Wisconsin Legislature: DHS 105.49

Alert! This chapter may be affected by an emergency rule:

EmR2421

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528; correction made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.45 Dialysis facilities. For MA certification, dialysis facilities shall meet the requirements enumerated in ss. DHS 152.05 and 152.08, and shall be certified to participate in medicare.

Note: For covered dialysis services, see s. DHS 107.26.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, November, 1994, No. 467; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.46 Blood banks. For MA certification, blood banks shall be licensed or registered with the U.S. food and drug administration and shall be approved pursuant to 42 CFR 493 (CLIA).

Note: For covered blood services, see s. DHS 107.27.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.47 Health maintenance organizations and prepaid health plans.

(1) Contracts and licensing. Except as provided in sub. (3), for MA certification, a health maintenance organization or prepaid health plan shall enter into a written contract with the department to provide services to enrolled recipients and shall be licensed by the Wisconsin commissioner of insurance.

(2) Requirements for health maintenance organizations. For MA certification, an HMO shall:

(a) Meet the requirements of 42 CFR 434.20 (c);

(b) Make services it provides to individuals eligible under MA accessible to these individuals, within the area served by the organization, to the same extent that the services are made accessible under the MA state plan to individuals eligible for MA who are not enrolled with the organization; and

(c) Make adequate provision against the risk of insolvency, which is satisfactory to the department and which ensures that individuals eligible for benefits under MA are not held liable for debts of the organization in case of the organization’s insolvency.

Note: For covered health maintenance organization and prepaid health plan services, see s. DHS 107.28.

(3) Care organizations providing the family care benefit. A care management organization under contract with the department under s. DHS 10.42 is not required to be licensed by the Wisconsin commissioner of insurance if both of the following apply:

(a) The organization enrolls only individuals who are eligible under s. 46.286, Stats.

(b) The services offered by the organization do not include hospital or physician services.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (3), Register, October, 2000, No. 538, eff. 11-1-00; correction in (3) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.48 Out-of-state providers.

(1) When a provider in a state that borders on Wisconsin documents to the department’s satisfaction that it is common practice for recipients in a particular area of Wisconsin to go for medical services to the provider’s locality in the neighboring state, the provider may be certified as a Wisconsin border status provider, subject to the certification requirements in this chapter and the same rules and contractual agreements that apply to Wisconsin providers, except that nursing homes are not eligible for border status.

(2) Out-of-state independent laboratories, regardless of location, may apply for certification as Wisconsin border status providers.

(2m) Out-of-state providers who meet the definition of a border-status provider as described in s. DHS 101.03 (19) and who provide services to Wisconsin members via telehealth, regardless of provider location, may apply for certification as Wisconsin border-status providers if they are licensed in Wisconsin under applicable Wisconsin statute and administrative code.

(3) Other out-of-state providers who do not meet the requirements of sub. (1) may be reimbursed for non-emergency services provided to a Wisconsin MA recipient upon approval by the department under s. DHS 107.04.

(4) The department may review border status certification of a provider annually. Border status certification may be canceled by the department if it is found to be no longer warranted by medical necessity, volume or other considerations.

(5)

(a) A provider certified in another state for services not covered in Wisconsin shall be denied border status certification for these services in the Wisconsin program.

Note: Examples of providers whose services are not covered in Wisconsin are music therapists and art therapists.

(b) A provider denied certification in another state shall be denied certification in Wisconsin, except that a provider denied certification in another state because the provider’s services are not MA-covered in that state may be eligible for Wisconsin border status certification if the provider’s services are covered in Wisconsin.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. Register, September, 1991, No. 429, eff. 10-1-91; correction in (3) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-043: cr. (2m) Register May 2023 No. 809, eff. 6-1-23.

DHS 105.49 Ambulatory surgical centers. For MA certification, an ambulatory surgical center shall be certified to participate in medicare as an ambulatory surgical center under 42 CFR 416.39.

Note: For covered ambulatory surgical center services, see s. DHS 107.30.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.50 Hospices. For MA certification, a hospice shall be certified to participate in medicare as a hospice under 42 CFR 418.50 to 418.100.

History: Cr. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.51 Case management agency providers.

(1) Agency. For MA certification, a provider of case management services shall be an agency with state statutory authority to operate one or more community human service programs. A case management agency may be a county or Indian tribal department of community programs, a department of social services, a department of human services, or a county or tribal aging unit. Each applicant agency shall specify each population eligible for case management under s. DHS 107.32 (1) (a) 2. for which it will provide case management services. Each certified agency shall offer all 3 case management components described under s. DHS 107.32 (1) so that a recipient can receive the component or components that meet his or her needs.

