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.
(17) Relationship to extent of services.
When full financial information is provided, the monthly payment rate established according to sub. (12)
and adjusted according to sub. (14) (a)
is the total ceiling amount that the family may be billed a month regardless of the number of family members receiving services, the number of agencies providing services, or the magnitude or extent of services received.
Parental payment limits set according to sub. (21)
shall be applied to billings to parents for each child who receives care or services in a state center for the developmentally disabled. The department may also approve parental payment limits set according to sub. (21)
which are requested by payment approval authorities for any other care or services provided to children. When parents of a child are divorced or separated, the total billed to both parents for the care of a child may not exceed the one billing limit used for the care or services received by the child. When a minor child and an adult from one family receive services, the parental payment limit may not be applied to billings for services to the adult. When used, parental payment limits shall be applied as follows:
For outpatient psychotherapy normally covered by health insurance and purchased or provided by county agencies, parents who provide full insurance information and necessary authorizations for billing all applicable insurance may not be billed a total amount per child per month greater than the monthly parental payment limit per month for each child who receives services;
For other services normally covered by health insurance, parents who provide full insurance information and necessary authorizations for billing all applicable insurance may not be billed more than the daily parental payment limit per day for each child who receives service;
For residential care not normally covered by health insurance, the following applies:
When a child is in care for less than 21 days in a calendar month, the parents may not be billed more than the daily parental payment limit per day for that child's care;
When a child is in care for more than 20 days in a calendar month, the payment approval authority shall adopt an agency policy for parental payment limits according to either the daily or monthly limit. The limit chosen shall apply uniformly to all parents;
When the daily limit is used, the agency may prorate daily billings for all families served by the agency according to their ability to pay. Under this prorating approach, the billing shall be the lesser of the daily limit or the family's monthly payment amount determined by s. DHS 1.03 (12)
multiplied by 12 and divided by 365; and
DHS 1.03 Note
Note: For example, if the maximum monthly payment for a family is $80, the daily rate would be $2.63 ($80× 12÷ 365 days = $2.63).
As an alternative to subd. 3. c.
, when the daily limit is used, an agency may bill all parents the daily limit for each day of care up to their monthly payment rate determined according to sub. (12)
The appropriate payment approval authority may bill a responsible party a minimum payment for therapeutic reasons for a fee chargeable service. The therapeutic charge may be a per month amount or a per visit or per unit of service charge and may result in a higher amount than the maximum monthly payment rate. A charge for “no-show" is considered a therapeutic charge. Therapeutic charges may not exceed the maximum monthly payment by more than $25.00 per month. Therapeutic charges and minimum charge(s) established under sub. (13)
may not total more than $25.00 per family nor may a therapeutic charge exceed the responsible party's available income.
When residential care is provided under ch. 48, Stats.
, and there is a support order under s. 49.90
, Stats., or ch. 767, Stats.
, which was in existence before the ch. 48, Stats.
, disposition, the billing amount to parents for residential care shall not be less than the previously ordered amount attributable to the child client. This provision supersedes maximum billing limitations in subs. (12)
, (18) (a)
DHS 1.03 Note
Note: Before October 1, 1984 this subsection included the following limits on the amount that parents were expected to pay each month for care or services provided or purchased for their minor children.
DHS 1.03 Note
For outpatient psychotherapy purchased or provided by county agencies, the maximum billing rate to qualified parents for outpatient psychotherapy was $4.00 per day per child client for such care from September 1, 1977 through December 31, 1979. For care from January 1, 1980 through June 30, 1980, the maximum rate for this service was $120 per month per child client. From July 1, 1980 through June 30, 1983, the maximum rate was $152 per month per child client. Since July 1, 1983 the maximum was $183 per month per child client.
DHS 1.03 Note
For all other services, the maximum billing rate for care from September 1, 1977 through June 30, 1980 was $4.00 per day per child client; from July 1, 1980 through June 30, 1983, $5.00 per day per child client; since July 1, 1983, $6.00 per day per child client. Since January 1, 1981 county departments of social services were permitted to convert the daily amounts for residential care to average monthly amounts.
(19) Redetermination of maximum monthly payment rate.
The maximum monthly payment rate established upon entry into the system shall be reviewed at least once per year. A redetermination shall be made at any time during the treatment or payment period that a significant change occurs in available income. The redetermined maximum monthly payment rate may be applied retroactively or prospectively.
(20) Payment period.
Monthly billing to responsible parties with ability to pay shall continue until:
Third-party sources have been exhausted and the responsible parties have a permanent inability or unlikely future ability to pay.
(21) Parental payment limit.
