DHS 105.47(2)
(2)
Requirements for health maintenance organizations. For MA certification, an HMO shall:
DHS 105.47(2)(b)
(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
DHS 105.47(2)(c)
(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.
DHS 105.47 Note
Note: For covered health maintenance organization and prepaid health plan services, see s.
DHS 107.28.
DHS 105.47(3)
(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:
DHS 105.47(3)(b)
(b) The services offered by the organization do not include hospital or physician services.
DHS 105.47 History
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(1)(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.
DHS 105.48(2)
(2) Out-of-state independent laboratories, regardless of location, may apply for certification as Wisconsin border status providers.
DHS 105.48(2m)
(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.
DHS 105.48(3)
(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.
DHS 105.48(4)
(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.
DHS 105.48(5)(a)(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.
DHS 105.48 Note
Note: Examples of providers whose services are not covered in Wisconsin are music therapists and art therapists.
DHS 105.48(5)(b)
(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.
DHS 105.48 History
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
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.
DHS 105.49 Note
Note: For covered ambulatory surgical center services, see s.
DHS 107.30.
DHS 105.50
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.
DHS 105.50 History
History: Cr.
Register, February, 1988, No. 386, eff. 3-1-88.
DHS 105.51
DHS 105.51 Case management agency providers. DHS 105.51(1)(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.
DHS 105.51(2)(a)(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:
DHS 105.51(2)(a)1.
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
DHS 105.51(2)(a)2.
2. Possess 2 years of supervised experience or an equivalent combination of training and experience.
DHS 105.51 Note
Note: The knowledge required in subd. 1. is typically gained through supervised experience working with persons in the target population.
DHS 105.51(2)(b)
(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.
DHS 105.51(3)
(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.
DHS 105.51(4)
(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).
DHS 105.51(5)
(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:
DHS 105.51(5)(g)
(g) A written record of all monitoring and quality assurance activities; and
DHS 105.51(5)(h)
(h) All pertinent correspondence relating to the recipient's case management.
DHS 105.51(6)(a)(a) Case management services shall be reimbursed when the services are provided by certified providers or their subcontractors to recipients eligible for case management.
DHS 105.51(6)(b)
(b) Payment shall be made to certified providers of case management services according to terms of reimbursement established by the department.
DHS 105.51(7)(a)(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.
DHS 105.51(7)(b)
(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.
DHS 105.51 History
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
DHS 105.52 Prenatal care coordination providers. DHS 105.52(1)(1)
Agency. For MA certification, an agency that provides prenatal care coordination services under s.
DHS 107.34 (1) may be:
DHS 105.52(1)(c)
(c) A county, city, or combined city and county public health agency;
DHS 105.52(2)(a)(a) Definition. In this subsection, “qualified professional" means any of the following:
DHS 105.52(2)(a)1.
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;
DHS 105.52(2)(a)6.
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;
DHS 105.52(2)(a)7.
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;
DHS 105.52(2)(a)8.
8. An employee with at least a bachelor's degree and 2 years of experience in a health care or family services program; or
DHS 105.52(2)(a)9.
9. A health educator with a master's degree in health education and at least 2 years of experience in community health services.
DHS 105.52(2)(b)
(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:
DHS 105.52(2)(b)1.
1. Employ at least one qualified professional with at least 2 years of experience in coordinating services for at-risk or low income women;
DHS 105.52(2)(b)2.
2. Have on staff, under contract or available in a volunteer capacity a qualified professional to supervise risk assessment and ongoing care coordination and monitoring; and
DHS 105.52(2)(b)3.
3. Have on staff, under contract or available in a volunteer capacity one or more qualified professionals with the necessary expertise, based on education or at least one year of work experience, to provide health education and nutrition counseling.
DHS 105.52(3)
(3)
Sufficiency of agency certification. Individuals employed by or under contract with an agency that is certified to provide prenatal care coordination services under this section may provide prenatal care coordination services upon the department's issuance of certification to the agency. The agency shall maintain a list of all persons who provide or supervise the provision of prenatal care coordination services. The list shall include the credentials of each named individual who is qualified to supervise risk assessment and ongoing care coordination under sub.
(2) (b) 2. and to provide health education or nutrition counseling under sub.
(2) (b) 3. Upon the department's request, an agency shall promptly report to the department in writing the names of persons hired to provide prenatal care coordination services under MA and the termination of employees who have been providing prenatal care coordination services under MA.
DHS 105.52(4)
(4)
Administrative records and required documentation. To be certified to provide prenatal care coordination services reimbursable under MA, the prenatal care coordination agency under sub.
(1) shall comply with s.
DHS 106.02 (9) and shall submit a plan to the department documenting:
DHS 105.52(4)(b)
(b) That the agency has a variety of techniques to identify low-income pregnant women;
DHS 105.52(4)(c)
(c) That, at a minimum, the agency has the name, location and telephone number of the following resources in the area to be served:
