DHS 101.03(87)
(87) “Institutionalized individual" means an individual who is:
DHS 101.03(87)(a)
(a) Involuntarily confined or detained in a rehabilitative facility, such as a psychiatric hospital or other facility for the care and treatment of mental illness, or under a civil or criminal statute in a correctional facility; or
DHS 101.03(87)(b)
(b) Confined, under a voluntary commitment, in a psychiatric hospital or other facility for the care and treatment of mental illness.
DHS 101.03(88)
(88) “Institutional provider" means a hospital, home health agency, county department operated facility, rehabilitation agency, portable x-ray provider, independent clinical laboratory, rural health clinic, skilled nursing facility, intermediate care facility, case management agency provider, personal care provider, ambulatory surgical center or hospice which is:
DHS 101.03(88)(b)
(b) Eligible to receive payment only as a certified group or organization, rather than as individuals providing services within a facility or agency; and
DHS 101.03(88)(c)
(c) Required by the department to establish that its personnel who provide services meet the applicable certification criteria contained in ch.
DHS 105, although they need not be separately certified by the department.
DHS 101.03(89)
(89) “Intermediate care facility" or “ICF" means a facility that:
DHS 101.03(89)(a)
(a) Provides, on a regular basis, health-related services to individuals who do not require hospital or skilled nursing facility care but whose mental or physical condition requires services that are above the level of room and board and that can be made available only through institutional facilities;
DHS 101.03(90)
(90) “Intermediate care services" means services provided by an intermediate care facility.
DHS 101.03(91)
(91) “Intermittent nursing services" means nursing services provided to a recipient who has a medically predictable recurring need for skilled nursing services. In most instances, this means that the recipient requires a skilled nursing visit at least once every 60 days.
DHS 101.03(92)
(92) “Laboratory" or “clinical laboratory" means a facility for the microbiological, serological, chemical, hematological, radiobiassay cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention or treatment of any disease or assessment of a medical condition.
DHS 101.03(92)(a)
(a) “Independent laboratory" means a laboratory performing diagnostic tests which is independent both of an attending or consulting physician's office and of a hospital.
DHS 101.03(92)(b)
(b) “Hospital laboratory" means a laboratory operated under the supervision of a hospital or its organized medical staff that serves hospital patients.
DHS 101.03(92)(c)
(c) “Physician's office laboratory" means a laboratory maintained by a physician for performing diagnostic tests for his or her own patients.
DHS 101.03 Note
Note: A physician's office laboratory which accepts at least 100 specimens in any category during any calendar year on referral from other physicians is considered an independent laboratory.
DHS 101.03(93)
(93) “Legally responsible" means a spouse's liability for the support of a spouse or a parent's liability for the support of a child as specified in s.
49.90, Stats.
DHS 101.03(94)
(94) “Legend drug" means, for the purposes of MA, any drug requiring a prescription under
21 USC 353 (b).
DHS 101.03(94p)
(94p) “Medicaid review period" is the calendar month of a medical assistance recipient's application plus 11 calendar months or the medicaid eligibility review calendar month plus 11 calendar months.
DHS 101.03(94r)
(94r) “Medical expense" means a cost paid by a medicaid purchase plan recipient, an institutionalized person, or someone receiving home and community-based services for goods or services that have been prescribed or provided by a medical practitioner licensed in Wisconsin or another state. The cost is not reimbursable by another source such as medicare, medical assistance, private insurance or an employer. Medical expenses may be used to expend excess income during a spend-down period.
DHS 101.03(95)
(95) “Medical assistance" or “MA" means the assistance program operated by the department under ss.
49.43 to
49.497, Stats., any services or items under ss.
49.45 to
49.497, Stats., and this chapter and chs.
DHS 102 to
108, or any payment or reimbursement made for these services or items.
DHS 101.03(96)
(96) “Medical assistance group" or “MA group" means all persons listed on an application for MA who meet nonfinancial eligibility requirements, except that each SSI recipient comprises a separate MA group.
