Chapter DHS 107

DHS 107.32(1)(b)9. 9. A description of the recipient’s physical environment, especially in regard to safety and mobility in the home and accessibility;

DHS 107.32(1)(b)10. 10. The recipient’s need for housing, residential support, adaptive equipment and assistance with decision-making;

DHS 107.32(1)(b)11. 11. An in-depth financial resource analysis, including identification of insurance, veterans’ benefits and other sources of financial and similar assistance;

DHS 107.32(1)(b)12. 12. If appropriate, vocational and educational status, including prognosis for employment, rehabilitation, educational and vocational needs, and the availability and appropriateness of educational, rehabilitation and vocational programs;

DHS 107.32(1)(b)13. 13. If appropriate, legal status, including whether there is a guardian and any other involvement with the legal system;

DHS 107.32(1)(b)14. 14. Accessibility to community resources which the recipient needs or wants; and

DHS 107.32(1)(b)15. 15. Assessment of drug and alcohol use and misuse, for AODA target population recipients.

DHS 107.32(1)(c) (c) Case planning. Following the assessment with its determination of need for case management services, a written plan of care shall be developed to address the needs of the recipient. Development of the written plan of care is a covered case management service. To the maximum extent possible, the development of a care plan shall be a collaborative process involving the recipient, the family or other supportive persons and the case management provider. The plan of care shall be a negotiated agreement on the short and long term goals of care and shall include:

DHS 107.32(1)(c)1. 1. Problems identified during the assessment;

DHS 107.32(1)(c)2. 2. Goals to be achieved;

DHS 107.32(1)(c)3. 3. Identification of all formal services to be arranged for the recipient and their costs and the names of the service providers;

DHS 107.32(1)(c)4. 4. Development of a support system, including a description of the recipient’s informal support system;

DHS 107.32(1)(c)5. 5. Identification of individuals who participated in development of the plan of care;

DHS 107.32(1)(c)6. 6. Schedules of initiation and frequency of the various services to be made available to the recipient; and

DHS 107.32(1)(c)7. 7. Documentation of unmet needs and gaps in service.

DHS 107.32(1)(d) (d) Ongoing monitoring and service coordination. Ongoing monitoring of services and service coordination are covered case management services when performed by a single and identifiable employee of the agency or person under contract to the agency who meets the requirements under s. DHS 105.51 (2) (b). This person, the case manager, shall monitor services to ensure that quality service is being provided and shall evaluate whether a particular service is effectively meeting the client’s needs. Where possible, the case manager shall periodically observe the actual delivery of services and periodically have the recipient evaluate the quality, relevancy and desirability of the services he or she is receiving. The case manager shall record all monitoring and quality assurance activities and place the original copies of these records in the recipient’s file. Ongoing monitoring of services and service coordination include:

DHS 107.32(1)(d)1. 1. Face to face and phone contacts with recipients for the purpose of assessing or reassessing their needs or planning or monitoring services. Included in this activity are travel time to see a recipient and other allowable overhead costs that must be incurred to provide the service;

DHS 107.32(1)(d)2. 2. Face to face and phone contact with collaterals for the purposes of mobilizing services and support, advocating on behalf of a specific eligible recipient, educating collaterals on client needs and the goals and services specified in the plan, and coordinating services specified in the plan. In this paragraph, “collateral” means anyone involved with the recipient, including a paid provider, a family member, a guardian, a housemate, a school representative, a friend or a volunteer. Collateral contacts also include case management staff time spent on case-specific staffings and formal case consultation with a unit supervisor and other professionals regarding the needs of a specific recipient. All contacts with collaterals shall be documented and may include travel time and other allowable overhead costs that must be incurred to provide the service; and

DHS 107.32(1)(d)3. 3. Recordkeeping necessary for case planning, service implementation, coordination and monitoring. This includes preparing court reports, updating case plans, making notes about case activity in the client file, preparing and responding to correspondence with clients and collaterals, gathering data and preparing application forms for community programs, and reports. All time spent on recordkeeping activities shall be documented in the case record. A provider, however, may not bill for recordkeeping activities if there was no client or collateral contact during the billable month.

DHS 107.32(2) (2) Other limitations.

DHS 107.32(2)(a) (a) Reimbursement for assessment and case plan development shall be limited to no more than one each for a recipient in a calendar year unless the recipient’s county of residence has changed, in which case a second assessment or case plan may be reimbursed.

