Chapter DHS 154
REIMBURSEMENT FOR TREATMENT OF ADULTS WITH CYSTIC FIBROSIS
DHS 154.01 Authority and purpose. DHS 154.035 Termination of eligibility. DHS 154.037 Retroactive eligibility. DHS 154.04 Patient certification. DHS 154.05 Provider approval. DHS 154.06 Provider reimbursement. DHS 154.07 Participant liability. Ch. DHS 154 NoteNote: Chapter HSS 154 was created as an emergency rule effective September 1, 1993. Chapter HSS 154 was renumbered to chapter HFS 154 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 1., Stats., Register, September, 1999, No. 525. Chapter HFS 154 was renumbered chapter DHS 154 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 154.01DHS 154.01 Authority and purpose. This chapter is promulgated under the authority of ss. 49.683, 49.687 (1) and 227.11 (2), Stats., to establish and implement a treatment cost reimbursement program for Wisconsin residents 18 years of age or older who have cystic fibrosis. DHS 154.01 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95. DHS 154.02DHS 154.02 Definitions. In this chapter: DHS 154.02(1)(1) “Adult” means a person 18 years of age or older. DHS 154.02(2)(2) “Current year” means the later of the 12-month period beginning with the month of a patient’s first application to the adult cystic fibrosis program or the 12-month period beginning with the month of a participant’s most recent subsequent annual recertification for the adult cystic fibrosis program. DHS 154.02(3)(3) “Cystic fibrosis” means an inherited disorder of the exocrine or outward secreting glands of the body, causing those glands to produce abnormally thick secretions of mucus. DHS 154.02(4)(4) “Cystic fibrosis treatment center” means a hospital unit which furnishes the full spectrum of diagnostic, therapeutic and rehabilitation services required for the care of cystic fibrosis patients and which is certified by the national cystic fibrosis foundation. DHS 154.02(5)(5) “Department” means the Wisconsin department of health services. DHS 154.02(6)(6) “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. DHS 154.02(7)(7) “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 154.02(8)(8) “Income” 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. DHS 154.02(9)(9) “Maintenance program” means a patient’s therapeutic and treatment regimen, including medical, dental, social and vocational rehabilitation services and home health care. DHS 154.02(11)(11) “Medical director” means a physician licensed under ch. 448, Stats., to practice medicine or osteopathy who is certified by the American board of internal medicine or is eligible for certification by that board, and who is directly responsible for a patient’s maintenance program. DHS 154.02(12)(12) “Medicare” means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395zz and 42 CFR Pts. 405 to 421. DHS 154.02(13)(13) “Participant” means a patient who has been found eligible by the department under s. 49.683, Stats., and this chapter for reimbursement for the costs of treatment of cystic fibrosis. DHS 154.02(14)(14) “Patient” means an adult who has been diagnosed as having cystic fibrosis. DHS 154.02(15)(15) “Provider” means a cystic fibrosis treatment center or another source of treatment approved by the department under s. DHS 154.05. DHS 154.02(16)(16) “Resident” means any adult who is living in Wisconsin with the intention of remaining permanently in the state. DHS 154.02(17)(17) “SeniorCare” means the program of prescription drug assistance for eligible elderly persons under s. 49.688, Stats., and ch. DHS 109. DHS 154.02 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (1m) and (17) Register November 2004 No. 587, eff. 12-1-04; corrections in (1m), (5), (12) and (17) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637. DHS 154.03DHS 154.03 Eligibility. To be eligible for the adult cystic fibrosis program, a patient shall: DHS 154.03(2)(2) Be diagnosed by the medical director of a cystic fibrosis treatment center as having cystic fibrosis; DHS 154.03(4)(4) Provide to the department or its designated agent full, truthful and correct information necessary for the department to determine eligibility and liability on forms specified by the department. A patient shall be ineligible for financial assistance if he or she refuses to provide information, withholds information, refuses to assist the department in verifying the information or provides inaccurate information. The department may verify or audit an applicant’s total family income. DHS 154.03(5)(5) 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. DHS 154.035DHS 154.035 Termination of eligibility. Eligibility for the adult cystic fibrosis program is terminated if either of the following events occur: DHS 154.035 HistoryHistory: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04. DHS 154.037DHS 154.037 Retroactive eligibility. Retroactive eligibility is not available under the adult cystic fibrosis program. Patients who are found to be eligible under s. DHS 154.03 become eligible for benefits on the date the application was received. DHS 154.037 HistoryHistory: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04. DHS 154.04(1)(1) Application. To apply for assistance in paying for the costs of treatment of adult cystic fibrosis, a patient shall complete a form available from a cystic fibrosis treatment center, and shall submit the completed form either to the center or directly to the department. When an application form is submitted to a cystic fibrosis treatment center, the center shall forward the application form to the department within 14 days from the date of receipt. DHS 154.04(2)(2) Notification of applicant. The department shall certify a patient as eligible for reimbursement for part of the medical costs of treatment of cystic fibrosis if all requirements under s. DHS 154.03 are met. The department shall notify the patient, in writing, of its decision within 60 days after the department receives an application for assistance. If the application is denied, the notice shall include the reason for denial with information that the patient may request a hearing under sub. (7) on that decision. DHS 154.04(3)(3) Recertification. Certification is for one year. To be recertified, a participant shall complete, sign and submit to the department a financial statement form received from the department. The participant shall provide to the department full, truthful and correct information necessary for the department to determine eligibility and liability. DHS 154.04(4)(4) Revocation or nonrenewal of certification. The department shall revoke or not renew a participant’s certification if the department finds that the participant is no longer eligible for the program. The department shall send written notice of revocation or nonrenewal to the