Wisconsin Legislature: DHS 107.24(4)(c)2.a.

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EmR2421

(f) Purchase of any item which is not covered by Medicare, part b, when prescribed for a recipient who is also eligible for Medicare.

(g) Any item required by a recipient in a nursing home which meets the requirements of sub. (4) (c).

(h) Purchase or rental of a hearing aid or other assistive listening device in any of the following circumstances:

1. A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient’s physician and an audiological report from an audiologist or hearing instrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing instrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines all of the following:

a. The recipient is over the age of 21.

b. The recipient is not cognitively or behaviorally impaired.

c. The recipient has no special need which would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist.

2. After a new or replacement hearing aid or other ALD has been worn for a 30-day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing instrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient.

3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization.

4. Provision of services in excess of the life expectancies of equipment enumerated in the MA speech and hearing provider handbook require prior authorization, except for hearing aid or other ALD batteries and repair services.

(i) A request for prior authorization of complex rehabilitation manual wheelchairs, complex rehabilitation power wheelchairs, and other complex rehabilitation seating components shall be reviewed only if the request consists of all of the following:

1. Documentation of a complex rehabilitative technology clinical evaluation performed by a qualified health care professional that includes all of the following:

a. A detailed description of the qualified health care professional’s assessment as outlined in the provider handbook including identification of the specific complex rehabilitation technology items requested.

b. A detailed description of the medical necessity as defined in ss. DHS 101.03 (96m) and 107.02 (3) (e), for each complex rehabilitation technology request.

c. The qualified health care professional’s signature and date of completion.

2. Documentation stating that a direct, on-premises complex rehabilitation technology evaluation was performed by a qualified complex rehabilitation technology professional that includes all of the following:

a. A detailed description of the recipient’s current durable medical equipment and requested complex rehabilitation technology items, the projected lifespan of both, the accessibility of the setting in which the requested items are to be used, the recipient’s applicable methods of transportation, and an analysis of at least one comparable alternative to each requested item including an explanation of why the alternative does not meet the recipient’s needs.

b. A statement asserting that the qualified complex rehabilitation technology professional will provide appropriate training to the recipient and will maintain adequate documentation of the training provided.

c. A statement indicating presence at the recipient’s complex rehabilitation technology clinical evaluation or other coordination with the qualified health care provider conducting the complex rehabilitation clinical evaluation to assist in selection of the most appropriate complex rehabilitation technology item.

d. The qualified complex rehabilitation technology professional’s signature and date of completion.

3. A signed statement from each qualified health care professional, who performs the complex rehabilitation technology clinical evaluation, providing documentation of a complex rehabilitation technology clinical evaluation in subd. 1. indicating he or she does not have a financial relationship with the complex rehabilitation technology supplier providing the requested items.

(j) A request for prior authorization of all complex rehabilitation technology not included in par. (i) shall be reviewed only if the request complies with MA policy and procedures as described in MA provider handbooks and bulletins and includes a detailed description of the medical necessity, as defined in s. DHS 101.03 (96m), of the complex rehabilitation technology requested.

Note: For more information on prior authorization, see s. DHS 107.02 (3).

(4) Other limitations.

(a) Payment for medical supplies ordered for a patient in a medical institution is considered part of the institution’s cost and may not be billed directly to the program by a provider. Durable medical equipment and medical supplies provided to a hospital inpatient to take home on the date of discharge are reimbursed as part of the inpatient hospital services. No recipient may be held responsible for charges or services in excess of MA coverage under this paragraph.

(b) Prescriptions shall be provided in accordance with s. DHS 107.02 (2m) (b) and may not be filled more than one year from the date the medical equipment or supply is ordered.

1. Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters.

2. Durable medical equipment which is personalized in nature or custom-made for a recipient and is to be used by the recipient on an individual basis for hygienic or other reasons. These items are orthoses, prostheses including hearing aids or other assistive listening devices, orthopedic or corrective shoes, and complex rehabilitation technology. For coverage and reimbursement complex rehabilitation technology shall be prescribed by a physician, require prior authorization to establish medically necessity, and meet all complex rehabilitation standards under sub. (3) (i). In order to be covered for a recipient who is a nursing home resident, the complex rehabilitation technology shall do at least one of the following:

a. Contribute to the recipient’s independent completion of activities of daily living.

b. Support the recipient’s occupational, vocational, or psychosocial activities.

c. Provide the recipient the independent ability to move about the facility, or to attain or retain self-care.

(d) The provider shall weigh the costs and benefits of the equipment and supplies when considering purchase or rental of DME and medical supplies.

Note: The program’s listing of covered services and the maximum allowable reimbursement schedules are based on basic necessity. Although the program does not intend to exclude any manufacturer of equipment, reimbursement is based on the cost-benefit of equipment when comparable equipment is marketed at less cost. Several medical supply items are reimbursed according to generic pricing.

(e) The department may determine whether an item is to be rented or purchased on behalf of a recipient. In most cases equipment shall be purchased; however, in those cases where short-term use only is needed or the recipient’s prognosis is poor, only rental of equipment shall be authorized.

(f) Orthopedic or corrective shoes or foot orthoses shall be provided only for postsurgery conditions, gross deformities, or when attached to a brace or bar. These conditions shall be described in the prior authorization request.

(g) Provision of hearing aid accessories shall be limited as follows:

1. For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;

2. For recipients over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per recipient per year; and

3. For all recipients: one harness, one contralateral routing of signals (CROS) fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per recipient per year.

(h) If a prior authorization request is approved, the person shall be eligible for MA reimbursement for the service on the date the final ear mold is taken.

(i) Reimbursement for complex rehabilitation technology is limited to qualified complex rehabilitation technology suppliers.

