order all eyeglasses and component parts prescribed for MA recipients directly from a supplier under contract with the department to supply those items.
DHS 107.20(2)(e)
(e) All contact lenses and all contact lens therapy, including related materials and services, except where the recipient's diagnosis is aphakia or keratoconus;
DHS 107.20(2)(g)
(g) Eyeglass frames or lenses beyond the original and one unchanged prescription replacement pair from the same provider in a 12-month period; and
DHS 107.20 Note
Note: For more information on prior authorization, see s.
DHS 107.02 (3).
DHS 107.20(3)(a)(a) Eyeglass frames, lenses, and replacement parts shall be provided by dispensing opticians, optometrists and ophthalmologists in accordance with the department's vision care volume purchase plan. The department may purchase from one or more optical laboratories some or all ophthalmic materials for dispensing by opticians, optometrists or ophthalmologists as benefits of the program.
DHS 107.20(3)(c)
(c) The dispensing provider shall be reimbursed only once for dispensing a final accepted appliance or component part.
DHS 107.20(3)(d)
(d) The department may define minimal prescription levels for lenses covered by MA. These limitations shall be published by the department in the MA vision care provider handbook.
DHS 107.20(4)
(4)
Non-covered services. The following services and materials are not covered services:
DHS 107.20(4)(c)
(c) Services provided principally for convenience or cosmetic reasons, including but not limited to gradient focus, custom prosthesis, fashion or cosmetic tints, engraved lenses and anti-scratch coating.
DHS 107.20 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.20 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.21(1)(a)(a) General. Covered family planning services are the services included in this subsection when prescribed by a physician and provided to a recipient, including initial physical exam and health history, annual office visits and follow-up office visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services and prescribing medication for specific treatments. All family planning services performed in family planning clinics shall be prescribed by a physician, and furnished, directed or supervised by a physician, registered nurse, nurse practitioner, licensed practical nurse or nurse midwife under s.
441.15 (1) and
(2) (b), Stats.
DHS 107.21(1)(b)
(b) Physical examination. An initial physical examination with health history is a covered service and shall include the following:
DHS 107.21(1)(b)1.
1. Complete obstetrical history including menarche, menstrual, gravidity, parity, pregnancy outcomes and complications of pregnancy or delivery, and abortion history;
DHS 107.21(1)(b)2.
2. History of significant illness-morbidity, hospitalization and previous medical care, particularly in relation to thromboembolic disease, any breast or genital neoplasm, any diabetic or prediabetic condition, cephalalgia and migraine, pelvic inflammatory disease, gynecologic disease and venereal disease;
DHS 107.21(1)(b)4.
4. Family, social, physical health, and mental health history, including chronic illnesses, genetic aberrations and mental depression;
DHS 107.21(1)(c)
(c) Laboratory and other diagnostic services. Laboratory and other diagnostic services are covered services as indicated in this paragraph. These services may be performed in conjunction with an initial examination with health history, and are the following:
DHS 107.21(1)(c)1.d.
d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and
DHS 107.21(1)(c)2.g.
g. Blood test for cholesterol, and triglycerides when related to oral contraceptive prescription;
DHS 107.21(1)(c)3.
3. Diagnostic and other procedures not for the purpose of enhancing the prospects of fertility in males or females;
DHS 107.21(1)(c)5.
5. Colposcopy, culdoscopy, and laparoscopy procedures which may be either diagnostic or treatment procedures.
DHS 107.21(1)(d)
(d) Counseling services. Counseling services in the clinic are covered as indicated in this paragraph. These services may be performed or supervised by a physician, registered nurse or licensed practical nurse. Counseling services may be provided as a result of request by a recipient or when indicated by exam procedures and health history. These services are limited to the following areas of concern:
DHS 107.21(1)(d)2.
2. Overview of available methods of contraception, including natural family planning. An explanation of the medical ramifications and effectiveness of each shall be provided;
DHS 107.21(1)(d)4.
4. Counseling about sterilization accompanied by a full explanation of sterilization procedures including associated discomfort and risks, benefits, and irreversibility;
