Chapter DHS 109

DHS 109.13(4) (4) Spend-down services.

DHS 109.13(4)(a) (a) Income category applicability.

DHS 109.13(4)(a)1. 1. A person may receive the SeniorCare spend-down services under this subsection when he or she is in a fiscal test group with an annual income that exceeds 240% of the poverty line for a family the size of the fiscal test group.

DHS 109.13(4)(a)2. 2. The department shall maintain an accounting of the prescription drug purchases of each person receiving the SeniorCare spend-down services and shall inform participating SeniorCare providers when he or she has met the spend-down within the benefit period as described in par. (c).

DHS 109.13(4)(b) (b) Amount. The amount of a person’s SeniorCare spend-down is the difference between the SeniorCare fiscal test group’s annual income and 240% of the poverty line for a family the size of the fiscal test group.

DHS 109.13(4)(c) (c) Meeting a spend-down. A SeniorCare spend-down shall be met and the person’s subsequent prescription purchases shall count toward meeting the deductible under sub. (3) (c) and (d) when the member or members of the fiscal test group, under the following conditions, have spent the amount of the spend-down in purchasing prescription drugs at the retail price:

DHS 109.13(4)(c)1. 1. When only one person is an eligible member of the SeniorCare fiscal test group in a calendar month, only purchases of prescription drugs prescribed for that person may be counted toward meeting the spend-down in that calendar month.

DHS 109.13(4)(c)2. 2. When 2 spouses are both eligible members of the same SeniorCare fiscal test group in a calendar month, purchases of prescription drugs prescribed for either person may be counted toward meeting the spend-down in that month.

DHS 109.13(4)(c)3. 3. Only prescription drugs dispensed with a date of service during the benefit period described in s. DHS 109.14 may count toward meeting the spend-down.

DHS 109.13(4)(c)4. 4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person’s other available coverage may be counted toward meeting the spend-down.

DHS 109.13(4)(c)5. 5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied to meeting the spend-down.

DHS 109.13(4)(c)6. 6. Only claims submitted by a SeniorCare provider may be considered in determining whether the participant has met the spend-down.

DHS 109.13(4)(d) (d) Carryover of spend-down. When the cost of a prescription applied towards meeting the spend-down under par. (c) exceeds the remaining spend-down amount, the excess prescription costs shall be applied towards meeting the deductible under sub. (3) (d). The program payment rate may not apply to that portion of the prescription counted for the deductible.

DHS 109.13(5) (5) Review of benefits. After the department learns of an error or omission in the information on the application form or other information provided by the recipient used to determine the benefits and services, the department shall promptly redetermine which SeniorCare benefits and services a participant may receive under this section. The benefits and services may only be changed if the error or omission is of factual information available to the recipient at the time he or she filed the application.

DHS 109.13(6) (6) Correction of benefits. The department shall correct in the following ways the benefits and services received in error under this section:

DHS 109.13(6)(a) (a) For underpayment errors caused by the department, benefits will be corrected back to the beginning of the benefit period.

DHS 109.13(6)(b) (b) For underpayment errors caused by the recipient when the recipient reports the error within 45 days after the date of the initial eligibility notice, benefits will be corrected back to the beginning of the benefit period.

DHS 109.13(6)(c) (c) For underpayment errors caused by the recipient when the recipient reports the error more than 45 days after the date of the initial eligibility notice, benefits will be corrected back to the first of the month in which the error was reported.

DHS 109.13(6)(d) (d) For overpayment errors, benefits will be corrected beginning the first of the month following the issuance by the department of a timely notice of decision under s. DHS 109.11 (5) (b). Recovery of benefits issued in error shall be in accordance with s. DHS 109.62.

DHS 109.13 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (3) (c) and (d) (intro) and 2. Register October 2004 No. 586, eff. 11-1-04; CR 22-046: cr. (2) (bm), am. (2) (c) (title), cr. (2) (d), (e) Register June 2023 No. 810, eff. 7-1-23; correction in (2) (d) (intro.), 1. made under s. 35.17, Stats., Register June 2023 No. 810.

DHS 109.14 DHS 109.14 SeniorCare benefit period.

DHS 109.14(1) (1) Duration. Except as provided in subs. (3) to (5), and in s. DHS 109.15 and s. 49.688 (7) (a), Stats., the benefit period for SeniorCare eligibility shall be 12 consecutive calendar months.

DHS 109.14(2) (2) Eligibility begin date. Except as provided in sub. (3), a person’s SeniorCare eligibility begins on the first day of the month after the date the department receives a complete application and the person meets all of the eligibility requirements.

DHS 109.14(3) (3) Exception for medicaid recipients. If the department receives a complete application and determines that the person meets all other eligibility requirements prior to the date medical assistance eligibility ends, the person’s SeniorCare eligibility begins the day after the person’s medical assistance eligibility ends.