Except as provided in s. DHS 1.065
, parental payment limits shall be determined as follows:
For care in the department's centers for the developmentally disabled, the daily parental limit shall be $6.00, subject to adjustment by the department under par. (b)
. For all other care or services the department may approve daily parental payment limits at amounts which the department determines to be administratively feasible, but not higher than the cost-based fee for the service;
The daily parental payment limit for care in the department's centers for the developmentally disabled shall be adjusted upward or downward in direct proportion to movement in the Milwaukee all-urban consumer price index for food and beverages, published by the U.S. department of labor. The adjustment shall be rounded downward to the nearest whole dollar. The base date for computing the adjustments shall be the date of the last published consumer price index for Milwaukee in 1982. The base dollar amount shall be $6.00 per day. This adjustment shall be computed at the end of each calendar year and shall be effective the following July 1; and
The monthly parental payment limit shall be determined by multiplying the appropriate daily limit by 365 and dividing the product by 12.
DHS 1.03 History
Cr. Register, August, 1978, No. 272
, eff. 9-1-78; am. (2) to (6), renum. (7) to (14) to be (8), (11), (12), (14), (17) to (20) respectively and am. (8), (11), (14), (17), (18) (b) and (20), r. and recr. (18) (a), cr. (7), (9), (10), (13), (15) and (16), Register, November, 1979, No. 287
, eff. 1-1-80; emerg. am. (18) (a), eff. 7-1-80; am. (18) (a), Register, October, 1980, No. 298
, eff. 11-1-80; r. and recr. (18) (a), cr. (18) (c) and (21), Register, December, 1980, No. 300
, eff. 1-1-81; cr. (13m), Register, June, 1981, No. 306
, eff. 7-1-81; am. (8), (10), (13), (13m), (14) (a), (15) and (18) (c), r. and recr. (11) (b) 4. and (12), r. (11) (b) 5., Register, September, 1984, No. 345
, eff. 10-1-84; am. (11) (b) 1., (13) and (18) (c), r. (16) (b) 3., renum. (16) (b) 4. to be 3., r. and recr. (18) (a) and (21), Register, December, 1987, No. 384
, eff. 1-1-88; emerg. cr. (12m), eff. 1-22-97; cr. (12m), Register, August, 1997, No. 500
, eff. 9-1-97; correction in (13m) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 2001, No. 546
; CR 08-017
: am. (12) (c) (intro.) and (21) (intro.) Register June 2008 No. 630
, eff. 7-1-08; correction in (13m) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635
; CR 10-146
: r. and recr. (20) (c) Register May 2011 No. 665
, eff. 6-1-11.
DHS 1.04 Fee establishment, calculation and approval. DHS 1.04(1)(1)
With respect to client services for which responsible parties incur liability and may be billed, each facility operated by the department, a county department of social services, county department established under s. 46.23
, Stats., or an agency providing services pursuant to a contract with the department, a county department of social services or a county department established under s. 46.23
, Stats., shall establish a fee or set of fees as follows if required by the appropriate fee approval authority in par. (g)
(a) Facility fee or service fee.
The division, county department of social services, board established under s. 51.42
, Stats., or private firm in charge of the facility shall establish a uniform facility fee, except that if the facility provides 2 or more services of a disparate nature with associated wide differences in per-service cost, separate per-service fees shall be established.
(b) Fee calculation.
Fees shall be determined in advance for each calendar year, except that divisions may determine fees in advance for each fiscal year. For purchased services, the contract rate and billable units to the purchaser should be identical to the fee and billable units to the responsible party or parties, wherever possible. Fees shall be determined by dividing either the number of patient days projected by the year in question, or, if the facility or service provides less than 24 hour care, the number of hours of billable client service projected for the year in question, into allowable anticipated facility or service-related expenditures for the year in question. For purchased services not easily converted to time units and where the contract or agreement specifies purchase units other than time, fees shall be set using the contract unit.
Expenditures mean ordinary and necessary budgeted non-capital expenses and depreciation on capital equipment. Cost standards that govern purchase of care and services under s. 46.036
, Stats., shall apply to expenditures for calculating the fee. Outlays associated with non-client-specific community service and with client services exempted under s. DHS 1.01 (4)
plus a pro-rata share of depreciation and associated administration or indirect costs are excluded. Where the facility establishes separate per-service fees, expenditures mean ordinary and necessary per-service expenses plus a pro-rata share of depreciation and indirect or administration costs.
(d) Calculating fees.
A division, a county department of social services, a county department established under s. 46.23
, Stats., or a private firm under contract to a division or county department responsible for the calculation of the facility or service fees may use forms provided by the department for the calculation of unit rates. Budgeted costs shall be segregated among cost centers based on groupings of programs which have significantly different costs. A single facility fee may be used if the facility does not provide services of a disparate nature with associated wide discrepancies in cost. Multi-service facilities providing services which are not covered by the uniform fee system may not include costs for those services in their calculations of fees.
DHS 1.04 Note
Note: An example of services of a disparate nature is services provided by psychiatrists in comparison with services provided by social workers.
DHS 1.04 Note
Note: A form that may be used to calculate unit rates is DMT 143, Uniform Fee Application, which is available along with instructions for filling it out from the Bureau of Fiscal Services, P.O. Box 7853, Madison, Wisconsin 53707-7853.
(e) Multiple therapist fees.
Where fees are computed according to professional disciplines (i.e. psychiatrist, psychologist, social worker, nurse, etc.), a fee for an hour of service provided by 2 or more professionals would be the sum of the hourly rates for each professional.
DHS 1.04 Note
Note: Example: The fee for an hour of service provided by a psychologist and social worker would be the sum of the hourly rate computed for each discipline.
(f) Group therapy fees.
Group therapy fees shall be computed by dividing the fee calculated according to par. (d)
by the projected number of non-family-related clients per group.
DHS 1.04 Note
DHS 1.04 Note
For group sessions conducted by one therapist with an average size of 7.
DHS 1.04 Note
Group fee = Therapist fee÷ 7
DHS 1.04 Note
For group sessions conducted by more than one therapist with an average group size of 10.
DHS 1.04 Note
Group fee = (Therapist 1 + Therapist 2 etc.) ÷ 10
Divisions, county departments of social services, and county departments established under s. 51.42
, Stats., shall approve rates for facilities they operate. This subdivision does not apply where another form of approval is set by law.
The administrative unit of a purchasing agency authorized to enter into contracts or agreements for purchased services may approve the fee or fees for purchased services. Any fee approval shall occur before execution of the contract or agreement and the approved fee or fees shall be part of the contract. If the purchaser chooses not to approve fees under this subdivision, fees shall be established in accordance with sub. (2) (a)
Where 2 or more agencies purchase the same service(s) from the same provider, the agency with the largest dollar contract shall have final approval of the facility fee or service fee(s) in question.
(h) Effective date of fee.
Fees in effect at any time shall remain in effect until new fees are determined and approved pursuant to these rules. No fees shall be modified without the prior consent of the fee-approving authority.
DHS 1.04(2)(a)(a) Contracted services.
Facilities providing services pursuant to contracts or agreements with a division, a county department of social services or a county department established under s. 46.23
, Stats., where the purchaser chooses not to approve fees under sub. (1) (g) 2.
, shall establish fees which are equal to the facility's usual and customary charge. Contracted facilities shall inform the purchasing authority of the usual and customary charges and of any changes in fees that take place during the contract period.
(b) Private practitioners.
For services provided by a private practitioner the fee shall be the usual and customary charge for such services when such charges are in accord with all laws or regulations governing such charges.
(c) Statewide rates.
Where the department has established a statewide rate for a service, that rate shall be the fee.
(d) County departments of social services.
In special circumstances with approval of the department, county departments of social services may use a fee of $12 per hour for services delivered by professional staff and $8 per hour for services provided by paraprofessionals instead of establishing fees under sub. (1)
. The department may adjust these rates to reflect changes in the Milwaukee consumer price index for all items, published by the U.S. department of labor. The base time for these adjustments shall be November 1978 at which time the index was 199.0.
(e) Other procedures.
With the approval of the department, fee approval authorities may use other fee-setting procedures for designated services or groups of services. The procedures shall follow these guidelines:
Those costs must be included in the department's allowable cost policy established under s. 46.036
The procedures may set more restrictive requirements for the costs to be considered; and
DHS 1.04 History
Cr. Register, August, 1978, No. 272
, eff. 9-1-78; am. (1) (intro.) and (a), renum. (1) (d) and (e) to be (1) (g) and (h), r. and recr. (1) (g), cr. (1) (d) to (f), Register, November, 1979, No. 287
, eff. 1-1-80; am. (1) (d) (intro.) and (2) (e), cr. (2) (f), Register, September, 1984, No. 345
, eff. 10-1-84; am. (1) (intro.), (g) 1. and 2., r. and recr. (1) (d) and (2) (a), Register, December, 1987, No. 384
, eff. 1-1-88.
DHS 1.05 Billing and collections responsibility and practice. DHS 1.05(1)(1)
Boards established under s. 51.42, 51.437 or 46.23, Stats. DHS 1.05(1)(a)(a)
With respect to each service not provided in state facilities, the responsibility for billing and collections pursuant to these rules shall be delegated to a board established under s. 51.42
, Stats., under authority established by s. 46.10 (16)
, Stats., subject to the conditions specified by the department. The board may further delegate responsibility for billing and collection to a service provider by written agreement specifying the conditions of such delegation.
