Register December 2021 No. 792
Chapter DHS 152
REIMBURSEMENT FOR TREATMENT OF CHRONIC RENAL DISEASE
Authority and purpose.
Eligibility and certification.
Events which affect eligibility.
Patient rights and responsibilities.
Certification of renal transplantation centers, dialysis centers and dialysis facilities.
Standards for renal transplantation centers.
Standards for renal dialysis centers and facilities.
CRD program advisory committee.
Ch. DHS 152 Note
Chapter H 52 as it existed on June 30, 1988, was repealed and a new chapter HSS 152 was created effective July 1, 1988. Chapter HSS 152 as it existed on September 30, 1999, was renumbered to chapter HFS 152, Register, September, 1999, No. 525
, eff. 10-1-99 and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, September, 1999, No. 525
. Chapter HFS 152 was renumbered chapter DHS 152 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637
DHS 152.01 Authority and purpose.
This chapter is promulgated under the authority of ss. 49.68 (2)
, 49.687 (1)
and 227.11 (2) (a)
, Stats., to implement a treatment cost reimbursement program for residents of Wisconsin who have chronic renal disease.
DHS 152.01 History
Cr. Register, June, 1988, No. 390
, eff. 7-1-88; am. Register, December, 1994, No. 468
, eff. 1-1-95.
DHS 152.02 Definitions.
In this chapter:
“Agreement" means a written document executed between an ESRD unit and another unit, in which the other unit agrees to assume responsibility for furnishing specified services to patients and for obtaining reimbursement for those services.
“Arrangement" means a written document executed between an ESRD unit and another unit, in which the other unit agrees to furnish specified services to patients but the ESRD unit retains responsibility for the services and for obtaining reimbursement.
“Chronic renal disease" or “CRD" means that stage of renal impairment which is virtually irreversible and requires a regular course of dialysis or kidney transplantation to maintain life.
“CRD program advisory committee" means the committee appointed by the department under s. DHS 152.09
“Current year" means the 12-month period beginning with the month of a patient's first application to the CRD program, or beginning with the month of a certified patient's subsequent annual recertification for the CRD program.
“Department" means the department of health services.
“Dialysis" means a process by which dissolved substances are removed from a patient's body by diffusion and osmosis from one fluid compartment to another across a semipermeable membrane.
“Dietitian" means a person who is eligible for registration by the American dietetic association and has at least 1 year of experience in clinical nutrition, or a person who has a baccalaureate or advanced degree with major studies in food and nutrition or dietetics and at least 1 year of experience in clinical nutrition.
“End-stage renal disease" or “ESRD" has the meaning prescribed for chronic renal disease or CRD in sub. (3)
“ESRD unit" or “unit" means a free-standing or hospital-based renal dialysis facility, a renal dialysis center or a renal transplantation center.
“Family" means a patient and that patient's spouse, if any, and any other person who is claimed as a dependent of that patient or that patient's spouse or who claims that patient as a dependent under the U.S. internal revenue code for the purpose of filing a federal income tax return.
“Federal poverty guidelines" means the annually updated poverty income thresholds by family size published each year by the U.S. department of health and human services in the federal register.
DHS 152.02 Note
The federal poverty guidelines for 1999 were published in the Federal Register,
March 18, 1999, 13428.
“Fiscal agent" means the organization under contract to the department to process claims and determine eligibility for services provided under the CRD program.
“Free-standing renal dialysis facility" means a non-hospital unit which is approved by the department under this chapter to furnish chronic maintenance dialysis with or without self-care dialysis training.
“Furnishes directly" means that the ESRD unit provides the service through its own staff and employees, or through individuals who are under personal contract to furnish services for the facility.
“Home dialysis" means dialysis performed by a trained ESRD patient or helper, or both, at home.
“Hospital-based renal dialysis facility" means a hospital unit approved by the department to furnish one or more of the following dialysis services to ESRD patients:
“Income," for the period January 1, 1994 to June 30, 1994, has the meaning prescribed in s. 49.485 (1) (dm)
, 1991 Stats., except that a certified patient may for that period elect to use the definition under par. (b)
“Income," beginning July 1, 1994, means a family's total earnings, including wages and salary and net income from self-employment, as well as unearned income including social security and supplemental security income, dividends and interest income, income from estates or trusts, net rental income, public assistance, pensions or annuities, unemployment compensation, maintenance or alimony, child support or family support, nontaxable deferred compensation, and nontaxable interest such as interest on federal, state or municipal bonds, but not capital gains income.
“Inpatient dialysis" means dialysis which, because of medical necessity, is furnished to an ESRD patient on a temporary basis in a hospital.
“Medicare" means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395
and 42 CFR Pts. 405 to 421.
“Nephrologist" means a physician licensed in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, who is board-eligible or board-certified by the American board of internal medicine, or by an equivalent certifying body as determined by the department on recommendation of the CRD program advisory committee, and who has a minimum of 12 months of fellowship training in nephrology or 2 years of experience in delivering care to ESRD patients. Pediatric training may be substituted for internal medicine board eligibility or board certification if the ESRD unit's services are associated with pediatric ESRD care.
