DHS 107.33DHS 107.33 Ambulatory prenatal services for recipients with presumptive eligibility. DHS 107.33(1)(1) Covered services. Ambulatory prenatal care services are covered services. These services include treatment of conditions or complications that are caused by, exist or are exacerbated by a pregnant woman’s pregnant condition. DHS 107.33(2)(2) Prior authorization. An ambulatory prenatal service may be subject to a prior authorization requirement, when appropriate, as described in this chapter. DHS 107.33(3)(a)(a) Ambulatory prenatal services shall be reimbursed only if the recipient has been determined to have presumptive MA eligibility under s. 49.465, Stats., by a qualified provider under s. DHS 103.11. DHS 107.33 HistoryHistory: Cr. Register, February, 1988, No. 386, eff. 3-1-88; correction in (3) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 107.34DHS 107.34 Prenatal care coordination services. DHS 107.34(1)(a)1.1. Prenatal care coordination services covered by MA are services described in this section that are provided by an agency certified under s. DHS 105.52 or by a qualified person under contract with an agency certified under s. DHS 105.52 to help a recipient and, when appropriate, the recipient’s family gain access to medical, social, educational and other services needed for a successful pregnancy outcome. Nutrition counseling and health education are covered services when medically necessary to ameliorate identified high-risk factors for the pregnancy. In this subdivision,“successful pregnancy outcome” means the birth of a healthy infant to a healthy mother. DHS 107.34(1)(a)2.2. Prenatal care coordination services are available as an MA benefit to recipients who are pregnant, from the beginning of the pregnancy up to the sixty-first day after delivery, and who are at high risk for adverse pregnancy outcomes. In this subdivision, “high risk for adverse pregnancy outcome” means that a pregnant woman requires additional prenatal care services and follow-up because of medical or nonmedical factors, such as psychosocial, behavioral, environmental, educational or nutritional factors that significantly increase her probability of having a low birth weight baby, a preterm birth or other negative birth outcome. “Low birth weight” means a birth weight less than 2500 grams or 5.5 pounds and “preterm birth” means a birth before the gestational age of 37 weeks. The determination of high risk for adverse pregnancy outcome shall be made by use of the risk assessment tool under par. (c). DHS 107.34(1)(b)(b) Outreach. Outreach is a covered prenatal care coordination service. Outreach is activity which involves implementing strategies for identifying and informing low-income pregnant women who otherwise might not be aware of or have access to prenatal care and other pregnancy-related services. DHS 107.34(1)(c)(c) Risk assessment. A risk assessment of a recipient’s pregnancy-related needs is a covered prenatal care coordination service. The assessment shall be performed by an employee of the certified prenatal care coordination agency or by an employee of an agency under contract with the prenatal care coordination agency. The assessment shall be completed in writing and shall be reviewed and finalized in a face-to-face contact with the recipient. All assessments performed shall be reviewed by a qualified professional under s. DHS 105.52 (2) (a). The risk assessment shall be performed with the risk assessment tool developed and approved by the department. DHS 107.34(1)(d)(d) Care planning. Development of an individualized plan of care for a recipient is a covered prenatal care coordination service when performed by a qualified professional as defined in s. DHS 105.52 (2) (a), whether that person is an employee of the agency or under contract with the agency under s. DHS 105.52 (2). The recipient’s individualized written plan of care shall be developed with the recipient. The plan shall identify the recipient’s needs and problems and possible services which will reduce the probability of the recipient having a preterm birth, low birth weight baby or other negative birth outcome. The plan of care shall include all possible needed services regardless of funding source. Services in the plan shall be related to the risk factors identified in the assessment. To the maximum extent possible, the development of a plan of care shall be done in collaboration with the family or other supportive persons. The plan shall be signed by the recipient and the employee responsible for the development of the plan and shall be reviewed and, if necessary, updated by the employee in consultation with the recipient at least every 60 days. Any updating of the plan of care shall be in writing and shall be signed by the recipient. The plan of care shall include: DHS 107.34(1)(d)1.1. Identification and prioritization of all risks found during the assessment, with an attached copy of the risk assessment under par. (c); DHS 107.34(1)(d)2.2. Identification and prioritization of all services to be arranged for the recipient by the care coordinator under par. (e) 2. and the names of the service providers including medical providers; DHS 107.34(1)(d)3.3. Description