DHS 101.03(96m)(a)
(a) Required to prevent, identify or treat a recipient's illness, injury or disability; and
DHS 101.03(96m)(b)1.
1. Is consistent with the recipient's symptoms or with prevention, diagnosis or treatment of the recipient's illness, injury or disability;
DHS 101.03(96m)(b)2.
2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;
DHS 101.03(96m)(b)3.
3. Is appropriate with regard to generally accepted standards of medical practice;
DHS 101.03(96m)(b)4.
4. Is not medically contraindicated with regard to the recipient's diagnoses, the recipient's symptoms or other medically necessary services being provided to the recipient;
DHS 101.03(96m)(b)6.
6. Is not duplicative with respect to other services being provided to the recipient;
DHS 101.03(96m)(b)7.
7. Is not solely for the convenience of the recipient, the recipient's family or a provider;
DHS 101.03(96m)(b)8.
8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and
DHS 101.03(96m)(b)9.
9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.
DHS 101.03(97)
(97) “Medically needy" means the group of persons who meet the non-financial eligibility conditions for MA, but whose income exceeds the financial eligibility limits for categorically needy MA groups. Medically needy eligibility exists if applicant's income does not exceed, for the applicant's family size, the income limits under. s.
49.47 (4) (c) 1. or
49.471 (7), Stats.
DHS 101.03(98)
(98) “Medicare" means the health insurance program operated by the U.S. department of health and human services under
42 USC 1395 and 42 CFR subchapter B.
DHS 101.03(99)
(99) “Modality" means a treatment involving physical therapy equipment that does not require the physical therapist's personal continuous attendance during the periods of use but that does require setting up, frequent observation, and evaluation of the treated body part by the physical therapist prior to and after treatment.
DHS 101.03(100)
(100) “Net income" means the amount of the applicant's income that is left after deductions are made for allowable expenses and income disregards.
DHS 101.03(101)
(101) “Net market value" means for the purposes of divestment the fair market value of the resource on the date it was disposed of less the reasonable costs of the transaction on the open market.
DHS 101.03(101m)
(101m) “Networking of existing resources" means the identification of and referral to an agency in the person's community for any services necessary to overcome the person's barriers to employment.
DHS 101.03(102)
(102) “Non-billing performing provider number" means the provider number assigned to an individual who is under professional supervision in order to be an eligible provider. A non-billing provider is not directly reimbursed for services rendered to an MA recipient.
DHS 101.03(103)
(103) “Non-covered service" means a service, item or supply for which MA reimbursement is not available, including a service for which prior authorization has been denied, a service listed as non-covered in ch.
DHS 107, or a service considered by consultants to the department to be medically unnecessary, unreasonable or inappropriate.
DHS 101.03(105)
(105) “Non-institutional provider" means a provider, eligible for direct reimbursement, who is in single practice rather than group practice, or a provider who, although employed by a provider group, has private patients for whom the provider submits claims to MA.
DHS 101.03(106)
(106) “Non-legally responsible relative case" or “NLRR case"means a case in which there is no legally responsible caretaker relative in the home for a dependent child defined under s.
49.19 (1) (a), Stats., but where the caretaker of the child is a qualified relative under s.
49.19 (1) (a), Stats.
DHS 101.03(107)
(107) “Nonprofit agency" means an agency exempt from federal income taxation under section
501 of the internal revenue code of 1954, as amended.
DHS 101.03(110)
(110) “Nursing home payment formula" means the prospective payment system for nursing home care established annually by the department.
DHS 101.03(111)
(111) “Occupational therapist" or “OTR" means a person who meets the requirements of s.
DHS 105.28 (1), is the primary performing provider of occupational therapy services, is responsible for and signs all billings for occupational therapy services, and is not required to be supervised.
DHS 101.03(112)
(112) “Occupational therapy procedure" means treatment, with or without equipment, which requires the continuous personal attendance of a registered occupational therapist or a certified occupational therapist assistant.