“Nurse" means a full-time supervisory nurse registered in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, with at least 12 months of experience in clinical nursing and an additional 6 months of experience in nursing care of an outpatient dialysis or kidney transplantation patient, including training in and experience with the dialysis process, or 18 months of experience in nursing care of an outpatient dialysis or kidney transplantation patient, including training in and experience with the dialysis process. If the nurse is in charge of home dialysis or self-dialysis training, at least 3 months of the total required ESRD experience shall be in home dialysis or self-dialysis patient training.
“Outpatient dialysis" means dialysis which is regularly furnished on an outpatient basis to an ESRD patient in a renal dialysis center, hospital-based renal dialysis facility or a free-standing renal dialysis facility.
“Patient" means a person who has been diagnosed as having ESRD and who receives treatment for ESRD. “Patient" does not include a kidney donor.
“Patient registry program" means a computerized list of all certified patients on dialysis which includes verification that each case has been reviewed by a transplant surgeon and that cases meeting criteria for a transplant are placed on the transplant list.
“Provider" means a renal dialysis facility or center, a renal transplantation center, or another source of dialysis or transplantation services approved by the department.
“Renal dialysis center" means a hospital unit approved by the department to furnish the full spectrum of diagnostic services, therapeutic services including inpatient dialysis furnished directly or under arrangement, and rehabilitative services, except renal transplantation, required for the care of ESRD patients.
“Renal transplantation center" means a hospital unit approved by the department to furnish transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement or agreement.
“Self-dialysis" means dialysis which is regularly furnished on an outpatient basis to an ESRD patient in a renal dialysis center, hospital-based renal dialysis facility or a free-standing renal dialysis facility, in which the ESRD patient is responsible for the dialysis treatment but is supervised by a dialysis nurse.
“SeniorCare" means the program of prescription drug assistance for eligible elderly persons under s. 49.688
, Stats., and ch. DHS 109
“Social worker" means a person who provides counseling to an ESRD patient and his or her family, and has either completed a course of study with specialization in clinical practice at a graduate school of social work accredited by the council on social work education and holds a masters degree from that school, or has worked for at least 2 years as a social worker, 1 year of which was in a dialysis or transplantation setting, and receives consultation from a social worker who holds a masters degree from an accredited school of social work.
“Transplant surgeon" means a physician licensed in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, who is board-eligible or board-certified by the American board of surgery or by an equivalent certifying body as determined by the department on recommendation of the CRD program advisory committee, and who has a minimum of 12 months of training or experience in the performance of renal transplantation and the care of renal transplant patients in an accredited teaching institution.
“Vascular surgeon" means a physician licensed in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, who is board-eligible or board-certified by the American board of surgery or by an equivalent certifying body as determined by the department on recommendation of the CRD program advisory committee under s. DHS 152.09
, and who has a minimum of 12 months of training or experience in the performance of vascular access procedures.
DHS 152.02 History
Cr. Register, June, 1988, No. 390
, eff. 7-1-88; cr. (15m), Register, May, 1992, No. 437
, eff. 6-1-92; emerg. cr. (9 g), am. (14), eff. 9-1-93; cr. (4m), (9m), (9t) and (9u), r. and recr. (14) and (25), Register, December, 1994, No. 468
, eff. 1-1-95; CR 04-051
: cr. (2m) and (26m) Register November 2004 No. 587
, eff. 12-1-04;
corrections in (2m), (5) and (26m) made under s. 13.92 (4) (b) 6.
, Stats., Register January 2009 No. 637
; CR 20-039
: r. (25) Register October 2021 No. 790
, eff. 11-1-21.
DHS 152.03 Eligibility and certification. DHS 152.03(1)(1)
To be eligible for the CRD program, a patient shall:
If eligible for medicare, register and pay the premium for coverage by medicare; and
Provide to the department or its designated agent full, truthful and correct information necessary for the department to determine patient eligibility and liability, including information about any change in income of more than 10%. A patient shall be denied reimbursement if he or she refuses to provide information, withholds information or provides inaccurate information. The department may verify or audit a certified patient's total family income. The department may redetermine a certified patient's estimated total family income for the current year based on change in the family's financial circumstances.
First apply for benefits under all other health care coverage programs for which the person may reasonably be eligible, including medicare, BadgerCare, medical assistance and SeniorCare.
Certification for coverage of dialysis shall be determined by the department upon the recommendation of a nephrologist from an approved dialysis unit. Certification for coverage of renal transplantation shall be determined by the department upon the recommendation of a transplant surgeon from an approved renal transplantation center.
A statewide list of certified ESRD patients shall be maintained either by the department or by another agency upon arrangement with the department. This list shall include names of all certified outpatient dialysis and kidney transplant patients in the state. Additional information deemed necessary and appropriate by the department shall be provided by the dialysis and transplant centers to determine eligibility and facilitate reimbursement.
The department or its fiscal agent shall certify an eligible patient for reimbursement upon receipt from any dialysis unit approved under ss. DHS 152.05
or renal transplantation center approved under ss. DHS 152.05
of a satisfactorily completed application for certification submitted on behalf of the patient.
DHS 152.03 History
Cr. Register, June, 1988, No. 390
, eff. 7-1-88; emerg. am. (1) (c), eff. 9-1-93; r. and recr. (1), am. (2) (c), Register, December, 1994, No. 468
, eff. 1-1-95; CR 04-051
: cr. (1) (e) Register November 2004 No. 587
, eff. 12-1-04.
DHS 152.035 Events which affect eligibility. DHS 152.035(1)(1)
Eligibility under the CRD program is terminated if any of the following events occur: