Ch. DHS 1 Note
Chapter HSS 1 as it existed on August 31, 1978 was replaced and a new chapter HSS 1 was created effective September 1, 1978. Chapter HSS 1 was renumbered chapter HFS 1 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, April, 1997, No. 496
. Chapter HFS 1 was renumbered chapter DHS 1 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635
DHS 1.01 Purpose, definitions, exempted services. DHS 1.01(1)(1)
Authority and purpose. Sections DHS 1.01
are promulgated under the authority of ss. 46.03 (18)
, 46.10 (1)
to (14) (a)
and 227.11 (2)
, Stats., to implement ss. 46.03 (18)
, 46.011 (1g)
, 46.10 (1)
to (14) (a)
, 46.27 (11)
, 48.837 (7)
, 48.839 (1)
and 51.30 (4) (b) 2.
, Stats. Sections DHS 1.01
standardize on a statewide basis the determination of liability and ability to pay and otherwise regulate billing and collection activities for care and services provided or purchased by the department, a county department of social services or a county department established under s. 46.23
“Administratively unfeasible" means that the total payments realized would approximate or be less than the cost of collections for a specified type of service.
“Department" means the state department of health services.
DHS 1.01 Note
Note: This chapter applies to Department of Health Services and Department of Children and Families programs until such time as each of the departments can adopt separate rules.
“Division" means one of the major subunits of the department.
“Facility" means any agency, office, institution, clinic, etc., that delivers client services.
“Family" means an adult and that person's spouse, if any, and any other person who meets internal revenue service standards as their dependent, except that:
When a foster parent seeks child day care for a foster child so that the foster parent may attend school or work, the foster child shall be counted as a member of the foster parent's family; and
Any of the following persons shall not be included as a family member in determining the ability to pay of any responsible party under this chapter:
A family member who is receiving services in an out-of-home placement;
A legal dependent living outside the household of the responsible party for whom there is a court-ordered support or maintenance obligation; or
An adult client residing in the home of his or her parent or parents. This person is considered a separate family in determining ability to pay under this chapter for any fee chargeable service that he or she may receive.
“Fee" means a single, cost-related, per unit charge or rate assigned to a purchased or provided service furnished by a provider of service calculated and/or approved according to the provisions of this rule for the purpose of establishing the liability of responsible parties and billing third-party payers.
DHS 1.01 Note
Note: “Fee" in the context of these rules is different from the term, “sliding fee" as used in some human service agencies. “Fee" in these rules indicates the cost of service—regardless of ability to pay. “Sliding fee" usually relates to ability to pay.
“Full financial information" means information about a family's income, expenses, assets, and insurance coverage that is necessarily and reasonably requested for the purpose of determining ability-to-pay and for billing all applicable insurance.
“Income" means gross earnings, including money, wages or salary, net income from non-farm self-employment, net income from farm self-employment, as well as unearned income, including social security, dividends, interest on savings or on money loaned, income from estates or trusts, net rental income or royalties, public assistance, pensions or annuities, unemployment compensation, workers' compensation, maintenance (alimony), child support, family support, veterans' pensions, educational grants given for living expenses and, for foster parents receiving day care services or funds under s. 49.155
, Stats., foster care payments.
DHS 1.01 Note
Note: “Public assistance" includes but is not limited to programs such as aid to families with dependent children (AFDC), county relief, and supplemental security income (SSI).
“Parent" means a child's adoptive or biological mother or father who has legal responsibility for the child.
“Parental payment limit" means the amount established or approved by the department under s. DHS 1.03 (21)
or under s. DHS 1.065
as the maximum daily or monthly amount that parents may be billed for care or services provided to their minor children.
“Payment approval authority" means an administrator of a division, the director of a county department of social services, or the program director of a board established under s. 51.42
, or 46.23
, Stats., or a designee.
“Secretary" means the secretary of the department of health services.
“Student" means an individual who is attending a school, college, university, or a course of vocational or technical training.
(3) Where rules apply.
These rules apply to all client-specific care and services purchased or provided by the department, county departments of social services, and boards created under s. 51.42
, Stats., except as provided in sub. (4)
The following services are not subject to direct billing to responsible parties under these rules:
Federal exemptions: any service for which the imposition of a charge is prohibited by federal law, regulation, or valid federal grant requirement, including educational services to handicapped pre-school age children with exceptional education needs under Title I of P.L. 89-313
Statutory or judicial exemptions: services exempted in ss. 46.03 (18) (a)
and 46.10 (2m)
, Stats., services for handicapped children with exceptional education needs which local school districts must ensure be available under s. 115.77
, Stats., and any other care or service for which the imposition of a charge is prohibited by state law.
Services offered, defined and funded under the state plan for Title XX of the Social Security Act which are specifically exempted from fee charging in the plan.
Probation and parole services, court ordered supervision and other supervision service provided to adults.
DHS 1.01 Note
Note: In situations where this provision conflicts with the Title XX Plan and Regulations, the latter take precedence.
Purchases of education services by the department of corrections.
Sheltered employment, work activity, and adult non-medical day services programs for the handicapped except, transportation related to these services.
Any provider of a service may request that the service be exempted from these rules under the following procedures unless prohibited by law, if the secretary or designee finds that the benefit of the service in question will be significantly impaired if the imposition of a charge continues or that the imposition of a charge is administratively unfeasible.
Agencies seeking an exemption of a service not listed in par. (c)
shall submit a request containing documentation. At a minimum data must include a full review for 3 continuous months of the maximum monthly payment rates computed according to s. DHS 1.03
for all clients receiving the service.
Each request shall also include the following summary information:
Full description of the type of service (e.g. how it is provided, its intended purpose, etc.).
Number of clients in each of the Maximum Monthly Payment Rate levels.
(Note: For example 15 clients - 0
3 clients - $4 - $10/mo.
4 clients - $11 - $20/mo., Etc.)
A statement indicating the potential recovery from third party payers and whether the services are eligible for federal financial participation under the state Title XX plan.
Documentation of extra administrative cost to operate the uniform fee system for this service.
Reason and evidence to sustain any contra-therapeutic claim for exemption.
Agencies providing services under contract with a county agency shall submit the supporting materials to the appropriate purchasing agency. If the county agency concurs with the request for exemption, the request and any additional supporting information and rationale shall be forwarded by the county agency to the Secretary, Department of Health Services - Subject: Uniform Fee Exemption.
Fee exemption, when approved, relates to all clients receiving the specified service from the service provider. The secretary may expand the fee exemption to include like services from all similar providers of service. Fee exemptions shall be communicated by letter to the appropriate county agency(ies).
DHS 1.01 History
Cr. Register, August, 1978, No. 272
, eff. 9-1-78; am. (1), (3), (4) (b) and (5), renum. (2) (j) to (l) to be (2) (k) to (m), cr. (2) (j), renum. (4) (d) to be (4) (d) 1., cr. (4) (d) 2. to 5., Register, November, 1979
. No. 287, eff. 1-1-80; am. (2) (j), (4) (c) 1. and (d) 2., r. (5), Register, December, 1980, No. 300
, eff. 1-1-81; correction in (3) under s. 13.93 (2m) (b) 4., Stats., Register, September, 1984, No. 345
; am. (1), (2) (g) and (4) (c), Register, September, 1984, No. 345
, eff. 10-1-84; r. and recr. (1), (2) (e), (h) and (j), Register, December, 1987, No. 384
, eff. 1-1-88; emerg. am. (1), eff. 1-22-97; am. (1), Register, August, 1997, No. 500
, eff. 9-1-97; corrections in (2) (h) and (4) (b) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 2001, No. 546
; CR 08-017
: am. (1) and (2) (j) Register June 2008 No. 630
, eff. 7-1-08; corrections in (2) (b), (L) and (4) (d) 4. made under s. 13.92 (4) (b) 6., Stats., Register November 2008 No. 635
; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register February 2017 No. 734
DHS 1.02 Liability for paying fees. DHS 1.02(1)
Whenever a client receives a service which is subject to this chapter, the client, the spouse of a married client, the parents of a minor client, and any other persons specified by statute as having liability payable according to ss. 46.03 (18)
, 48.837 (7)
and 48.839 (1)
, Stats., shall be responsible for paying for the service in the manner set forth in this chapter.