participant, stating the reason for it and with information that the participant may request a hearing under sub. (7) on that decision. DHS 154.04(5)(5) Participant responsibility to provide information. DHS 154.04(5)(a)(a) A participant shall inform the department within 30 days of any change in address, other source of health care coverage or family size, or any change in income of more than 10%. DHS 154.04(5)(b)(b) The department may verify or audit a participant’s total family income. The department may redetermine a participant’s estimated total family income for the current year based on change in the family’s financial circumstances. DHS 154.04(6)(6) Confidentiality of patient information. All personally identifiable information provided by or on behalf of a patient to the department shall remain confidential and may not be used for any purpose other than to determine program eligibility, participant liability, the types of medical services required for proper care and the payment of claims. Statistical analyses of program data may not reveal patient identity. DHS 154.04(7)(7) Appeal. A patient denied assistance under sub. (2) or a participant whose certification is revoked or not renewed under sub. (4) may request a hearing on that decision under ss. 227.44 to 227.50, Stats., by the department of administration’s division of hearings and appeals. The request for a hearing shall be in writing and shall be sent to the office of administrative hearings so that it is received there within 30 days after the date of the notice of denial, revocation or nonrenewal of certification. DHS 154.04 NoteNote: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 154.04 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95. DHS 154.05(1)(a)(a) Condition. To be reimbursed by the program for medical care provided to program participants, a cystic fibrosis treatment center shall be certified by the national cystic fibrosis foundation and, except as provided in par. (b), shall be located in Wisconsin. DHS 154.05(1)(b)(b) Border state treatment centers. The department may approve a treatment center in a state bordering on Wisconsin as a cystic fibrosis treatment center if the center is within 100 miles of the Wisconsin border, has a practice that includes providing services to Wisconsin residents and is certified by the national cystic fibrosis foundation. A border state cystic fibrosis treatment center is subject to the same requirements and contractual agreements as cystic fibrosis treatment centers located in Wisconsin. DHS 154.05(1)(c)(c) Availability of a grievance mechanism for program participants. A cystic fibrosis treatment center shall have a written grievance procedure and shall provide a copy to each program participant. The cystic fibrosis treatment center may not discriminate against or take other retaliatory measures against a participant because the participant filed a grievance. DHS 154.05(2)(a)(a) A hospital or physician located in Wisconsin shall be deemed approved for reimbursement for treatment rendered to a program participant upon the department’s receipt of a valid claim for services rendered. DHS 154.05(2)(b)(b) A pharmacy or a provider of home health care supplies shall be deemed approved for reimbursement for treatment-related services provided to a program participant upon the department’s receipt of a valid claim for services rendered. DHS 154.05 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95. DHS 154.06(1)(a)(a) A provider shall use claim forms furnished or prescribed by the department or its fiscal agent, except that a provider may submit claims by electronic media or electronic submission if the provider or billing service is approved by the department for electronic claims submission. DHS 154.06(1)(b)(b) Claims shall be submitted in accordance with the claims submission requirements, claim form instructions and coding information provided by the department or its fiscal agent. DHS 154.06(1)(c)(c) Every claim submitted shall be signed by the provider or the provider’s authorized representative, certifying to the truthfulness, accuracy and completeness of the claim. DHS 154.06(2)(a)(a) A claim shall be submitted within 12 months after the date that medical services were provided, except that a claim may be submitted later if the department is notified within that 12 month period that the sole reason for late submission concerns another funding source and the claim is submitted within 180 days after obtaining a decision on reimbursement from the other funding source. DHS 154.06(2)(b)(b) A claim may not be submitted until after the patient has received the medical services. DHS 154.06(3)(a)(a) The department shall establish allowable costs for medical services as a basis for reimbursing providers. DHS 154.06(3)(b)(b) Reimbursement may not be made for any portion of the cost of medical care which is payable under any other state or federal program or any grant, contract or contractual agreement. DHS 154.06(3)(c)(c) Before submitting a claim to the adult cystic fibrosis program, a provider shall seek payment for services provided to a participant from medicare, medical assistance or another health care plan if the participant is eligible for services under medicare, medical assistance or the other health care plan. DHS 154.06(3)(d)(d) When benefits from medicare, medical assistance or another health care plan or other third party payer have been paid, in whole or in part to the provider or participant, the amount of the payment from all other payers shall be indicated on or with the bill to the adult cystic fibrosis program. The amount of the medicare, medical assistance, other health care plan or other third party payer reimbursement shall reduce the amount of the claim for adult cystic fibrosis program payment. DHS 154.06(3)(e)(e) If a provider receives a payment under the program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall promptly return the amount of the erroneous or excess payment to the department. DHS 154.06(3)(f)(f) A provider may request a hearing to review a decision to deny payment or the level of payment. A request for a hearing shall be filed with the department of administration’s division of administrative hearings within 90 days after the date of the payment or decision to deny payment. A request for a hearing is considered filed upon its receipt by the division of administrative hearings. All appeals shall include written documentation and any information deemed necessary by the department. Hearings shall be conducted in accordance with subch. III of ch. 227, Stats. DHS 154.06 NoteNote: The mailing address of the Division of Administrative Hearings is P.O. Box 7875, Madison, Wisconsin 53707.
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