of the recipient’s informal support system, including collaterals as defined in par. (e) 1., and any activities to strengthen it; DHS 107.34(1)(d)4.4. Identification of individuals who participated in the development of the plan of care; DHS 107.34(1)(d)5.5. Arrangements made for and frequency of the various services to be made available to the recipient and the expected outcome for each service; DHS 107.34(1)(e)1.1. In this paragraph, “collaterals” means anyone who is in direct supportive contact with the recipient during the pregnancy such as a service provider, a family member, the prospective father or any person acting as a parent, a guardian, a medical professional, a housemate, a school representative or a friend. DHS 107.34(1)(e)2.2. Ongoing coordination is a covered prenatal care coordination service when performed by an employee of the agency or person under contract to the agency who serves as care coordinator and who is supervised by the qualified professional required under s. DHS 105.52 (2) (b) 2. The care coordinator shall follow-up the provision of services to ensure that quality service is being provided and shall evaluate whether a particular service is effectively meeting the recipient’s needs as well as the goals and objectives of the care plan. The amount of service provided shall be commensurate with the specific risk factors addressed in the plan of care and the overall level of risk. Ongoing care coordination services include: DHS 107.34(1)(e)2.a.a. Face-to-face and phone contacts with recipients for the purpose of determining if arranged services have been received and are effective. This shall include reassessing needs and revising the written plan of care. Face-to-face and phone contact with collaterals are included for the purposes of mobilizing services and support, advocating on behalf of a specific eligible recipient, informing collateral of client needs and the goals and services specified in the care plan and coordinating services specified in the care plan. Covered contacts also include prenatal care coordination staff time spent on case-specific staffings regarding the needs of a specific recipient. All billed contacts with a recipient or a collateral and staffings related to the recipient shall be documented in the recipient prenatal care coordination file; and DHS 107.34(1)(e)2.b.b. Recordkeeping documentation necessary and sufficient to maintain adequate records of services provided to the recipient. This may include verification of the pregnancy, updating care plans, making notes about the recipient’s compliance with program activities in relation to the care plan, maintaining copies of written correspondence to and for the recipient, noting of all contacts with the recipient and collateral, ascertaining and recording pregnancy outcome including the infant’s birth weight and health status and preparation of required reports. All plan of care management activities shall be documented in the recipient’s record including the date of service, the person contacted, the purpose and result of the contact and the amount of time spent. A care coordination provider shall not bill for recordkeeping activities if there was no client contact during the billable month. DHS 107.34(1)(f)(f) Health education. Health education, either individually or in a group setting, is a covered prenatal care coordination service when provided by an individual who is a qualified professional under s. DHS 105.52 (2) (a) and who by education or at least one year of work experience has the expertise to provide health education. Health education is a covered service if the medical need for it is identified in the risk assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant woman’s identified risk factors in areas including, but not limited to, the following: DHS 107.34(1)(f)4.4. Education and assistance to stop potentially dangerous sexual practices; DHS 107.34(1)(f)5.5. Education on environmental and occupational hazards related to pregnancy; DHS 107.34(1)(g)(g) Nutrition counseling. Nutrition counseling is a covered prenatal care coordination service if provided either individually or in a group setting by an individual who is a qualified professional under s. DHS 105.52 (2) (a) with expertise in nutrition counseling based on education or at least one year of work experience. Nutrition counseling is a covered prenatal care coordination service if the medical need for it is identified in the risk assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant woman’s identified risk factors in areas including, but not limited to, the following: DHS 107.34(2)(a)(a) Reimbursement for risk assessment and development of a care plan shall be limited to no more than one each for a recipient per pregnancy. DHS 107.34(2)(b)(b) Reimbursement of a provider for on-going prenatal care coordination and health education and nutrition counseling provided to a recipient shall be limited to one claim for each recipient per month and only if the provider has had contact with the recipient during the month for which services are billed. DHS 107.34(2)(c)(c) Prenatal care coordination is available to a recipient residing in an intermediate care