DHS 1.02 Note
Note: Chapter 81, Laws of 1981
, added proposed adoptive parents (s. 48.837 (7)
, Stats.) and guardians of foreign children (s. 48.839 (1)
, Stats.) to those liable to pay for services that clients receive which are subject to this chapter.
(2) Extent of liability.
Liability for a service shall equal the fee, as determined pursuant to these rules, times the number of units of service provided.
(3) Recording units of service to establish liability.
Except as provided in sub. (5)
, facilities shall maintain records of all clients receiving fee-chargeable services using the following specified data. For each client receiving a fee-chargeable service, units of service shall be as follows unless an exception is granted by the secretary or a designee:
Rounded to the next highest 1
hour for outpatient, counseling and similar services.
Rounded to the nearest whole hour for child day care, homemaker services, day services, or similar services.
Per day for residential care services including those in the following settings: (Also see sub. (4)
for additional provisions.)
For other services, supplies or materials, where the cost is the fee, an itemized statement describing the service and cost will suffice.
(4) Additional provisions for recording per day units of service. DHS 1.02(4)(a)(a)
Except as otherwise stated, a charge shall be made for each day a patient or resident is physically at the institution or facility at midnight of the day. No charge shall be made for the day the patient or resident leaves.
A charge shall be made if the patient or resident both enters and leaves during the same day.
No charge shall be made for any day during which a patient or resident has been granted a leave or furlough or is on unauthorized absence for one or more overnights.
(5) Reporting exception for social services.
For fee-chargeable services of the type that have no potential for third-party payment recovery, a simplified reporting system may be established to eliminate the reporting of units of service to the facility's or agency's billing unit for clients and other responsible parties who show a documented zero ability to pay according to s. DHS 1.03
. However, agency records shall contain information specified in s. DHS 1.06
(6) Discharge of liability other than by means of full payment.
Except where statutes require payment of full liability, the liability of responsible parties remaining after recovery of benefits from all applicable insurance shall be considered discharged if responsible parties provide department or agency staff who have billing responsibility with full financial information and pay according to the following provisions:
For adult inpatient care and services or for disability-related modifications of the home or vehicle of an adult client, when the remaining liability exceeds $1,000 or discharge of liability at the maximum monthly payment rate would exceed 5 years, a responsible party may enter into an agreement with the appropriate payment approval authority to pay a substantial portion of the outstanding liability as a lump sum.
For adoption investigations and non-residential services specified in s. 48.837
, Stats., a responsible party shall pay the lesser of full liability or 24 times the monthly payment amount as calculated according to s. DHS 1.03 (12)
For care and services in non-medical facilities, clients shall pay the lesser of full liability each month or the monthly payment rate calculated according to s. DHS 1.03 (2)
for each month the client is a resident of the facility. Other responsible parties shall pay according to the provisions of par. (d)
For all other care and services, the liability of responsible parties may be discharged by less than full payment if they pay the lesser of liability remaining after crediting third party payments each month or the monthly payment rate as calculated under s. DHS 1.03 (12)
and adjusted, as appropriate, under s. DHS 1.03 (14)
or under s. DHS 1.065
. When inpatient clients are minors who receive medical assistance, parents shall be billed before the medical assistance program is billed, and medical assistance claims shall be reduced by the amount of parental payments.