(2) Employed personnel.

(a) To provide case assessment or case planning services reimbursable under MA, persons employed by or under contract to the case management agency under sub. (1) shall:

1. Possess a degree in a human services-related field, possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed, and have acquired at least one year of supervised experience with the type of recipients with whom he or she will work; or

2. Possess 2 years of supervised experience or an equivalent combination of training and experience.

Note: The knowledge required in subd. 1. is typically gained through supervised experience working with persons in the target population.

(b) To provide ongoing monitoring and service coordination reimbursable under MA, personnel employed by a case management agency under sub. (1) shall possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed.

(3) Sufficiency of agency certification for employed personnel. Individuals employed by or under contract to an agency certified to provide case management services under this section may provide case management services upon the department’s issuance of certification to the agency. The agency shall maintain a list of the names of individuals employed by or under contract to the agency who are performing case management services for which reimbursement may be claimed under MA. This list shall certify the credentials possessed by the named individuals which qualify them under the standards specified in sub. (2). Upon request, an agency shall promptly advise the department in writing of the employment of persons who will be providing case management services under MA and the termination of employees who have been providing case management services under MA.

(4) Contracted personnel. Persons under contract with a certified case management agency to provide assessments or case plans shall meet the requirements of sub. (2) (a), and to provide ongoing monitoring and service coordination, shall meet the requirements of sub. (2) (b).

(5) Recordkeeping. The case manager under s. DHS 107.32 (1) (d) shall maintain a file for each recipient receiving case management services which includes the following:

(a) The assessment document;

(b) The case plan;

(d) Financial forms;

(e) Release of information forms;

(f) Case reviews;

(g) A written record of all monitoring and quality assurance activities; and

(h) All pertinent correspondence relating to the recipient’s case management.

(6) Reimbursement.

(a) Case management services shall be reimbursed when the services are provided by certified providers or their subcontractors to recipients eligible for case management.

(b) Payment shall be made to certified providers of case management services according to terms of reimbursement established by the department.

(7) County election to participate.

(a) The department may not certify a case management agency for a target population unless the county board or tribal government of the area in which the agency will operate has elected to participate in providing benefits under s. DHS 107.32 through providers operating in the county or tribal area. The county board or tribal government may terminate or modify its participation by giving a 30 day written notice to the department. This election is binding on any case management agencies providing services within the affected county or tribal area.

(b) Any case management agency provider requesting certification under this section shall provide written proof of the election of the county or tribal government to participate under this subsection.

History: Cr. Register, February, 1988, No. 386, eff. 3-1-88; corrections in (1) (a), (5) (intro.) and (7) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.52 Prenatal care coordination providers.

(1) Agency. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be:

(a) A community-based health organization;

(b) A community-based social services agency or organization;

(d) A county department of human services under s. 46.23, Stats., or social services under s. 46.215 or 46.22, Stats.;

(e) A family planning agency certified under s. DHS 105.36;

(f) A federally qualified health center (FQHC) as defined in 42 CFR 405.2401 (b);

(g) A health maintenance organization (HMO);

(h) An independent physician association (IPA);

(i) A hospital;

(j) A physician’s office or clinic;

(k) A private case management agency;

(L) A registered nurse or nurse practitioner;

(m) A rural health clinic certified under s. DHS 105.35;

(n) A tribal agency health center; or

(o) A women, infants, and children (WIC) program under 42 USC 1786.

(2) Qualified professionals.

(a) Definition. In this subsection, “qualified professional” means any of the following:

1. A nurse practitioner licensed as a registered nurse pursuant to s. 441.06, Stats., and currently certified by the American nurses’ association, the national board of pediatric nurse practitioners and associates or the nurses’ association of the American college of obstetricians and gynecologists’ certification corporation;

2. A nurse midwife certified under s. DHS 105.201;

3. A public health nurse meeting the qualifications of s. DHS 139.08;

4. A physician licensed under ch. 448, Stats., to practice medicine or osteopathy;

5. A physician assistant certified under ch. 448, Stats.;

6. A dietitian certified or eligible for registration by the commission on dietetic registration of the American dietetic association with at least 2 years of community health experience;

7. A registered nurse with at least 2 years of experience in maternity nursing or community health services or a combination of maternity nursing and community health services;

8. An employee with at least a bachelor’s degree and 2 years of experience in a health care or family services program; or

9. A health educator with a master’s degree in health education and at least 2 years of experience in community health services.

(b) Required qualified professionals. To be certified to provide prenatal care coordination services that are reimbursable under MA, the prenatal care coordination agency under sub. (1) shall: