DHS 101.03(22m)
(22m) “Case management" means activities which help MA recipients and, when appropriate, their families, identify their needs and manage and gain access to necessary medical, social, rehabilitation, vocational, educational and other services. Case management includes assessment, case plan development, and ongoing monitoring and service coordination under s.
DHS 107.32.
DHS 101.03(23)
(23) “Categorically needy" means the group of persons who meet the nonfinancial and financial eligibility conditions to be eligible for MA and designated as covered groups in Wisconsin under the MA state plan.
DHS 101.03(24m)
(24m) “CESA" means a cooperative educational service agency under ch.
116, Stats.
DHS 101.03(25)
(25) “Chronic mental illness" means a mental illness which may be of lifelong duration, which is severe in degree and persistent in duration, which causes a substantially diminished level of functioning in the primary activities of daily living and an inability to cope with the ordinary demands of life, and which may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support.
DHS 101.03(26)
(26) “Claim" means a request from a provider on an approved claim form for payment for services to a recipient.
DHS 101.03(27)
(27) “Clinical note" means a dated written notation of contact with a patient by a member of a health care team, which contains a description of signs and symptoms, treatment or drugs given, the patient's reaction and any changes in physical or emotional condition.
DHS 101.03(27m)
(27m) “Community support program" or “CSP" means a community-based coordinated care and treatment program operated by a provider certified under s.
DHS 105.255 to provide mental health and psychosocial rehabilitative services, including case management services, to MA-eligible, chronically mentally ill recipients residing in the community.
DHS 101.03(28)
(28) “Compensation received" means the dollar value that can be attached to what is received in return for property and, without limitation by enumeration, that is in one or more of the following forms:
DHS 101.03(28)(b)
(b) Other assets such as accounts receivable and promissory notes, both of which must be valid and collectible to be of value, and stocks, bonds, and both land contracts and life estates;
DHS 101.03(28)(d)
(d) Prepayment of a bona fide and irrevocable contract such as a mortgage, shelter lease or loan, or the prepayment of taxes; or
DHS 101.03(28)(e)
(e) Services, for which a valuation equal to the cost of purchase on the open market is assigned.
DHS 101.03 Note
Note: The presumption that services and accommodations rendered to each other by the members of a family or other relatives were gratuitous can be rebutted only by direct and positive evidence of a prior express contract for payment.
DHS 101.03(28m)
(28m) “Complex rehabilitation technology professional” means an individual who is certified as an assistive technology professional by the Rehabilitation Engineering and Assistive Technology Society of North America.
DHS 101.03(29)
(29) “Concurrent review" means the department's informal review of a complaint on the basis of which a fair hearing has been requested, including an investigation into the facts of a recipient's request for a fair hearing, whereby the department attempts to achieve an informal resolution acceptable to the recipient before the fair hearing takes place.
DHS 101.03 Note
Note: This review does not preclude the recipient's right to a fair hearing.
DHS 101.03(31)
(31) “Confined to a place of residence" means a recipient's physical medical condition or functional limitation in one or more of the areas listed in s.
DHS 134.13 (9) (c), including self-care, understanding and use of language, learning, mobility, self-direction and capacity for independent learning, which:
DHS 101.03(31)(a)
(a) Restricts the recipient's ability to leave his or her place of residence except with the aid of a supportive device such as crutches, a cane, a wheelchair or a walker, the assistance of another person or the use of special transportation;
DHS 101.03(31)(b)
(b) Is such that leaving the residence is medically contraindicated; or
DHS 101.03(31)(c)
(c) Requires a considerable and taxing effort to leave the home for medical services.
DHS 101.03(32)
(32) “Consultation" means communication between 2 or more providers concerning the diagnosis or treatment in a given case, which may include, but is not limited to, history-taking examination of the patient, rendering an opinion concerning diagnosis or treatment, or offering service, assistance or advice.
DHS 101.03(33)
(33) “Controlling interest or ownership" means that a person:
DHS 101.03(33)(a)
(a) Possesses a direct or indirect interest in 5% or more of the issued shares of stock in a corporate entity;
DHS 101.03(33)(b)
(b) Is the owner of an interest of 5% or more in any mortgage, deed of trust, note, or other secured obligation;
DHS 101.03(33m)
(33m) “Convalescent leave" means a resident's temporary release from an institution for mental diseases (IMD) to residency in a community setting, not more frequently than once a year and beginning on the fourth day after release, with the trial period of residence in the community lasting at least 4 days but not longer than 30 days or until the person is permanently discharged from the IMD, whichever occurs first.
DHS 101.03(34)(b)
(b) Any shoe attached to a brace, not including arch supports, for prosthesis;
DHS 101.03(34)(c)
(c) Mismated shoes involving a difference of a full size or more; or
DHS 101.03(34)(d)
(d) Shoe modifications for a discrepancy in limb length or a rigid foot deformation.
DHS 101.03(34m)
(34m) “Cost-effectiveness" means the cost of paying premiums or purchasing health insurance for a medicaid purchase plan recipient through an employer and the associated administrative cost is likely to be less than or equal to the cost of providing medical assistance.
DHS 101.03(35)
(35) “Covered service" means a service, procedure, item or supplies for which MA reimbursement is available, provided to a recipient of MA by an MA-certified provider qualified to provide the particular service, procedure, item or supplies or under the supervision of a certified and qualified provider.
DHS 101.03(36)
(36) “Daily nursing home rate" means the amount that a nursing home is reimbursed for providing each day of routine health care services to a recipient who is a patient in the home, determined in accordance with s.
49.45 (6m) (a), Stats.
DHS 101.03(36m)
(36m) “Date of account creation" means the date the recipient establishes an independence account with a financial institution.
DHS 101.03(37)
(37) “Day treatment" or “day hospital" means a non-residential program in a medically supervised setting that provides case management, medical care, psychotherapy and other therapies, including recreational, physical, occupational and speech therapies, and follow-up services, to alleviate problems related to mental illness or emotional disturbances.
DHS 101.03 Note
Note: Day treatment services are provided by an interdisciplinary team on a routine, continuous basis for a scheduled portion of a 24-hour day and may include structural rehabilitative activities including training in basic living skills, interpersonal skills and problem-solving skills.
DHS 101.03(38)
(38) “Deeming" means a process by which income and assets are considered available to applicants or recipients for the purpose of determining financial eligibility for MA under s.
49.46 (1),
49.47 (4), or
49.471, Stats., and ch.
DHS 103.
DHS 101.03(39)
(39) “Department" means the department of health services.
DHS 101.03(40)
(40) “Department-approved occupancy rate" means a rate of nursing home occupancy established by the department and communicated to providers which is used for purposes of determining whether a bed-hold payment may be made to a nursing home.
DHS 101.03(41)
(41) “Developmental disability" means intellectual disability or a related condition such as cerebral palsy, epilepsy, or autism, but excluding mental illness and degenerative brain disorder, which is:
DHS 101.03(41)(c)
(c) Results in substantial functional limitations in 3 or more of the following areas of major life activity:
DHS 101.03(42)
(42) “Differential diagnostic examination" means an examination and assessment of a recipient's emotional and social functioning which includes one or more of the following: neurologic studies, psychological tests and psycho-social assessments.
DHS 101.03(42m)
(42m) “Direct deposit" means an electronic transfer of funds from the recipient's financial institution to the medicaid purchase plan or the department's fiscal agent, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.
DHS 101.03(43)
(43) “Direct, immediate, on-premises supervision" means supervision with face-to-face contact between the supervisor and the person being supervised, as necessary, with the supervisor being physically present in the same building when the service is being performed by the person being supervised.
DHS 101.03(44)
(44) “Direct services" mean nursing home services that benefit patient recipients on an individual basis rather than a group basis, including physician visits to patients, therapy modalities, drug dispensing, radiology or laboratory services provided by a certified radiology or laboratory unit, oral exams, and physical examinations.“Direct services" are often referred to as billable services, medical services or professional services.
DHS 101.03(45)
(45) “Dispensary providers" means providers who dispense drugs, medical supplies or equipment upon a prescription or order from a prescriber authorized under ch.
447 or
448, Stats., to prescribe the items.
DHS 101.03 Note
Note: Examples of dispensary providers are pharmacies, durable medical equipment suppliers and providers of vision care supplies.
DHS 101.03(46)
(46) “Divestment" means the disposal of any nonexempt resource for a value received which is less than the net market value.
DHS 101.03(47)
(47) “Division" means the department's division of health care financing.
DHS 101.03(48)
(48) “Drug dispensing" means the interpretation of an order for a drug or biological and the proper selection, measuring, labeling, packaging and issuance of the drug or biological for a patient or for a service unit of a hospital or other health care facility.
DHS 101.03(49)
(49) “Drug index" means the list of covered legend and nonlegend drugs maintained and updated by the department.
DHS 101.03(50)
(50) “Durable medical equipment" means equipment which can withstand repeated use, is primarily used for medical purposes, is generally not useful to a person in the absence of illness or injury and is appropriate for use in the home.
DHS 101.03 Note
Note: Examples of “durable medical equipment" are wheelchairs, hospital beds and side rails.
DHS 101.03(51)
(51) “Earned income" means income received in the form of wages, salary, commissions or profits from activities in which the applicant or recipient is engaged as an employee or as a self-employed person.
DHS 101.03(51m)
(51m) “Electronic funds transfer" means any electronic transfer of a recipient's financial holdings or a portion of these holdings as determined by the recipient to another account, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.
DHS 101.03(51p)
(51p) “
Electronic visit verification" or “EVV” means, with respect to personal care services or home health care services as defined and required in Section 12006 of the 21st Century Cures Act,
42 USC 1396b (l), a system under which in-home visits conducted as part of such services are electronically verified.
DHS 101.03(51t)
(51t) “
EVV record” means the information or data related to an electronically verified visit which contains all of the following:
DHS 101.03(52)
(52) “Emergency services" means those services necessary to treat an emergency medical condition, including labor and delivery, that without immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, seriously impair bodily functions, or seriously disable any body part or bodily organ.
DHS 101.03(52g)
(52g) “Employed" means the person receives income for ongoing services and as a result of this income has incurred a potential tax liability. Any of the following may be used to verify employment:
DHS 101.03(52g)(f)
(f) Statements from employers. Employer statements may include those from personnel officers, supervisors or other employees of the company who have direct knowledge of the applicant's or recipient's wages. The person making the statement must provide evidence (such as employment records, business correspondence, etc.) that the applicant or recipient is or was an employee of the company during the calendar month for which the applicant or recipient requests eligibility.
DHS 101.03(52g)(g)
(g) Other agencies who receive reports of the applicant's or recipient's income directly from the employer.
DHS 101.03(52m)
(52m) “Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80% of the cost, excluding any deductibles or copayments that may be required under the plan.