The department may set annual minimum payment amounts for services billable under par. (c)
. An annual minimum payment may not exceed $1,000 unless there is a specific statutory mandate for a higher amount. An annual minimum payment shall be applied to the client's uninsured liability. Any uninsured liability beyond the annual minimum payment shall be subject to the provisions of par. (c)
, as applicable. For medical services, the department may credit a family payment for an annual minimum payment up to the amount the family pays for medical insurance in a year if the insurance pays at least the amount of the credit. Where the statutes set other minimum amounts, bond amounts, deductibles or copayments, those provisions supersede this paragraph. The department may also establish as a minimum payment amount the actual deductible used by an insurer in processing a claim.
When a child participates simultaneously in multiple human service programs subject to parental liability under this chapter, the parents are responsible for the financial obligation of the program with the greatest parental financial obligation.
(7) Exemption from liability.
If it is determined in the case of a particular family that the accomplishment of the purpose of a service would be significantly impaired by the imposition of liability, the accrual of liability during a period not to exceed 90 days may be voided in whole or in part by the appropriate payment approval authority. If the need to avoid imposition of liability continues, a further cancellation may be granted.
DHS 1.02 History
Cr. Register, August, 1978, No. 272
, eff. 9-1-78; am. (1), (2) (b), renum. (3) and (4) to be (8) and (9) and am. (8) (a) and (9), cr. (3) to (7), Register, November, 1979, No. 287
, eff. 1-1-80; emerg. am. (6) (intro.) and (b) and (7), eff. 7-1-80; am. (6) (intro.) and (b) and (7), Register, October, 1980, No. 298
, eff. 11-1-80; am. (2) (intro.), r. (2) (a) and (b), (6) and (7), renum. (8) and (9) to be (6) and (7) and am. (6), Register, December, 1980, No. 300
, eff. 1-1-81; am. (1), r. and recr. (6), Register, September, 1984, No. 345
, eff. 10-1-84; am. (6) (a) and (e), Register, December, 1987, No. 384
, eff. 1-1-88; r. (4) (d), Register, August, 1997, No. 500
, eff. 9-1-97; CR 08-017
: am. (6) (d), cr. (6) (f) Register June 2008 No. 630
, eff. 7-1-08.
DHS 1.03 Billing rates and ability to pay. DHS 1.03(1)
Where applicable insurance exists, the insurer shall be billed an amount equal to the fee, as determined pursuant to these rules, times the number of units of service provided.
(2) Clients residing in facilities (medical or non-medical) with unearned income.
A client receiving room and board with care or services and who is the beneficiary of monthly payments intended to meet maintenance needs and/or accrues unearned income (including but not limited to interest from assets such as savings and investments), shall be expected to pay the lesser of the monthly liability for that care or the total amount of unearned income that month less an amount sufficient to satisfy the client's unmet personal needs and any court-ordered payments or support of legal dependents. The monthly amount of interest income is determined by dividing the current annual interest income by 12. If payments of unearned income are made to a representative payee or guardian, that person shall be expected to pay from the resources of the client as specified for the client but subject to further possible reductions according to other prerequisite uses of the benefit payments a payee may be required or permitted to make as established by the payer. For clients in full-care, non-medical facilities receiving SSI benefits, no attempt shall be made to collect from any responsible party any remaining liability for those months that SSI payments are applied to the cost if such collections would reduce the SSI payment.
(3) Clients residing in facilities (medical or non-medical) with earned income.
Except for clients who are full time students or part-time students who are not full time employees, clients receiving room and board with care or services who have earned income shall be expected to pay any remaining liability for that care each month from earnings as follows: after subtraction of the first $65 of net earnings (after taxes) and any unmet court-ordered obligations or support of legal dependents, up to one-half the remaining amount of earnings.
(4) Payment adjustment from client's earned income.
The appropriate payment approval authority may authorize the following modification to sub. (3)
for clients whose care-treatment plans provide for economic independence within less than one year: subtract up to $240 of net earnings after taxes and proceed under the provisions of sub. (3)
provided that any amounts subtracted beyond $65 per month under this subsection are used for the following purposes:
Savings to furnish and initiate an independent living arrangement for the client upon release from the facility. Under this provision, earnings shall not be conserved beyond the point that the client would no longer meet the asset eligibility limits for SSI or Medicaid.