DHS 107.32(2)(b) (b) Reimbursement for ongoing monitoring and service coordination shall be limited to one claim for each recipient by county per month and shall be only for the services of the recipient’s designated case manager.

DHS 107.32(2)(c) (c) Ongoing monitoring or service coordination is not available to recipients residing in hospitals, intermediate care or skilled nursing facilities. In these facilities, case management is expected to be provided as part of that facility’s reimbursement.

DHS 107.32(2)(d) (d) Case management services are not reimbursable when rendered to a recipient who, on the date of service, is enrolled in a health maintenance organization under s. DHS 107.28.

DHS 107.32(2)(e) (e) Persons who require institutional care and who receive services beyond those available under the MA state plan but which are funded by MA under a federal waiver are ineligible for case management services under this section. Case management services for these persons shall be reimbursed as part of the regular per diem available under federal waivers and included as part of the waiver fiscal report.

DHS 107.32(2)(f) (f) A recipient receiving case management services, or the recipient’s parents, if the recipient is a minor child, or guardian, if the recipient has been judged incompetent by a court, may choose a case manager to perform ongoing monitoring and service coordination, and may change case managers, subject to the case manager’s or agency’s capacity to provide services under this section.

DHS 107.32(3) (3) Non-covered services. Services not covered as case management services or included in the calculation of overhead charges are any services which:

DHS 107.32(3)(a) (a) Involve provision of diagnosis, treatment or other direct services, including:

DHS 107.32(3)(a)1. 1. Diagnosis of a physical or mental illness;

DHS 107.32(3)(a)2. 2. Monitoring of clinical symptoms;

DHS 107.32(3)(a)3. 3. Administration of medications;

DHS 107.32(3)(a)4. 4. Client education and training;

DHS 107.32(3)(a)5. 5. Legal advocacy by an attorney or paralegal;

DHS 107.32(3)(a)6. 6. Provision of supportive home care;

DHS 107.32(3)(a)7. 7. Home health care;

DHS 107.32(3)(a)8. 8. Personal care; and

DHS 107.32(3)(a)9. 9. Any other professional service which is a covered service under this chapter and which is provided by an MA certified or certifiable provider, including time spent in a staffing or case conference for the purpose of case management; or

DHS 107.32(3)(b) (b) Involve information and referral services which are not based on a plan of care.

DHS 107.32 History History: Cr. Register, February, 1988, No. 386, eff. 3-1-88; corrections in (1) (a) 1. and (d) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.33 DHS 107.33 Ambulatory prenatal services for recipients with presumptive eligibility.

DHS 107.33(1) (1) Covered services. Ambulatory prenatal care services are covered services. These services include treatment of conditions or complications that are caused by, exist or are exacerbated by a pregnant woman’s pregnant condition.

DHS 107.33(2) (2) Prior authorization. An ambulatory prenatal service may be subject to a prior authorization requirement, when appropriate, as described in this chapter.

DHS 107.33(3) (3) Other limitations.

DHS 107.33(3)(a) (a) Ambulatory prenatal services shall be reimbursed only if the recipient has been determined to have presumptive MA eligibility under s. 49.465, Stats., by a qualified provider under s. DHS 103.11.

DHS 107.33(3)(b) (b) Services under this section shall be provided by a provider certified under ch. DHS 105.

DHS 107.33 History History: Cr. Register, February, 1988, No. 386, eff. 3-1-88; correction in (3) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.34 DHS 107.34 Prenatal care coordination services.

DHS 107.34(1) (1) Covered services.

DHS 107.34(1)(a) (a) General.

DHS 107.34(1)(a)1. 1. Prenatal care coordination services covered by MA are services described in this section that are provided by an agency certified under s. DHS 105.52 or by a qualified person under contract with an agency certified under s. DHS 105.52 to help a recipient and, when appropriate, the recipient’s family gain access to medical, social, educational and other services needed for a successful pregnancy outcome. Nutrition counseling and health education are covered services when medically necessary to ameliorate identified high-risk factors for the pregnancy. In this subdivision,“successful pregnancy outcome” means the birth of a healthy infant to a healthy mother.

DHS 107.34(1)(a)2. 2. Prenatal care coordination services are available as an MA benefit to recipients who are pregnant, from the beginning of the pregnancy up to the sixty-first day after delivery, and who are at high risk for adverse pregnancy outcomes. In this subdivision, “high risk for adverse pregnancy outcome” means that a pregnant woman requires additional prenatal care services and follow-up because of medical or nonmedical factors, such as psychosocial, behavioral, environmental, educational or nutritional factors that significantly increase her probability of having a low birth weight baby, a preterm birth or other negative birth outcome. “Low birth weight” means a birth weight less than 2500 grams or 5.5 pounds and “preterm birth” means a birth before the gestational age of 37 weeks. The determination of high risk for adverse pregnancy outcome shall be made by use of the risk assessment tool under par. (c).

DHS 107.34(1)(b) (b) Outreach. Outreach is a covered prenatal care coordination service. Outreach is activity which involves implementing strategies for identifying and informing low-income pregnant women who otherwise might not be aware of or have access to prenatal care and other pregnancy-related services.

DHS 107.34(1)(c) (c) Risk assessment. A risk assessment of a recipient’s pregnancy-related needs is a covered prenatal care coordination service. The assessment shall be performed by an employee of the certified prenatal care coordination agency or by an employee of an agency under contract with the prenatal care coordination agency. The assessment shall be completed in writing and shall be reviewed and finalized in a face-to-face contact with the recipient. All assessments performed shall be reviewed by a qualified professional under s. DHS 105.52 (2) (a). The risk assessment shall be performed with the risk assessment tool developed and approved by the department.

DHS 107.34(1)(d) (d) Care planning. Development of an individualized plan of care for a recipient is a covered prenatal care coordination service when performed by a qualified professional as defined in s. DHS 105.52 (2) (a), whether that person is an employee of the agency or under contract with the agency under s. DHS 105.52 (2). The recipient’s individualized written plan of care shall be developed with the recipient. The plan shall identify the recipient’s needs and problems and possible services which will reduce the probability of the recipient having a preterm birth, low birth weight baby or other negative birth outcome. The plan of care shall include all possible needed services regardless of funding source. Services in the plan shall be related to the risk factors identified in the assessment. To the maximum extent possible, the development of a plan of care shall be done in collaboration with the family or other supportive persons. The plan shall be signed by the recipient and the employee responsible for the development of the plan and shall be reviewed and, if necessary, updated by the employee in consultation with the recipient at least every 60 days. Any updating of the plan of care shall be in writing and shall be signed by the recipient. The plan of care shall include:

DHS 107.34(1)(d)1. 1. Identification and prioritization of all risks found during the assessment, with an attached copy of the risk assessment under par. (c);

DHS 107.34(1)(d)2. 2. Identification and prioritization of all services to be arranged for the recipient by the care coordinator under par. (e) 2. and the names of the service providers including medical providers;

DHS 107.34(1)(d)3. 3. Description of the recipient’s informal support system, including collaterals as defined in par. (e) 1., and any activities to strengthen it;

DHS 107.34(1)(d)4. 4. Identification of individuals who participated in the development of the plan of care;

DHS 107.34(1)(d)5. 5. Arrangements made for and frequency of the various services to be made available to the recipient and the expected outcome for each service;

DHS 107.34(1)(d)6. 6. Documentation of unmet needs and gaps in service; and

DHS 107.34(1)(d)7. 7. Responsibilities of the recipient.

DHS 107.34(1)(e) (e) Ongoing care coordination.

DHS 107.34(1)(e)1. 1. In this paragraph, “collaterals” means anyone who is in direct supportive contact with the recipient during the pregnancy such as a service provider, a family member, the prospective father or any person acting as a parent, a guardian, a medical professional, a housemate, a school representative or a friend.