DHS 109.14(4) (4) Termination of SeniorCare benefit period.

DHS 109.14(4)(a) (a) Except as provided in sub. (5), the department shall terminate the SeniorCare benefit period of a SeniorCare participant who no longer meets the eligibility conditions in s. DHS 109.11, or who requests a withdrawal from the program under s. DHS 109.11 (5) (d).

DHS 109.14(4)(b) (b) The department shall restore the SeniorCare benefit period for a person terminated from SeniorCare without a break in coverage if, within one calendar month of the effective termination date, he or she does both of the following:

DHS 109.14(4)(b)1. 1. Meets all of the eligibility criteria under s. DHS 109.11.

DHS 109.14(4)(b)2. 2. Notifies the department of the change in circumstances.

DHS 109.14(4)(c) (c) The department shall reinstate the SeniorCare benefit period for a person who has requested a withdrawal from the program under s. DHS 109.11 (5) (d) if within 30 calendar days of the effective date of the withdrawal both of the following occur:

DHS 109.14(4)(c)1. 1. The department receives the person’s request to have SeniorCare benefits restored.

DHS 109.14(4)(c)2. 2. The person meets all of the eligibility criteria under s. DHS 109.11, including a new payment of the program enrollment fee specified in s. DHS 109.16 for persons who were issued a refund under s. DHS 109.11 (5) (d) 1.

DHS 109.14(5) (5) Continuation of benefit period for medical assistance recipients. The department may not terminate the benefit period of SeniorCare participants who lose eligibility solely due to receipt of medical assistance benefits. A SeniorCare participant is not eligible for any SeniorCare benefits or services under s. DHS 109.13 for any calendar months in which he or she receives medical assistance benefits.

DHS 109.14(6) (6) Request for new benefit period. A SeniorCare participant may request a new benefit period for SeniorCare at any time. Upon receipt of a new application, the department shall determine the participant’s eligibility for a new benefit period in the following manner unless the application is from the spouse of a participant and meets the conditions under s. DHS 109.15:

DHS 109.14(6)(a) (a) The person shall submit a new application as required under s. DHS 109.11.

DHS 109.14(6)(b) (b) The department shall redetermine eligibility when the request for a new benefit period is made beginning with the date a new complete application is received.

DHS 109.14(6)(c) (c) The department shall redetermine annual income for a 12-month period beginning with the date a new complete application is received.

DHS 109.14(6)(d) (d) The department shall redetermine which benefits and services under s. DHS 109.13 the applicant may receive.

DHS 109.14(6)(e) (e) The participant may withdraw the request for a new benefit period as allowed under s. DHS 109.11 (5).

DHS 109.14(6)(f) (f) Eligibility for the new benefit period shall begin on the first day of the month after the date a new complete application is received and all the eligibility requirements are met, including payment of a new enrollment fee specified in s. DHS 109.16.

DHS 109.14(6)(g) (g) Prescription drug costs that had been applied to a spend-down or deductible in a previous benefit period may not apply to the new benefit period.

DHS 109.14(6)(h) (h) Notwithstanding s. DHS 109.15, if a person eligible for SeniorCare requests a new benefit period at the same time the person’s spouse applies for SeniorCare or requests a new benefit period, eligibility shall be determined under this section.

DHS 109.14(6)(i) (i) The department shall terminate a participant’s current benefit period once the department determines eligibility for a request for a new benefit period.

DHS 109.14(7) (7) Annual eligibility review. Eligibility for a new benefit period determined under s. DHS 109.11 (6) (b) shall begin on the first day of the month immediately following the end of the previous benefit period when the department receives a complete application and all the eligibility requirements are met, including payment of a new enrollment fee specified in s. DHS 109.16, prior to the end of the 12th month of the previous benefit period.

DHS 109.14 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.15 DHS 109.15 Treatment of spouses. Notwithstanding ss. DHS 109.13 and 109.14, when the spouse of a SeniorCare participant files an application or review of eligibility for SeniorCare under s. DHS 109.14 (7), or requests a new benefit period, and is required under s. DHS 109.12 (1) to be in the same fiscal test group as the participant, the eligibility of the spouse for benefits and services under s. DHS 109.13 and the duration of the spouse’s benefit period shall be determined in the following manner, unless both the participant and the participant’s spouse jointly file a request for a new benefit period under s. DHS 109.14:

DHS 109.15(1) (1) The department shall determine the eligibility of the spouse under s. DHS 109.11, and, if eligible for SeniorCare, determine the beginning eligibility date of the spouse’s benefit period according to s. DHS 109.14.

DHS 109.15(2) (2) If the department under sub. (1) determines the spouse is eligible for SeniorCare the spouse’s benefit period shall end on the same date as the participant’s benefit period ends.

