Wisconsin Legislature: subch. I of ch. DHS 109

DHS 109.11 Application and determining eligibility.

DHS 109.12 Calculation of eligible benefits and services.

DHS 109.13 SeniorCare benefits and services.

DHS 109.14 SeniorCare benefit period.

DHS 109.15 Treatment of spouses.

DHS 109.16 Fees.

DHS 109.17 Applicant appeals.

Subchapter III — Drug Benefits

DHS 109.31 Covered drugs and limitations on coverage.

DHS 109.32 Coverage while out-of-state.

Subchapter IV — Program Integrity

DHS 109.41 Annual report to legislature.

DHS 109.42 Prohibition on fraud.

Subchapter V — Provider Rights and Responsibilities

DHS 109.51 Provider responsibility.

DHS 109.52 Provider certification.

DHS 109.53 Department recovery of overpayments from SeniorCare providers.

DHS 109.54 Incorporation of Medicaid standards.

Subchapter VI — Participant Rights and Responsibilities

DHS 109.61 Participant duties.

DHS 109.62 Recovery of incorrect payments from participants.

DHS 109.63 Participant appeals.

Subchapter VII — Program Administration

DHS 109.71 Rebate agreement.

DHS 109.72 Payment for drugs.

DHS 109.73 Program suspension.

DHS 109.74 Safeguarded information.

Note: Chapter HFS 109 was created as an emergency rule effective September 1, 2002. Chapter HFS 109 was renumbered to chapter DHS 109 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

Subchapter I — General Provisions

DHS 109.01 Authority and purpose. This chapter is promulgated under the authority of ss. 49.688 and 227.11 (2), Stats., to implement a program called SeniorCare that is designed to provide prescription drug assistance for Wisconsin residents aged 65 years or older and who meet the program’s eligibility criteria. The chapter does all of the following:

(1) Establishes the application process for SeniorCare.

(2) Describes how the department will determine eligibility for SeniorCare benefits and services.

(3) Identifies SeniorCare benefits, services and fees.

(4) Establishes requirements of SeniorCare participants and providers.

(5) Identifies the applicability of other department rules.

History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.02 Applicability. This chapter applies to all of the following:

(1) The department.

(2) All persons applying to receive SeniorCare benefits and services.

(3) All persons found eligible to receive SeniorCare benefits and services.

(4) All persons prescribing or providing drugs to SeniorCare participants.

(5) All drug manufacturers who sell drugs for prescribed use in Wisconsin by SeniorCare participants.

History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.03 Definitions. Unless otherwise defined in this chapter, the definitions in s. DHS 101.03 apply to this chapter. In addition, in this chapter:

(1) “Deductible benefits and services” means both of the following:

(a) The prescription drugs which may be purchased by a SeniorCare participant with income over 160% of the poverty line for amounts no greater than the program payment rate.

(b) The department’s tracking of prescription drug purchases by a SeniorCare participant with income over 160% of the poverty line so SeniorCare providers know when the participant may receive the SeniorCare prescription benefit.

(2) “Department” means the department of health services, or its agent.

(3) “Fiscal test group” means the person or persons in a household whose income and need is included in determining which SeniorCare benefits or services an applicant may receive.

(4) “Generic name” has the meaning given in s. 450.12 (1) (b), Stats.

(5) “Innovator multiple-source drug” means a multiple source drug that was originally marketed under an original new drug application approved by the U.S. food and drug administration.

(6) “Lock-in provider” means a single, SeniorCare-certified provider, selected by the participant or designated by the department in the event the participant is unwilling or unable to identify a provider, who is responsible for either personally providing all non-emergency care received by the participant under the MA program, or referring the participant to a specific provider for such needed non-emergency care.

(7) “Participant” means a person who has applied for SeniorCare and meets the eligibility criteria under s. DHS 109.11 (1) and may receive benefits and services during the benefit period under s. DHS 109.14.

(8) “Pharmacist” has the meaning given in s. 450.01 (15), Stats.

(9) “Prescription benefit” means the prescription drugs that may be purchased with a $5 or $15 payment by a SeniorCare participant with low income or who has spent at least the dollar amount specified in s. DHS 109.13 (3) on the purchase of prescription drugs during the current benefit period.