Formal delegation is required for care received in county hospitals under s. 51.09
, Stats., on or after January 1, 1975. Until collections responsibility is delegated for these services, the department's bureau of fiscal services shall continue to manage these accounts. Delegation of collections for county hospitals may be granted to the program director of the appropriate 51.42 board upon submission of required form DMT 142 to the Secretary of the Department - Attention: Bureau of Fiscal Services. Where the board of trustees of the hospital is not the 51.42
board, application for delegated collections authority shall specify the role in the collections function and how any disposition of monies collected by the facility will be handled. When an application is received, a representative of the bureau of fiscal services shall visit the facility in question to determine the facility's capability to operate in accord with statutes and rules relative to the collections function.
DHS 1.05 Note
Note: Form DMT 142 may be obtained from:
Department of Health Services
Bureau of Fiscal Services
P.O. Box 7853
Madison, Wisconsin 53707-7853
For services provided in Milwaukee county-operated facilities, the provisions of s. 46.10 (12)
, Stats., take precedence over s. 46.10 (16)
, Stats. Therefore, Milwaukee county may continue to collect for these services without additional delegation authority. However, if Milwaukee county chooses not to operate under s. 46.10 (12)
, Stats., the provisions of s. 46.10 (16)
, Stats., will apply according to par. (d)
Collections for all other services purchased or provided by boards not mentioned in par. (b)
are delegated to the program director of the board.
Accounts collected by the department's bureau of fiscal services for boards established under s. 51.42
, Stats., shall be distributed according to s. 46.10 (8m)
Where services covered by these rules are delivered through a county department of social services, the county department of social services shall have billing and collection responsibility for those services unless it delegates such responsibility to a provider agency or agencies by written agreement specifying the conditions of such delegation.
Accounts collected by the department's bureau of fiscal services for county departments of social services shall be distributed according to s. 46.03 (18) (g)
When a child is placed in substitute care, as defined in s. DHS 1.07 (2) (i)
, pursuant to a court order under ch. 48
, Stats., the county agency under s. 46.215
, Stats., shall enter into an agreement with the county child support agency under s. 59.53 (5)
, Stats., to maximize federal financial participation in funding substitute care and to conform to federal statutes and regulations relating to parental support or payment for substitute care.
(3) Revocation of delegated authority.
All delegations under subs. (1)
are subject to revocation should the department find violations of these rules or of generally recognized good accounting practices.
(4) State bureau of fiscal services.
Except where responsibility for collections is delegated under sub. (1)
, the bureau of fiscal services of the department shall be responsible for the billing and collection function, unless otherwise specified by the secretary. The bureau of fiscal services shall also provide collection services for individual delinquent, or otherwise referred, client accounts.
(5) Further delegation.
Agencies with delegated collection responsibility may contract out the billing and collection functions as part of a purchase of service agreement. Such contracts shall specifically provide that all billing and collections functions be carried out according to these rules. However, no contract may be negotiated with a private collections firm without written permission from the bureau of fiscal services.
All billing and collection efforts shall strive toward what is fair and equitable treatment for both clients who receive service and taxpayers who bear unmet costs.
Billing and collection activity shall consider the rights, dignity, and physical and mental condition of the client and other responsible parties. Responsible parties with no ability to pay and without applicable insurance shall not be pursued for payment.
All billing and collection activity shall be pursued in a forthright and timely manner according to these rules:
Where applicable insurance exists, the insurance company shall be billed directly wherever possible by the unit with collection responsibility for the facility providing the service. Where a responsible party is covered by Medicare and private insurance, Medicare shall be billed for the full coverage it provides and the private insurance company shall be billed for any remaining amount. Medicaid, where applicable, is the payer of last resort. For services exempted by s. DHS 1.01 (4)
, third-party reimbursement shall be pursued where applicable, but direct billings to the client or other responsible parties shall not occur. Agencies shall follow the claims processing procedures of third-party payers to assure payment of claims.
Responsible private parties shall be billed for liability not covered by insurance, according to applicable provisions of s. DHS 1.03
(7) First billings to responsible parties who have an ability to pay or who have not provided full financial information.
Where it is anticipated third-parties will pay less than the full liability, the first billing to responsible parties shall be sent during the calendar month following the month in which services were provided, except where an agreement to delay billing exists. If a responsible party has not provided full financial information and the payment approval authority determines that it is unlikely that the responsible party is able to pay full uninsured liability, the payment approval authority may set an estimated payment amount which shall be adjusted retroactively after the responsible party has provided full financial information. A cover letter explaining the liability and arrangements for making payment shall accompany the first billing statement to the responsible person(s) billed.