DHS 107.34(1)(e)2. 2. Ongoing coordination is a covered prenatal care coordination service when performed by an employee of the agency or person under contract to the agency who serves as care coordinator and who is supervised by the qualified professional required under s. DHS 105.52 (2) (b) 2. The care coordinator shall follow-up the provision of services to ensure that quality service is being provided and shall evaluate whether a particular service is effectively meeting the recipient’s needs as well as the goals and objectives of the care plan. The amount of service provided shall be commensurate with the specific risk factors addressed in the plan of care and the overall level of risk. Ongoing care coordination services include:

DHS 107.34(1)(e)2.a. a. Face-to-face and phone contacts with recipients for the purpose of determining if arranged services have been received and are effective. This shall include reassessing needs and revising the written plan of care. Face-to-face and phone contact with collaterals are included for the purposes of mobilizing services and support, advocating on behalf of a specific eligible recipient, informing collateral of client needs and the goals and services specified in the care plan and coordinating services specified in the care plan. Covered contacts also include prenatal care coordination staff time spent on case-specific staffings regarding the needs of a specific recipient. All billed contacts with a recipient or a collateral and staffings related to the recipient shall be documented in the recipient prenatal care coordination file; and

DHS 107.34(1)(e)2.b. b. Recordkeeping documentation necessary and sufficient to maintain adequate records of services provided to the recipient. This may include verification of the pregnancy, updating care plans, making notes about the recipient’s compliance with program activities in relation to the care plan, maintaining copies of written correspondence to and for the recipient, noting of all contacts with the recipient and collateral, ascertaining and recording pregnancy outcome including the infant’s birth weight and health status and preparation of required reports. All plan of care management activities shall be documented in the recipient’s record including the date of service, the person contacted, the purpose and result of the contact and the amount of time spent. A care coordination provider shall not bill for recordkeeping activities if there was no client contact during the billable month.

DHS 107.34(1)(f) (f) Health education. Health education, either individually or in a group setting, is a covered prenatal care coordination service when provided by an individual who is a qualified professional under s. DHS 105.52 (2) (a) and who by education or at least one year of work experience has the expertise to provide health education. Health education is a covered service if the medical need for it is identified in the risk assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant woman’s identified risk factors in areas including, but not limited to, the following:

DHS 107.34(1)(f)1. 1. Education and assistance to stop smoking;

DHS 107.34(1)(f)2. 2. Education and assistance to stop alcohol consumption;

DHS 107.34(1)(f)3. 3. Education and assistance to stop use of illicit or street drugs;

DHS 107.34(1)(f)4. 4. Education and assistance to stop potentially dangerous sexual practices;

DHS 107.34(1)(f)5. 5. Education on environmental and occupational hazards related to pregnancy;

DHS 107.34(1)(f)6. 6. Lifestyle management consultation;

DHS 107.34(1)(f)8. 8. Reproductive health education;

DHS 107.34(1)(f)9. 9. Parenting education; and

DHS 107.34(1)(f)10. 10. Childbirth education.

DHS 107.34(1)(g) (g) Nutrition counseling. Nutrition counseling is a covered prenatal care coordination service if provided either individually or in a group setting by an individual who is a qualified professional under s. DHS 105.52 (2) (a) with expertise in nutrition counseling based on education or at least one year of work experience. Nutrition counseling is a covered prenatal care coordination service if the medical need for it is identified in the risk assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant woman’s identified risk factors in areas including, but not limited to, the following:

DHS 107.34(1)(g)1. 1. Weight and weight gain;

DHS 107.34(1)(g)2. 2. A biochemical condition such as gestational diabetes;

DHS 107.34(1)(g)3. 3. Previous nutrition-related obstetrical complications;

DHS 107.34(1)(g)4. 4. Current nutrition-related obstetrical complications;

DHS 107.34(1)(g)5. 5. Psychological problems affecting nutritional status;

DHS 107.34(1)(g)6. 6. Dietary factors affecting nutritional status; and

DHS 107.34(1)(g)7. 7. Reproductive history affecting nutritional status.

DHS 107.34(2) (2) Limitations.

DHS 107.34(2)(a) (a) Reimbursement for risk assessment and development of a care plan shall be limited to no more than one each for a recipient per pregnancy.

DHS 107.34(2)(b) (b) Reimbursement of a provider for on-going prenatal care coordination and health education and nutrition counseling provided to a recipient shall be limited to one claim for each recipient per month and only if the provider has had contact with the recipient during the month for which services are billed.

DHS 107.34(2)(c) (c) Prenatal care coordination is available to a recipient residing in an intermediate care facility or skilled nursing facility or as an inpatient in a hospital only to the extent that it is not included in the usual reimbursement to the facility.

DHS 107.34(2)(d) (d) Reimbursement of a provider for prenatal care coordination services provided to a recipient after delivery shall only be made if that provider provided prenatal care coordination services to that recipient before the delivery.