(10) “Prescription drug” or “drug” means any of the following:

(a) A drug under s. 450.01 (20), Stats., that is included in the drugs specified under s. 49.46 (2) (b) 6. h., Stats., and s. DHS 109.31 and is manufactured by a drug manufacturer that enters into a rebate agreement in force under s. DHS 109.71.

(b) A vaccine recommended and approved for administration to adults by the federal centers for disease control and prevention’s advisory committee on immunization practices.

(11) “Prescription order” has the meaning given in s. 450.01 (21), Stats.

(12) “Program payment rate” means the rate of payment made for the identical drug specified under s. 49.46 (2) (b) 6. h., Stats., plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h., Stats.

(13) “Retail price” means the provider’s charge for providing the same service to private paying customers.

(14) “SeniorCare” means the program of prescription drug assistance for eligible elderly persons under s. 49.688, Stats.

(15) “SeniorCare provider” means an MA certified pharmacist, pharmacy or dispensing physician.

(16) “Spend-down” means the amount of money a SeniorCare participant must spend on prescription drugs before the participant becomes eligible for SeniorCare deductible and copayment benefits and services.

(17) “Spend-down services” means the department’s monitoring of participant prescription drug purchases to determine when the participant’s SeniorCare fiscal test group’s purchases have equaled the difference between the fiscal test group’s annual income and 240% of the poverty line for a family the size of the fiscal test group.

(18) “U.S. national” means any of the following:

(a) A person born in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), America Samoa, Swain’s Island or the Northern Mariana Islands.

(b) A person born outside of the United States to at least one U.S. citizen parent.

History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (9) Register October 2004 No. 586, eff. 11-1-04; corrections in (intro.) and (2) made under s. 13.92 (4) (b) 6. and 7., Stats., Register December 2008 No. 636; CR 20-039: am. (12) Register October 2021 No. 790, eff. 11-1-21; CR 22-046: renum. (10) to (10) (intro.) and am., cr. (10) (a), (b) Register June 2023 No. 810, eff. 7-1-23.

Subchapter II — Eligibility for SeniorCare Benefits and Services

DHS 109.11 Application and determining eligibility.

(1) Conditions for eligibility. A person who meets all of the following requirements shall be eligible for SeniorCare and shall be issued a prescription drug card for use in purchasing prescription drugs:

(a) The person is a resident of the state of Wisconsin as defined in s. 27.01 (10) (a), Stats. The temporary absence of a resident from the state shall not be grounds for denying or terminating SeniorCare eligibility unless another state has determined the person is a resident in the other state for purposes of medical assistance.

(b) The person is at least 65 years of age.

(c) The person is not a recipient of medical assistance, or as a recipient, does not receive prescription drug coverage. Persons who only receive Medicare buy-in benefits under s. 49.468, Stats., 42 USC 1396a(a)(10)(E), or 42 USC 1396u-3, are not considered a medical assistance recipient under this chapter.

(d) The person pays the program enrollment fee specified in s. DHS 109.16.

(e)

1. Except as provided in subd. 2., the person requesting SeniorCare benefits has a social security number and furnishes the number to the department.

a. If an applicant does not have a social security number, the applicant or a person acting on behalf of the applicant shall apply to the federal social security administration for a number. The department may not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual’s social security number.

b. If the applicant or a person acting on behalf of an applicant refuses to furnish a number or apply for a number, the applicant shall be ineligible for SeniorCare.

(f) The person is a U.S. national or an alien legally residing in the U.S. and whose status qualifies them for medical assistance under 8 USC 1611 through 8 USC 1613, except that an alien whose status would qualify them only for emergency medical assistance benefits under 42 USC 1396b(v)(3) is not eligible for SeniorCare.

(g) The applicant, participant, or person described in sub. (2) (d) who is acting on behalf of the applicant or participant provides correct and truthful information as specified under sub. (2) (c).

(h) The person is not an inmate of a public institution as defined in 42 CFR 435.1009.

(2) Application for SeniorCare. Application for SeniorCare shall be made pursuant to s. 49.688, Stats., and this chapter. Applications shall be made and reviewed by the department in accordance with the following provisions:

(a) Right to apply. Any person may apply to the department for SeniorCare on a form prescribed by the department.

Note: Application forms for SeniorCare are widely available through various local agencies. A copy of the application form is also available at the Department’s Internet web site at: http://dhs.wisconsin.gov.