(j) The cost of mailing or delivery, such as shipping and handling charges and fees, of diagnostic tools or equipment needed to assess, diagnose, repair or setup medical supplies, hearing aids, cochlear implants, or other equipment cannot be billed to the recipient.

(5) Non-covered services. The following services are not covered services:

(a) Foot orthoses or orthopedic or corrective shoes for the following conditions:

1. Flattened arches, regardless of the underlying pathology;

2. Incomplete dislocation or subluxation metatarsalgia with no associated deformities;

3. Arthritis with no associated deformities; and

4. Hypoallergenic conditions;

(b) Services denied by both Medicare and MA for lack of medical necessity.

(d) Items which are not appropriate for home usage, such as oscillating beds;

(e) Items which are not generally accepted by the medical profession as being therapeutically effective, such as a heat and massage foam cushion pad;

(f) Items which are for comfort and convenience, such as cushion lift power seats or elevators, or luxury features which do not contribute to the improvement of the recipient’s medical condition;

(g) Repair, maintenance or modification of rented durable medical equipment;

(h) Delivery or set-up charges for equipment as a separate service;

(i) Fitting, adapting, adjusting or modifying a prosthetic or orthotic device or corrective or orthopedic shoes as a separate service;

(j) All repairs of a hearing aid or other assistive listening device performed by a dealer within 12 months after the purchase of the hearing aid or other assistive listening device. These are included in the purchase payment and are not separately reimbursable;

(k) Hearing aid or other assistive listening device batteries which are provided in excess of the guidelines enumerated in the MA speech and hearing provider handbook;

(L) Items that are provided for the purpose of enhancing the prospects of fertility in males or females;

(m) Impotence devices, including but not limited to penile prostheses;

(n) Testicular prosthesis;

(o) Food; and

(p) Infant formula and enteral nutritional products except as allowed under s. DHS 107.10 (2) (c).

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (3) (h) 1. and 2., eff. 7-1-89; am. (2) (d) 6., (3) (e), (h) 4., (4) (c) 2., (5) (j) and (k), r. and recr. (3) (h) (intro.), 1. and 2. and (4) (g), cr. (4) (h), Register, May, 1990, No. 413, eff. 6-1-90; r. and recr. (4) (a), Register, September, 1991, No. 429, eff. 10-1-91; am. (5) (j) to (k), cr. (5) (L) to (p), Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (b) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; CR 03-033: am. (2) (a), (3) (h) 1. (intro.), 2., and (5) (j) Register December 2003 No. 576, eff. 1-1-04; CR 20-012: renum. (1) to (1) (intro.) and am., cr. (1) (b), am. (2) (a), cr. (2) (a) 2., am. (2) (c) 1., 4., 6., cr. (2) (c) 9., am. (3) (intro.), (a) to (g), (h) 1. to 3., cr. (3) (i), (j), (4) (i), am. (5) (b) Register October 2021 No. 790, eff. 11-1-21; correction in (3) (g) made under s. 35.17, Stats., Register October 2021 No. 790; CR 20-039: am. (2) (c) 1., 4. to 6. Register October 2021 No. 790, eff. 11-1-21; merger of (2) (c) 1., 4., 6. treatments by CR 20-012 and CR 20-039 made under s. 13.92 (4) (bm), Stats., Register October 2021 No. 790; correction in (2) (a) 1. made under s. 35.17, Stats., Register December 2021, No. 792; CR 22-043: Register May 2023 No. 809, eff. 6-1-23; CR 23-005: am. (4) (c) 1., renum. (4) (c) 2. to (4) (c) 2. (intro.) and am., cr. (4) (c) 2. a. to c., r. (4) (c) 3. Register April 2024 No. 820, eff. 5-1-24; merger of (2) (c) 1., 4., 6. treatments by CR 20-012 and CR 23-046 and merger of (2) (c) 1., 4. to 6. treatments by CR 20-012, CR 20-039, and CR 23-046 made under s. 13.92 (4) (bm), Stats., Register April 2024 No. 820.

DHS 107.25 Diagnostic testing services.

(1) Covered services. Professional and technical diagnostic services covered by MA are laboratory services provided by a certified physician or under the physician’s supervision, or prescribed by a physician and provided by an independent certified laboratory, and x-ray services prescribed by a physician and provided by or under the general supervision of a certified physician.

(2) Other limitations.

(a) All diagnostic services shall be prescribed or ordered by a physician or dentist.

(b) Laboratory tests performed which are outside the laboratory’s certified areas are not covered.

(c) Portable x-ray services are covered only for recipients who reside in nursing homes and only when provided in a nursing home.

(d) Reimbursement for diagnostic testing services shall be in accordance with limitations set by P.L. 98-369, Sec. 2303.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 107.26 Dialysis services. Dialysis services are covered services when provided by facilities certified pursuant to s. DHS 105.45.

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

DHS 107.27 Blood. The provision of blood is a covered service when provided to a recipient by a physician certified pursuant to s. DHS 105.05, a blood bank certified pursuant to s. DHS 105.46 or a hospital certified pursuant to s. DHS 105.07.

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

DHS 107.28 Health maintenance organization and prepaid health plan services.

(1) Covered services.

(a) HMOs.

1. Except as provided in subd. 2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covered services at the time the medicaid HMO contract becomes effective with the exception of the following:

a. EPSDT outreach services;

b. County transportation by common carrier;

c. Dental services; and

d. Chiropractic services.

2. The department may permit an HMO to provide less than comprehensive coverage, but only if there is adequate justification and only if commitment is expressed by the HMO to progress to comprehensive coverage.

(b) Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.

(c) Family care benefit. A care management organization under contract with the department to provide the family care benefit under s. DHS 10.41 shall provide those MA services specified in its contract with the department and shall meet all applicable requirements under ch. DHS 10.

(2) Contracts. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall: