DHS 105.42 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) and (2) made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.43 DHS 105.43 Hospital and independent clinical laboratories. For MA certification, a clinical laboratory that is a hospital laboratory or an independent laboratory shall be licensed pursuant to 42 CFR 493 (CLIA). In addition, the laboratory shall be certified to participate in medicare and meet the requirements of 42 CFR 405.1310 to 405.1317.

DHS 105.43 Note Note: For covered diagnostic testing services, see s. DHS 107.25.

DHS 105.43 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.44 DHS 105.44 Portable x-ray providers. For MA certification, a portable x-ray provider shall be directed by a physician or group of physicians, registered pursuant to s. 254.35, Stats., and ch. DHS 157, certified to participate in medicare, and shall meet the requirements of 42 CFR 405.1411 to 405.1416.

DHS 105.44 Note Note: For covered diagnostic testing services, see s. DHS 107.25.

DHS 105.44 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528; correction made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.45 DHS 105.45 Dialysis facilities. For MA certification, dialysis facilities shall meet the requirements enumerated in ss. DHS 152.05 and 152.08, and shall be certified to participate in medicare.

DHS 105.45 Note Note: For covered dialysis services, see s. DHS 107.26.

DHS 105.45 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, November, 1994, No. 467; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.46 DHS 105.46 Blood banks. For MA certification, blood banks shall be licensed or registered with the U.S. food and drug administration and shall be approved pursuant to 42 CFR 493 (CLIA).

DHS 105.46 Note Note: For covered blood services, see s. DHS 107.27.

DHS 105.46 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.47 DHS 105.47 Health maintenance organizations and prepaid health plans.

DHS 105.47(1) (1) Contracts and licensing. Except as provided in sub. (3), for MA certification, a health maintenance organization or prepaid health plan shall enter into a written contract with the department to provide services to enrolled recipients and shall be licensed by the Wisconsin commissioner of insurance.

DHS 105.47(2) (2) Requirements for health maintenance organizations. For MA certification, an HMO shall:

DHS 105.47(2)(a) (a) Meet the requirements of 42 CFR 434.20 (c);

DHS 105.47(2)(b) (b) Make services it provides to individuals eligible under MA accessible to these individuals, within the area served by the organization, to the same extent that the services are made accessible under the MA state plan to individuals eligible for MA who are not enrolled with the organization; and

DHS 105.47(2)(c) (c) Make adequate provision against the risk of insolvency, which is satisfactory to the department and which ensures that individuals eligible for benefits under MA are not held liable for debts of the organization in case of the organization’s insolvency.

DHS 105.47 Note Note: For covered health maintenance organization and prepaid health plan services, see s. DHS 107.28.

DHS 105.47(3) (3) Care organizations providing the family care benefit. A care management organization under contract with the department under s. DHS 10.42 is not required to be licensed by the Wisconsin commissioner of insurance if both of the following apply:

DHS 105.47(3)(a) (a) The organization enrolls only individuals who are eligible under s. 46.286, Stats.

DHS 105.47(3)(b) (b) The services offered by the organization do not include hospital or physician services.

DHS 105.47 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (3), Register, October, 2000, No. 538, eff. 11-1-00; correction in (3) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.48 DHS 105.48 Out-of-state providers.

DHS 105.48(1) (1) When a provider in a state that borders on Wisconsin documents to the department’s satisfaction that it is common practice for recipients in a particular area of Wisconsin to go for medical services to the provider’s locality in the neighboring state, the provider may be certified as a Wisconsin border status provider, subject to the certification requirements in this chapter and the same rules and contractual agreements that apply to Wisconsin providers, except that nursing homes are not eligible for border status.

DHS 105.48(2) (2) Out-of-state independent laboratories, regardless of location, may apply for certification as Wisconsin border status providers.

DHS 105.48(2m) (2m) Out-of-state providers who meet the definition of a border-status provider as described in s. DHS 101.03 (19) and who provide services to Wisconsin members via telehealth, regardless of provider location, may apply for certification as Wisconsin border-status providers if they are licensed in Wisconsin under applicable Wisconsin statute and administrative code.

DHS 105.48(3) (3) Other out-of-state providers who do not meet the requirements of sub. (1) may be reimbursed for non-emergency services provided to a Wisconsin MA recipient upon approval by the department under s. DHS 107.04.