Wisconsin Legislature: DHS 107.28(3)(d)4.

Alert! This chapter may be affected by an emergency rule:

EmR2421

c. Dental services; and

d. Chiropractic services.

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.

(b) Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.

(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.

(2) Contracts. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall:

(a) Specify the contract period;

(b) Specify the services provided by the contractor;

(d) Specify any procedures for enrollment or reenrollment of the recipients;

(e) Specify the amount, duration and scope of medical services to be covered;

(f) Provide that the department may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed under the contract;

(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;

(h) Provide that the contractor safeguards recipient information;

(i) Specify activities to be performed by the contractor that are related to third-party liability requirements; and

(j) Specify which functions or services may be subcontracted and the requirements for subcontracts.

(3) Other limitations. Contracted organizations shall:

(a) Allow each enrolled recipient to choose a health professional in the organization to the extent possible and appropriate;

(b)

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

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;

1. Is approved in writing by the department;

2. Provides for prompt resolution of the grievance; and

3. Assures the participation of individuals with authority to require corrective action;

(d) Provide for an internal quality assurance system that:

1. Is consistent with the utilization control requirements established by the department and set forth in the contract;

2. Provides for review by appropriate health professionals of the process followed in providing health services;

3. Provides for systematic data collection of performance and patient results;

4. Provides for interpretation of this data to the practitioners; and

5. Provides for making needed changes;

(e) Provide that the organization submit marketing plans, procedures and materials to the department for approval before using the plans;

(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;

(g) Provide for development of a medical record-keeping system that:

1. Collects all pertinent information relating to the medical management of each enrolled recipient; and

2. Makes that information readily available to member health care professionals;

(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

(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.

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 Rural health clinic services. Covered rural health clinic services are the following:

(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;

(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;

(3) Services and supplies that are furnished incidental to professional services furnished by a physician, physician assistant or nurse practitioner;

(4) Part-time or intermittent visiting nurse care and related medical supplies, other than drugs and biologicals, if:

(a) The clinic is located in an area in which there is a shortage of home health agencies;

(b) The services are furnished by a registered nurse or licensed practical nurse employed by or otherwise compensated for the services by the clinic;

(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

(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

(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.

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 Ambulatory surgical center services.

(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:

(a) Surgical procedures:

1. Adenoidectomy or tonsillectomy;

2. Arthroscopy;

3. Breast biopsy;

4. Bronchoscopy;

5. Carpal tunnel;

6. Cervix biopsy or conization;

7. Circumcision;

8. Dilation and curettage;

9. Esophago-gastroduodenoscopy;

10. Ganglion resection;

11. Hernia repair;

12. Hernia — umbilical;

13. Hydrocele resection;

14. Laparoscopy, peritoneoscopy or other sterilization methods;

15. Pilonidal cystectomy;

16. Procto-colonoscopy;

17. Tympanoplasty;

18. Vasectomy;

19. Vulvar cystectomy; and

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

(b) Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par. (a):

1. Complete blood count (CBC);

2. Hemoglobin;

3. Hematocrit;

4. Urinalysis;

5. Blood sugar;

6. Lee white coagulant; and

7. Bleeding time.

(2) Services requiring prior authorization. Any surgical procedure under s. DHS 107.06 (2) requires prior authorization.

Note: For more information on prior authorization, see s. DHS 107.02 (3).

(3) Other limitations.

(a) A sterilization is a covered service only if the procedures specified in s. DHS 107.06 (3) are followed.

1. Nursing, technician, and related services;

2. Use of ambulatory surgical center facilities;

3. Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;