DHS 107.28(1)(a)1.1. Except as provided in subd.
2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covered services at the time the medicaid HMO contract becomes effective with the exception of the following:
DHS 107.28(1)(a)2.
2. The department may permit an HMO to provide less than comprehensive coverage, but only if there is adequate justification and only if commitment is expressed by the HMO to progress to comprehensive coverage.
DHS 107.28(1)(b)
(b) Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.
DHS 107.28(1)(c)
(c)
Family care benefit
. A care management organization under contract with the department to provide the family care benefit under s.
DHS 10.41 shall provide those MA services specified in its contract with the department and shall meet all applicable requirements under ch.
DHS 10.
DHS 107.28(2)
(2)
Contracts. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall:
DHS 107.28(2)(d)
(d) Specify any procedures for enrollment or reenrollment of the recipients;
DHS 107.28(2)(e)
(e) Specify the amount, duration and scope of medical services to be covered;
DHS 107.28(2)(f)
(f) Provide that the department may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed under the contract;
DHS 107.28(2)(g)
(g) Provide that the department may audit and inspect any of the contractor's records that pertain to services performed and the determination of amounts payable under the contract and stipulate the required record retention procedures;
DHS 107.28(2)(h)
(h) Provide that the contractor safeguards recipient information;
DHS 107.28(2)(i)
(i) Specify activities to be performed by the contractor that are related to third-party liability requirements; and
DHS 107.28(2)(j)
(j) Specify which functions or services may be subcontracted and the requirements for subcontracts.
DHS 107.28(3)
(3)
Other limitations. Contracted organizations shall:
DHS 107.28(3)(a)
(a) Allow each enrolled recipient to choose a health professional in the organization to the extent possible and appropriate;
DHS 107.28(3)(b)1.1. Provide that all medical services that are covered under the contract and that are required on an emergency basis are available on a 24-hour basis, 7 days a week, either in the contractor's own facilities or through arrangements, approved by the department, with another provider; and
DHS 107.28(3)(b)2.
2. Provide for prompt payment by the contractor, at levels approved by the department, for all services that are required by the contract, furnished by providers who do not have arrangements with the contractor to provide the services, and are medically necessary to avoid endangering the recipient's health or causing severe pain and discomfort that would occur if the recipient had to use the contractor's facilities;
DHS 107.28(3)(c)3.
3. Assures the participation of individuals with authority to require corrective action;
DHS 107.28(3)(d)1.
1. Is consistent with the utilization control requirements established by the department and set forth in the contract;
DHS 107.28(3)(d)2.
2. Provides for review by appropriate health professionals of the process followed in providing health services;
DHS 107.28(3)(d)3.
3. Provides for systematic data collection of performance and patient results;
DHS 107.28(3)(e)
(e) Provide that the organization submit marketing plans, procedures and materials to the department for approval before using the plans;
DHS 107.28(3)(f)
(f) Provide that the HMO advise enrolled recipients about the proper use of health care services and the contributions recipients can make to the maintenance of their own health;
DHS 107.28(3)(g)
(g) Provide for development of a medical record-keeping system that:
DHS 107.28(3)(g)1.
1. Collects all pertinent information relating to the medical management of each enrolled recipient; and
DHS 107.28(3)(g)2.
2. Makes that information readily available to member health care professionals;
DHS 107.28(3)(h)
(h) Provide that HMO-enrolled recipients may be excluded from specific MA requirements, including but not limited to copayments, prior authorization requirements, and the second surgical opinion program; and
DHS 107.28(3)(i)
(i) Provide that if a recipient who is a member of an HMO or other prepaid plan seeks medical services from a certified provider who is not participating in that plan without a referral from a provider in that plan, or in circumstances other than emergency circumstances as defined in
42 CFR 434.30, the recipient shall be liable for the entire amount charged for the service.
DHS 107.28 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; cr. (1) (c),
Register, October, 2000, No. 538, eff. 11-1-00; correction in (1) (c) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.29
DHS 107.29 Rural health clinic services. Covered rural health clinic services are the following:
DHS 107.29(1)
(1) Services furnished by a physician within the scope of practice of the profession under state law, if the physician performs the services in the clinic or the services are furnished away from the clinic and the physician has an agreement with the clinic providing that the physician will be paid by it for these services;
DHS 107.29(2)
(2) Services furnished by a physician assistant or nurse practitioner if the services are furnished in accordance with the requirements specified in s.
DHS 105.35;
DHS 107.29(3)
(3) Services and supplies that are furnished incidental to professional services furnished by a physician, physician assistant or nurse practitioner;
DHS 107.29(4)
(4) Part-time or intermittent visiting nurse care and related medical supplies, other than drugs and biologicals, if:
DHS 107.29(4)(a)
(a) The clinic is located in an area in which there is a shortage of home health agencies;
DHS 107.29(4)(b)
(b) The services are furnished by a registered nurse or licensed practical nurse employed by or otherwise compensated for the services by the clinic;
DHS 107.29(4)(c)
(c) The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic, or that is established by a physician, physician assistant or nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and
DHS 107.29(4)(d)
(d) The services are furnished to a homebound recipient. In this paragraph, “homebound recipient" means, for purposes of visiting nurse care, a recipient who is permanently or temporarily confined to a place of residence, other than a hospital or skilled nursing facility, because of a medical or health condition. The person may be considered homebound if the person leaves the place of residence infrequently; and
DHS 107.29(5)
(5) Other ambulatory services furnished by a rural health clinic. In this subsection, “other ambulatory services" means ambulatory services other than the services in subs.
(1),
(2), and
(3) that are otherwise included in the written plan of treatment and meet specific state plan requirements for furnishing those services. Other ambulatory services furnished by a rural health clinic are not subject to the physician supervision requirements under s.
DHS 105.35.
DHS 107.29 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; corrections in (2) and (5) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.30
DHS 107.30 Ambulatory surgical center services. DHS 107.30(1)(1)
Covered services. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulatory surgical center. The physician shall demonstrate that the recipient requires general or local anesthesia, and a postanesthesia observation time, and that the services could not be performed safely in an office setting. These services shall be performed in conformance with generally-accepted medical practice. Covered ambulatory surgical center services shall be limited to the following procedures:
DHS 107.30(1)(a)20.
20. Any other surgical procedure that the department determines shall be covered and that the department publishes notice of in the MA provider handbook; and
DHS 107.30(1)(b)
(b) Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par.
(a):
DHS 107.30 Note
Note: For more information on prior authorization, see s.
DHS 107.02 (3).
