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.
Purchase of clothing and other reasonable personal expenses the client will need to enter an independent living arrangement.
(5) Payment adjustment from client's unearned and earned income.
When a client resides in a facility less than 15 days in any calendar month, payments expected under subs. (2)
may be prorated between the days the client spends in and out of the facility. A daily payment rate may be calculated by multiplying the monthly amount determined under subs. (2)
by 12 and dividing by 365. The daily payment rate times the days the client spends in the facility determines the amount of the payment expected from the client's income. The provisions for determining the client's “available income" in billing Medicaid shall take precedence over this procedure wherever applicable.
(6) Clients residing in facilities (medical or non-medical) with liquid assets in excess of eligibility for ssi or medicaid.
Clients residing in facilities shall be expected to pay any remaining liability for that care until their assets are reduced to eligibility limits for SSI or Medicaid except as follows:
As may be protected in full or in part by a written agreement approved by the appropriate payment approval authority upon presentation in writing by the client or client's guardian, trustee or advocate, any specific and viable future plans or uses for which the excess assets are intended. Such documentation shall include the extent to which the client's funds need to be protected for purposes of preventing further dependency of the client upon the public and/or of enhancing development of the client into a normal and self-supporting member of society.
The payment approval authority shall assure that clients and responsible parties are informed as early as administratively and clinically feasible of their rights and responsibilities under the uniform fee system. The department shall provide sample brochures for the various service categories to assist payment approval authorities with this requirement.
(8) Refusal to provide full financial information.
A responsible party who is informed of his or her rights and knowingly refuses to provide full financial information and authorizations for billing all applicable insurance shall not be eligible under s. DHS 1.02 (6)
to discharge liability other than by means of full payment.
(9) Intake process.
In conjunction with appropriate notification, the intake process for each client who receives fee-chargeable or third-party billable services shall include sufficient time and capability to complete all necessary information for billing including an application for ability to pay considerations.
Except as otherwise provided in this chapter, the Financial Information Form (DMT 130) is mandatory when a responsible party chooses to be considered for ability to pay provisions.
DHS 1.03 Note
Note: Form DMT 130 may be ordered from:
Department of Health Services
Forms Center P.O. Box 7850
Madison, Wisconsin 53707
County agencies may use their own forms in place of DMT 130 subject to the prior approval of the department. Any substitute form must be capable of fulfilling the same provisions as the current DMT 130.
A responsible party who provides full financial information and authorizations for billing all applicable insurance shall be billed on the basis of the family's ability to pay.
For each family, ability to pay shall be determined in the following manner:
The annual gross income of all family members shall be determined and totaled except that the earned income of a child who is a full-time student or a part-time student but not a full-time employee shall be excluded. Income from self-employment or rent shall be the total net income after expenses. Depreciation on farm, business or rental property and wages paid to members of the family shall not be treated as expenses for this purpose. Actual principal payments on capital equipment and depreciated property shall be allowed as an expense. The income of any family member in a residential setting is treated separately under this section.
The monthly average income shall be computed by dividing the annual gross income by 12.
Monthly payments from court ordered obligations shall be subtracted from monthly average income.
For services other than care to minors in state institutions, the department may permit a payment approval authority to add an amount based on the value of assets to monthly income. This amount may not exceed 1/6 of the assets that would be considered excess assets for the purpose of determining eligibility for the medical assistance program.
(12) Maximum monthly payment.
A family providing full financial information shall be billed at a monthly rate that does not exceed the maximum amount computed by means of the following formulas:
(a) Long-term support for adults.
For long-term support for adults in the department's community options program and similar programs, an amount not to exceed the monthly income computed according to sub. (11)
less the following:
Estimated income taxes, social security or federal retirement obligations; and
An amount determined annually by the department which is no less than current income limits for medically needy persons in the Wisconsin medical assistance program.
(b) Child day care.
For child day care, the monthly payment when income computed under sub. (11)
is less than 50% of the state median income as defined by the department shall be zero. For income at 50% of the state median income, the maximum payment shall be $5.00 per month. For income at 60% of the state median income, the payment shall be $30.00 per month. The maximum payment for income at 100% of the state median income shall be $266 per month. The department shall annually publish a schedule which prorates the day care payments for income levels for each one percent increase in income from 50% to 100% of the state median income. Parental payment limits in sub. (18) (a)
do not apply to this paragraph.
(c) Other services for children.
Except as provided in s. DHS 1.065
, for other services to children, the maximum monthly payment for a parent shall be computed as follows:
For years after calendar year 1985, the department shall update the allowances in Table DHS 1.03 (12) by the same percentage used to update family budgets in the aid to families with dependent children program.