DHS 109.15(3) (3) If the department determines the spouse is ineligible for SeniorCare, the benefits and services that the participant spouse may receive during the participant’s current benefit period may not be affected.

DHS 109.15(4) (4) If the income of the spouse was not used to determine the SeniorCare benefit for the participant spouse, both of the following apply:

DHS 109.15(4)(a) (a) The department shall determine the annual income for the fiscal test group for the 12-month period beginning with the month the application request for the spouse is received.

DHS 109.15(4)(b) (b) The benefit and services under s. DHS 109.13 that the spouse may receive shall be determined as follows:

DHS 109.15(4)(b)1. 1. ‘Annual income exceeds 240% of poverty line.’

DHS 109.15(4)(b)1.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, the spouse may receive spend-down services under s. DHS 109.13 (4) (a) 2.

DHS 109.15(4)(b)1.b. b. When determining whether the spouse meets the SeniorCare spend-down under s. DHS 109.13 (4) (c), the amount of the SeniorCare spend-down shall be prorated. The prorated amount shall be the annual spend-down amount under s. DHS 109.13 (4) (b) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12. Only prescription drug costs of the spouse may count towards meeting the prorated spend-down.

DHS 109.15(4)(b)1.c. c. If the spouse meets the prorated spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b). When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(4)(b)1.d. d. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(4)(b)2. 2. ‘Annual income between 160-240% of poverty line.’

DHS 109.15(4)(b)2.a. a. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b).

DHS 109.15(4)(b)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(4)(b)2.c. c. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(4)(b)3. 3. ‘Annual income less than 160% of poverty line.’

DHS 109.15(4)(b)3.a. a. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15(5) (5) If the income of the spouse was used to determine the SeniorCare benefit for the participant, the department shall determine the benefit as follows:

DHS 109.15(5)(a) (a) Annual income exceeds 240% of poverty line.

DHS 109.15(5)(a)1. 1. ‘Participant has not met spend-down.’ If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, and the participant has not met the spend-down by the date the spouse becomes eligible for SeniorCare, the spouse may receive spend-down services under s. DHS 109.13 (4).

DHS 109.15(5)(a)2. 2. ‘Participant has met spend-down.’

DHS 109.15(5)(a)2.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family and the participant met the spend-down before the spouse becomes eligible for SeniorCare, or the participant and spouse meet the spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(a)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(a)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(b) (b) Annual income between 160-240% of poverty line.

DHS 109.15(5)(b)1. 1. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(b)2. 2. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(b)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(c) (c) Annual income less than 160% of poverty line. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (4) (b) 1. c. and 2. b. and (5) (a) 2. b. and (b) 2. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.16 DHS 109.16 Fees. For each 12-month benefit period, a program participant shall pay a program enrollment fee of $30. The department shall refund the fee to applicants found to be ineligible for SeniorCare.

DHS 109.16 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.17 DHS 109.17 Applicant appeals.

DHS 109.17(1) (1) Except as provided under sub. (2), any person whose application for SeniorCare is denied or is not acted upon promptly under s. DHS 109.11 (5), or who believes that the benefits or services the person may receive under s. DHS 109.13 have not been properly determined, or that his or her eligibility has not been properly determined under s. DHS 109.11 (5), may file an appeal pursuant to the requirements under ch. HA 3 that apply to the medical assistance program.

DHS 109.17(2) (2) 

DHS 109.17(2)(a) (a) A request for a hearing concerning the SeniorCare program may only be made in writing and only to the division of hearings and appeals.

DHS 109.17(2)(b) (b) The applicant shall have 45 days from the effective date of the adverse action in which to file a request for hearing.

DHS 109.17 Note Note: A hearing request should be mailed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI, 53707-7875. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or transmitted by facsimile machine to 608-264-9885.

DHS 109.17 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

subch. III of ch. DHS 109 Subchapter III — Drug Benefits

DHS 109.31 DHS 109.31 Covered drugs and limitations on coverage.

DHS 109.31(1) (1) Covered services. Drugs and drug products covered under this chapter include prescription drugs and insulin listed in the Wisconsin medical assistance drug index that are prescribed by a physician licensed under s. 448.04, Stats., by a dentist licensed under s. 447.04, Stats., by a podiatrist licensed under s. 448.04, Stats., by an optometrist licensed under ch. 449, Stats., or by a nurse prescriber under ch. N 8, or when a physician delegates prescription of drugs to a nurse practitioner or to a physician’s assistant certified under s. 448.04, Stats., and the requirements under s. N 6.03 for nurse practitioners and under s. Med 8.07 for physician assistants are met. The limitations on coverage and services in this section apply to co-pay, spend-down and deductible.

DHS 109.31(2) (2) Prior authorization.