facility or skilled nursing facility or as an inpatient in a hospital only to the extent that it is not included in the usual reimbursement to the facility. DHS 107.34(2)(d)(d) Reimbursement of a provider for prenatal care coordination services provided to a recipient after delivery shall only be made if that provider provided prenatal care coordination services to that recipient before the delivery. DHS 107.34(2)(e)(e) A prenatal care coordination service provider shall not terminate provision of services to a recipient it has agreed to provide services for during the recipient’s pregnancy unless the recipient initiates or agrees to the termination. If services are terminated prior to delivery of the child, the termination shall be documented in writing and the recipient shall sign the statement to indicate agreement. If the provider cannot contact a recipient in order to obtain a signature for the termination of services, the provider will document all attempts to contact the recipient through telephone logs and certified mail. DHS 107.34(2)(f)(f) Reimbursement for prenatal care coordination services shall be limited to a maximum amount per pregnancy as established by the department. DHS 107.34(3)(3) Non-covered services. Services not covered as prenatal care coordination services are the following: DHS 107.34(3)(a)4.4. Any other professional service, except nutrition counseling or health education, which is a covered service by an MA certified or certifiable provider under this chapter; DHS 107.34(3)(d)(d) Care monitoring, nutrition counseling or health education not based on a plan of care; DHS 107.34(3)(e)(e) Care monitoring, nutrition counseling or health education which is not reasonable and necessary to ameliorate identified prenatal risk factors; and DHS 107.34 HistoryHistory: Cr. Register, June, 1994, No. 462, eff. 7-1-94; corrections in (1) (a) 1., (c), (d) (intro.), (e) 2. (intro.), (f) (intro.) and (g) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 107.36(1)(a)1.1. School-based services covered by the MA program are services described in this section that are provided by a school district or CESA. DHS 107.36(1)(a)2.2. The school district or CESA shall ensure that individuals who deliver the services, whether employed directly by or under contract with the school district or CESA, are licensed under ch. PI 34, Trans 301 or ch. 441, Stats. DHS 107.36(1)(a)3.3. Notwithstanding s. DHS 106.13 (intro.) and (1) (c), requirements under chs. DHS 101 to 108 as they relate to school-based services, to the extent consistent with 42 CFR ch. IV, may be waived if they are inconsistent with other federal education mandates. DHS 107.36(1)(a)4.4. Consultation, case monitoring and coordination related to developmental testing under the individuals with disabilities education act, 20 USC 1400 to 1485, are included in the MA-covered services described in this subsection when an IEP results from the testing. Consultation, case monitoring and coordination for IEP services are also included in the covered services described in this subsection. DHS 107.36(1)(b)(b) Speech, language, hearing and audiological services. Speech, language, hearing and audiological services for a recipient with a speech, language or hearing disorder that adversely affects the individual’s functioning are covered school-based services. These services include evaluation and testing to determine the individual’s need for the service, recommendations for a course of treatment and treatment. The services may be delivered to an individual or to a group of 2 to 7 individuals. The services shall be performed by or under the direction of a speech and language pathologist licensed by the department of public instruction under s. PI 34.0475 or by an audiologist licensed by the department of public instruction under s. PI 34.090, and shall be identified in the recipient’s IEP. DHS 107.36(1)(c)(c) Occupational therapy services. Occupational therapy services which identify, treat, or compensate for medical problems that interfere with age-appropriate functional performance are covered school-based services. These services include evaluation to determine the individual’s need for occupational therapy, recommendations for a course of treatment, and rehabilitative, active or restorative treatment services. The services may be delivered to an individual or to a group of 2 to 7 individuals. The services shall be performed by or under the direction of an occupational therapist licensed by the department of public instruction under s. PI 34.091 and shall be identified in the recipient’s IEP. DHS 107.36(1)(d)(d) Physical therapy services. Physical therapy services which identify, treat, or compensate for medical problems are covered school-based services. These services include evaluation to determine the individual’s need for physical therapy, recommendations for a course of treatment, and therapeutic exercises and rehabilitative procedures. The services may be delivered to an individual or to a group of 2 to 7 individuals. The services shall be performed by or under the direction of a physical therapist licensed by the department of public instruction under s. PI 34.093 and shall be prescribed