DHS 101.03(114)
(114) “Outpatient physical therapy services" means physical therapy services furnished by a provider of these services, a rehabilitation agency or by others under an arrangement with and supervised by the provider or rehabilitation agency, to an individual on an outpatient basis, which may include services to correct a pathological condition of speech.
DHS 101.03(114m)
(114m) “Palliative care" means treatment provided to persons experiencing the last stages of terminal illness for the reduction and management of pain and other physical and psychosocial symptoms of terminal illness, rather than treatment aimed at investigation and intervention for the purpose of cure. “Palliative care" will normally include physician services, skilled nursing care, medical social services and counseling.
DHS 101.03(114p)(d)
(d) A man adjudged in a judicial proceeding to be the biological father of a child if the child is a nonmarital child who is not adopted or whose parents do not subsequently marry each other under s.
767.803, Stats.
DHS 101.03(114q)
(114q) “Participant" means a person who is participating in a health and employment counseling program.
DHS 101.03(114r)
(114r) “Part-time, intermittent" means skilled nursing and therapy services provided in the home for less than 8 hours in a calendar day.
DHS 101.03(115)
(115) “Person" means an individual, corporation, partnership, association, trustee, governmental unit or other entity.
DHS 101.03(115m)
(115m) “Period of eligibility" means nine calendar months from the initial calendar month of participation in a health and employment counseling program.
DHS 101.03(116)
(116) “Personal care service" means a service enumerated in s.
DHS 107.112 (1) when provided by a provider meeting the certification requirements for a personal care provider under s.
DHS 105.17.
DHS 101.03(117)
(117) “Personal care worker" means an individual employed by a personal care provider certified under s.
DHS 105.17 or under contract to the personal care provider to provide personal care services under the supervision of a registered nurse.
DHS 101.03(118)
(118) “Personal needs allowance" means that amount of monthly unearned income identified in s.
49.45 (7) (a), Stats., which may be retained for the personal needs of an institutionalized person.
DHS 101.03(119)
(119) “Persons with related conditions" means individuals who have epilepsy, cerebral palsy or another developmental disability.
DHS 101.03(122m)
(122m) “Physically or sensory disabled" means a condition which affects a person's physical or sensory functioning by limiting his or her mobility or ability to see or hear, is the result of injury, disease or congenital deficiency, and significantly interferes with or limits one or more major life activities and the performance of major personal or social roles.
DHS 101.03(123)
(123) “Physician" means a person licensed under ch.
448, Stats., to practice medicine and surgery, including a graduate of an osteopathic college who holds an unlimited license to practice medicine and surgery.
DHS 101.03(124)
(124) “Physician assistant" means a person certified by the department to participate in MA who holds the minimum qualifications specified in s.
DHS 105.05 (2).
DHS 101.03(124m)
(124m) “Plan of care," for purposes of ss.
DHS 105.16,
105.19,
107.11,
107.113 and
107.12, means a written plan of care for a recipient prescribed and periodically reviewed by a physician and developed in consultation with the agency staff which covers all pertinent diagnoses, including mental status, type of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency and duration. Orders for therapy services may be developed in accord with the therapist or other agency personnel. Agency personnel shall participate in developing the plan of care.
DHS 101.03 Note
Note: The federal poverty guidelines for 1999 were published in the
Federal Register, March 18, 1999, pp. 13428-13430.
DHS 101.03(126)
(126) “Practical nurse" or “LPN" means a person who is licensed as a practical nurse under ch.
441, Stats., or, if practicing in another state, is licensed as a practical nurse by that state.
DHS 101.03(127)
(127) “Prepaid health plan" or “PHP" means a plan made available by a provider, other than a health maintenance organization, that provides medical services to enrolled recipients under contract with the department on a capitation fee basis.
DHS 101.03(129m)(a)
(a) A pregnant woman for MA coverage of ambulatory prenatal care and other services, as determined under s.
49.465 (2), Stats.
DHS 101.03(129m)(c)
(c) A woman diagnosed with breast or cervical cancer or precancerous conditions for MA coverage, as defined under s.
49.473 (3), Stats.
