DHS 107.13(4)(a)(a) Covered services. Day treatment or day hospital services are covered services when prescribed by a physician, when provided by a provider who meets the requirements of s.
DHS 105.24, and when the following conditions are met:
DHS 107.13(4)(a)1.
1. Before becoming involved in a day treatment program, the recipient is evaluated through the use of the functional assessment scale provided by the department to determine the medical necessity for day treatment and the person's ability to benefit from it;
DHS 107.13(4)(a)2.
2. The supervising psychiatrist approves, signs and dates a written treatment plan for each recipient and reviews and signs the plan no less frequently than once every 60 days. The treatment plan shall be based on the initial evaluation and shall include the individual goals, the treatment modalities including identification of the specific group or groups to be used to achieve these goals and the expected outcome of treatment;
DHS 107.13(4)(a)3.
3. Up to 90 hours of day treatment services in a calendar year may be reimbursed without prior authorization. Psychotherapy services or occupational therapy services provided as component parts of a person's day treatment package may not be billed separately, but shall be billed and reimbursed as part of the day treatment program;
DHS 107.13(4)(a)4.
4. Day treatment or day hospital services provided to recipients with inpatient status in a hospital are limited to 20 hours per inpatient admission and shall only be available to patients scheduled for discharge to prepare them for discharge;
DHS 107.13(4)(a)5.
5. Reimbursement is not made for day treatment services provided in excess of 5 hours in any day or in excess of 120 hours in any month;
DHS 107.13(4)(a)6.
6. Day treatment services are covered only for the chronically mentally ill and acutely mentally ill who have a need for day treatment and an ability to benefit from the service, as measured by the functional assessment scale provided by the department; and
DHS 107.13(4)(a)7.
7. Billing for day treatment is submitted by the provider. Day treatment services shall be billed as such, and not as psychotherapy, occupational therapy or any other service modality.
DHS 107.13(4)(a)8.
8. The groups shall be led by a qualified professional staff member, as defined under s.
DHS 105.24 (1) (b) 4. a., and the staff member shall be present throughout the group sessions and shall perform or direct the service.
DHS 107.13(4)(b)1.1. Providers shall obtain authorization from the department before providing the following services, as a condition for coverage of these services:
DHS 107.13(4)(b)1.a.
a. Day treatment services provided beyond 90 hours of service in a calendar year;
DHS 107.13(4)(b)1.b.
b. All day treatment or day hospital services provided to recipients with inpatient status in a nursing home. Only those patients scheduled for discharge are eligible for day treatment. No more than 40 hours of service in a calendar year may be authorized for a recipient residing in a nursing home;
DHS 107.13(4)(b)1.c.
c. All day treatment services provided to recipients who are concurrently receiving psychotherapy, occupational therapy or AODA services;
DHS 107.13(4)(b)1.d.
d. All day treatment services in excess of 90 hours provided to recipients who are diagnosed as acutely mentally ill.
DHS 107.13(4)(b)2.b.
b. The name, address, and provider number of the provider of the service and of the billing provider;
DHS 107.13(4)(b)2.e.
e. A statement of the estimated additional dates of service necessary and total cost; and
DHS 107.13(4)(b)2.f.
f. The demographic and client information form from the initial and most recent functional assessment. The assessment shall have been conducted within 3 months prior to the authorization request.
DHS 107.13(4)(b)3.
3. The department's decision on a prior authorization request shall be communicated to the provider in writing. If the request is denied, the department shall provide the recipient with a separate notification of the denial.
DHS 107.13(4)(c)1.1. All assessment hours beyond 6 hours in a calendar year shall be considered part of the treatment hours and shall become subject to the relevant prior authorization limits. Day treatment assessment hours shall be considered part of the 6 hour per 2-year mental health evaluation limit.
DHS 107.13(4)(c)2.
2. Reimbursement for day treatment services shall be limited to actual treatment time and may not include time devoted to meals, rest periods, transportation, recreation or entertainment.
DHS 107.13(4)(c)3.
3. Reimbursement for day treatment services shall be limited to no more than 2 series of day treatment services in one calendar year related to separate episodes of acute mental illness. All day treatment services in excess of 90 hours in a calendar year provided to a recipient who is acutely mentally ill shall be prior-authorized.
DHS 107.13(4)(c)4.
4. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub.
(6) or psychosocial services provided through a community-based psychosocial service program under sub.
(7).
DHS 107.13(4)(d)
(d) Non-covered services. The following services are not covered services:
DHS 107.13(4)(d)1.
1. Day treatment services which are primarily recreation-oriented and which are provided in non-medically supervised settings such as 24 hour day camps, or other social service programs. These include sports activities, exercise groups, activities such as craft hours, leisure time, social hours, meal or snack time, trips to community activities and tours;
DHS 107.13(4)(d)2.
2. Day treatment services which are primarily social or educational in nature, in addition to having recreational programming. These shall be considered non-medical services and therefore non-covered services regardless of the age group served;
DHS 107.13(4)(d)3.
3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;
DHS 107.13(4)(d)4.
4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;
DHS 107.13(4)(d)5.
5. Aftercare programs, provided independently or operated by or under contract to boards;
DHS 107.13(4)(d)6.
6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;
DHS 107.13(4)(d)8.
8. Court appearances except when necessary to defend against commitment.
DHS 107.13 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.13(6)(a)(a)
Covered services. Community support program (CSP) services shall be covered services when prescribed by a physician and provided by a provider certified under s.
DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient's independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows:
DHS 107.13(6)(a)1.
1. Initial assessment. At the time of admission, the recipient, upon a psychiatrist's order, shall receive an initial assessment conducted by a psychiatrist and appropriate professional personnel to determine the need for CSP care;
DHS 107.13(6)(a)2.
2. In-depth assessment. Within one month following the recipient's admission to a CSP, a psychiatrist and a treatment team shall perform an in-depth assessment to include all of the following areas:
DHS 107.13(6)(a)3.
3. Treatment plan. A comprehensive written treatment plan shall be developed for each recipient and approved by a psychiatrist. The plan shall be developed by the treatment team with the participation of the recipient or recipient's guardian and, as appropriate, the recipient's family. Based on the initial and in-depth assessments, the treatment plan shall specify short-term and long-term treatment and restorative goals, the services required to meet these goals and the CSP staff or other agencies providing treatment and psychosocial rehabilitation services. The treatment plan shall be reviewed by the psychiatrist and the treatment team at least every 30 days to monitor the recipient's progress and status;
DHS 107.13(6)(a)4.d.
d. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and
DHS 107.13(6)(a)5.a.
a. Employment-related services. These services consist of counseling the recipient to identify behaviors which interfere with seeking and maintaining employment; development of interventions to alleviate problem behaviors; and supportive services to assist the recipient with grooming, personal hygiene, acquiring appropriate work clothing, daily preparation for work, on-the-job support and crisis assistance;
DHS 107.13(6)(a)5.b.
b. Social and recreational skill training. This training consists of group or individual counseling and other activities to facilitate appropriate behaviors, and assistance given the recipient to modify behaviors which interfere with family relationships and making friends;
DHS 107.13(6)(a)5.c.
c. Assistance with and supervision of activities of daily living. These services consist of aiding the recipient in solving everyday problems; assisting the recipient in performing household tasks such as cleaning, cooking, grocery shopping and laundry; assisting the recipient to develop and improve money management skills; and assisting the recipient in using available transportation;
DHS 107.13(6)(a)5.d.
d. Other support services. These services consist of helping the recipient obtain necessary medical, dental, legal and financial services and living accommodations; providing direct assistance to ensure that the recipient obtains necessary government entitlements and services, and counseling the recipient in appropriately relating to neighbors, landlords, medical personnel and other personal contacts; and
DHS 107.13(6)(b)2.
2. An initial assessment shall be reimbursed only when the recipient is first admitted to the CSP and following discharge from a hospital after a short-term stay.
DHS 107.13(6)(b)3.
3. Group therapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group therapy. Mental health technicians shall not be reimbursed for group therapy.
DHS 107.13(6)(b)4.
4. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub.
(7).
DHS 107.13(6)(c)
(c)
Non-covered services. The following CSP services are not covered services:
DHS 107.13(6)(c)2.
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community;
DHS 107.13(6)(c)3.
3. Services related to specific job-seeking, job placement and work activities;
DHS 107.13(7)
(7) Psychosocial services provided through a community-based psychosocial service program. DHS 107.13(7)(a)
(a)
Covered services. Psychosocial services provided through a community-based psychosocial service program shall be covered services when authorized by a mental health professional under s.
DHS 36.15 for recipients determined to have a need for the services under s.
DHS 36.14. These non-institutional services must fall within the definition of “rehabilitative services" under
42 CFR 440.130 (d) and must be described in a service plan under s.
DHS 36.17. Covered services include assessment under s.
DHS 36.16 and service planning and review under s.
DHS 36.17.
DHS 107.13(7)(b)2.
2. Group psychotherapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group psychotherapy. Mental health technicians shall not be reimbursed for group psychotherapy.
DHS 107.13(7)(b)3.
3. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub.
(6).
DHS 107.13(7)(c)
(c)
Non-covered services. The following are not covered services under this subsection:
DHS 107.13(7)(c)2.
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community.
DHS 107.13(7)(c)3.
3. Services performed by volunteers, except that out-of-pocket expenses incurred by volunteers in performing services may be covered.
DHS 107.13(7)(c)4.
4. Services that are not rehabilitative, including services that are primarily recreation-oriented.
DHS 107.13 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (f) 8.,
Register, February, 1988, No. 386, eff. 3-1-88; emerg. cr. (3m), eff. 3-9-89; cr. (3m),
Register, December, 1989, No. 408, eff. 1-1-90; emerg. cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), eff. 1-1-90; cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6),
Register, September, 1990, No. 417, eff. 10-1-90; emerg. r. and recr. (1) (b) 3., am. (1) (f) 6., eff. 1-1-91; am. (1) (a), (b) 1. and 2., (c), (f) 5., 6. and 8., (2) (a) 1., 3. a. and b., 4. f., 6., 7., (b) 1. and 2., (c) 2., (3) (a) (intro.), 4., 5., 7., (b) 1. and 2., (c) 1. (3) (d) 1. and 2., (4) (a) 3. and 6. and (d) 6., r. and recr. (1) (b) 3. and (e), r. (4) (b) 1. d., renum. (4) (b) 1. c. to be d., cr. (2) (c) 6., (3) (c) 3. and 4., (3) (d) 3.,
Register, September, 1991, No. 429, eff. 10-1-91; am. (4) (a) 2., cr. (4) (a) 8.,
Register, February, 1993, No. 446, eff. 3-1-93; corrections in (3) (d) 3. and (3m) (a) 1. made under s. 13.93 (2m) (b) 7., Stats.,
Register February 2002 No. 554; emerg. am. (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7), eff. 7-1-04;
CR 04-025: am (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7)
Register October 2004 No. 586, eff. 11-1-04; corrections in (1) (a), (f) 5., (2) (a) (intro.), 3., (c) 6., (3) (a) (intro.), (c) 3., (d) 3., (3m) (a) (intro.), 1., (b) 3., (4) (a) (intro.), 8., (6) (a) (intro.), (c) 1., (7) (a) and (c) 1. made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 06-080: am. (2) (a) (intro.), 1. (intro.), 3. a., b., 4. a. to f., 6., 7., (b) 1., 4. a. to d., (c) 4., 6. and (d) 2., cr. (2) (a) 1. a. to g. and (2m)
Register May 2009 No. 641, eff. 6-1-09;
CR 14-066: am. (2) (a) (intro.), r. (2) (a) 2., am. (2) (a) 4. (intro.), cr. (2) (a) 4. g., r. (2) (b) 4. b., am. (2) (d) (intro.), 1. to. 4.
Register August 2015 No. 716, eff. 9-1-15;
2019 Wis. Act 1: am. (2) (d) 2.
Register May 2019 No. 761; eff. 6-1-19;
CR 20-039: am. (2) (d) 1.
Register October 2021 No. 790, eff. 11-1-21; correction in (6) (c) 2. made under s. 35.17, Stats.,
Register July 2022 No. 799; correction in (3) (d) 3., (3m) (a) 1. made under s. 13.92 (4) (b) 7., Stats., made under s. 13.92 (4) (b) 7., Stats.,
Register September 2022 No. 801;
CR 22-043: cr. (2) (a) 4. h., am. (2) (a) 5., (b) 4. e., (3) (a) 5., 6., (b) 4. d., (3m) (d) 6., (4) (a) 8., (d) 7.
Register May 2023 No. 809, eff. 6-1-23; correction in (2) (a) 5., (3) (a) 6. made under s. 35.17, Stats.,
Register May 2023 No. 809;
CR 23-046: r. (2) (a) 6., 7., (b), (3) (a) 4., 7., (b) Register April 2024 No. 820, eff. 5-1-24; correction in (2) (a) 5., (3) (a) 6. made under s. 35.17, Stats., Register April 2024 No. 820.