by a physician when required by the physical therapists affiliated credentialing board and identified in the recipient’s IEP. DHS 107.36(1)(e)(e) Nursing services. Professional nursing services relevant to the recipient’s medical needs are covered school-based services. These services include evaluation and management services, including screens and referrals for treatment of health needs; treatment; medication management; and explanations given of treatments, therapies and physical or mental conditions to family members or school district or CESA staff. The services shall be performed by a registered nurse licensed under s. 441.06, Stats., or a licensed practical nurse licensed under s. 441.10, Stats., or be delegated under nursing protocols pursuant to ch. N 6. The services shall be prescribed or referred by a physician or an advanced practice nurse as defined under s. N 8.02 (1) with prescribing authority granted under s. 441.16 (2), Stats., and shall be identified in the recipient’s IEP. DHS 107.36(1)(f)(f) Psychological counseling and social work services. Psychological counseling and social work services relevant to the recipient’s mental health needs with the intent to reasonably improve the recipient’s functioning are covered school-based services. These services include testing, assessment and evaluation that appraise cognitive, emotional and social functioning and self-concept; therapy or treatment that plans, manages and provides a program of psychological counseling or social work services to individuals with psychological or behavioral problems; and crisis intervention. The services may be delivered to an individual or to a group of 2 to 10 individuals. The services shall be performed by a school psychologist, school counselor or school social worker licensed by the department of public instruction under ch. PI 34. The services shall be identified in the individual’s IEP. DHS 107.36(1)(g)(g) Developmental testing and assessments under IDEA. Developmental testing and assessments under the individuals with disabilities education act (IDEA), 20 USC 1400 to 1485, are covered school–based services when an IEP results. These services include evaluations, tests and related activities that are performed to determine if motor, speech, language or psychological problems exist, or to detect developmental lags for the determination of eligibility under IDEA. The services are also covered when performed by a therapist, psychologist, social worker, counselor or nurse licensed by the department of public instruction under ch. PI 34, as part of their respective duties. DHS 107.36(1)(h)(h) Transportation. Transportation services provided to individuals who require special transportation accommodations are covered school–based services if the recipient receives a school–based service other than transportation on the day transportation is provided. These services include transportation from the recipient’s home to and from school on the same day if the school–based service is provided in the school, and transportation from school to a service site and back to school or home if the school–based service is provided at a non–school location, such as at a hospital. Transportation shall be performed by a school district, CESA or contracted provider. The service shall be included in the IEP. The covered service that the recipient is transported to and from shall meet MA requirements for that service under ch. DHS 105 and this chapter. DHS 107.36(1)(i)(i) Durable medical equipment. Durable medical equipment except equipment covered in s. DHS 107.24 is a covered service if the need for the equipment is identified in the recipient’s IEP, the equipment is recipient-specific, the equipment is not duplicative of equipment the recipient currently owns and the equipment is for the recipient’s use at school and home. Only durable medical equipment related to speech-language pathology, physical therapy or occupational therapy will be covered under the school based services benefit. The recipient, not the school district or the CESA, shall own the equipment. DHS 107.36(2)(a)(a) Age limit. School-based services may only be provided to MA-eligible recipients between 3 and 21 years of age, or for the school term during which an MA-eligible recipient becomes 21 years of age. DHS 107.36(2)(b)(b) Medically necessary. School-based services shall be medically necessary. In this paragraph “medically necessary” has the meaning prescribed in s. DHS 101.03 (96m) and in addition means services that: DHS 107.36(2)(b)1.1. Identify, treat, manage or address a medical problem or a mental, emotional or physical disability; DHS 107.36(2)(b)4.4. Are referred or prescribed by a physician or advanced practice nurse, as defined under s. N 8.02 (1), with prescribing authority granted under s. 441.16 (2), Stats., where appropriate, or a psychologist, where appropriate. DHS 107.36(3)(3) Non-covered services. Services not covered as school-based services are the following: DHS 107.36(3)(b)(b) Services that are strictly educational, vocational or pre-vocational in nature, or that are otherwise without a defined medical component;
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