At least $1.00 but less than $543, the maximum monthly payment is 28% of the income in excess of $1.00;
At least $543, the maximum monthly payment is $152 plus 7% of the income in excess of $543.
The department shall publish a schedule annually for agencies to compute maximum monthly payment rates under this paragraph.
DHS 1.03 Note
Note: $152 is assumed to represent a basic allowance to provide support for a child living in a family, and 7% of gross income above support is assumed to represent added support above basic needs that a family with higher income would provide for a child in the home.
(d) All other services.
For all other services, the department shall publish maximum monthly payment schedules or formulas that require payments no higher than those computed under par. (a)
(12m) Maximum monthly payment for a child in a court-ordered out-of-home placement.
The maximum monthly payment of parents for court-ordered out-of-home placements of their children under chs. 48
, Stats., shall be determined according to procedures in s. DHS 1.07
(13) Minimum payment.
The appropriate payment approval authority may establish a minimum payment rate up to $25.00 per month or 3% of gross income across-the-board for all persons or families incurring liability for a fee chargeable service whose maximum monthly payment as calculated according to subs. (2)
is less than the minimum rate. Where minimum rates are used, all persons or families shall be expected to pay the applicable minimum rate except where liability is waived according to s. DHS 1.02 (7)
or where a minimum payment exceeds the available income of the responsible party or parties. Minimum charges under this section may also be set on a per unit basis, for instance, per hour or per day, provided the charges do not accumulate to exceed $25.00 per month or 3% of monthly income.
(13m) Special payment schedules.
The department may establish special payment schedules, to be used in place of schedules determined according to sub. (12)
, for designated providers and types of services on a pilot basis for periods not to exceed 3 years. Special payment schedules shall be directed toward goals which include, but are not limited to, increasing revenue to expand or maintain service levels, improving administration of the fee system and assessing the impact of different fee approaches on service. Beyond the pilot period, the payment schedule for the designated type of service shall be established according to sub. (12)
or any other applicable provision of law. Special payment schedules shall incorporate standards for income and may incorporate standards for assets. These standards may not be more stringent than the income and assets provisions of the Wisconsin medical assistance program described in ss. DHS 103.04
. However, where income is less than the limit for medical assistance eligibility, the department may approve schedules where assets are not considered and payments for a month of service do not exceed 3% of the family's gross monthly income.
The maximum monthly payment rate calculated under sub. (12)
is adjustable in the following situations:
In cases where family members who contribute to the family income are not responsible parties for the liability being charged to the family, the maximum monthly payment rate shall not exceed the sum of the unearned and one-half the earned income of responsible party or parties, less an amount equal to that used by the Wisconsin AFDC program for work related expenses.
When payment at the maximum monthly payment rate, as calculated in sub. (12)
, would create a documentable hardship on the family, (such as the forced sale of the family residence or cessation of an education program), a lower maximum monthly payment rate may be authorized by the appropriate payment approval authority under the following provisions:
Hardship adjustments are normally restricted to situations where services extend more than one year, and sufficient relief is not afforded to the family through an extended or deferred payment plan.
Each hardship adjustment shall be documented by additional family financial information. Such documentation shall become part of the client's collection file as provided in s. DHS 1.06
Responsible parties shall be informed in writing of approval or denial with approval taking the form of a written agreement.
Hardship adjustments shall be reviewed annually and, if necessary, renegotiated.
(15) Extended payment plans.
Agencies may work out an extended payment plan with any responsible party who indicates that payment at the monthly payment rate would place a burden on the responsible party's family. This payment plan has the effect of the responsible party paying a lesser monthly amount over a longer period of time but with the total expected amount to equal the full application of the monthly payment rate under s. DHS 1.02 (6)
. Authority to approve extended payment plans may be placed at whatever staff level the payment approval authority determines is appropriate.
(16) Shortcuts to document no ability to pay for services not covered by third-party payers. DHS 1.03(16)(a)(a)
Family income information in form DMT 130 is not required where no family member receives earned income and the family is supported in full or in part by income maintenance benefits.
The financial information form (DMT 130) is not required for fee-chargeable services when zero ability to pay can be documented. The following families making application for services are automatically considered to have no ability to pay when the following financial information is documented on other forms required by the department.
When the family has no earned income and are recipients of AFDC, Medical Assistance, Food Stamps or General Relief.
Families whose income is lower than the point at which payment begins according to the maximum monthly payment rate schedule for families of similar size.