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.
DHS 154.06(3)(g)(g) The department shall use common methods employed by managed care programs and the medical assistance program to contain costs, including prior authorization and other limitations regarding health care utilization and reimbursement. DHS 154.06 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (3) (g) Register November 2004 No. 587, eff. 12-1-04. DHS 154.07(1)(1) Calculation. A participant’s liability to contribute toward the cost of treatment shall be calculated in accordance with subs. (2) to (4). If there are 2 or more participants in the same family, the family’s liability shall be limited to the liability of one member of the family. DHS 154.07(2)(2) Income deductible. A participant whose estimated total family income in the current year is at or above 200% of the federal poverty guidelines shall obligate or expend the following percentage of that income to pay the cost of medical treatment for the condition before the adult cystic fibrosis program will provide assistance in paying for the cost of treatment: DHS 154.07(2)(a)(a) When total family income is from 200% to 250% of the federal poverty guidelines, 0.50% of that income. DHS 154.07(2)(b)(b) When total family income is more than 250% but not more than 275% of the federal poverty guidelines, 0.75% of that income. DHS 154.07(2)(c)(c) When total family income is more than 275% but not more than 300% of the federal poverty guidelines, 1.0% of that income. DHS 154.07(2)(d)(d) When total family income is more than 300% but not more than 325% of the federal poverty guidelines, 1.25% of that income. DHS 154.07(2)(e)(e) When total family income is more than 325% but not more than 350% of the federal poverty guidelines, 2.0% of that income. DHS 154.07(2)(f)(f) When total family income is more than 350% but not more than 375% of the federal poverty guidelines, 2.75% of that income. DHS 154.07(2)(g)(g) When total family income is more than 375% but not more than 400% of the federal poverty guidelines, 3.5% of that income. DHS 154.07(2)(h)(h) When total family income is more than 400% of the federal poverty guidelines, 4.5% of that income. DHS 154.07(3)(a)(a) A participant shall pay a coinsurance amount to cover part of the cost of treating the participant’s adult cystic fibrosis. DHS 154.07(3)(b)(b) A participant’s coinsurance amount shall be determined at the time the patient is certified for eligibility and annually thereafter. DHS 154.07(3)(c)(c) The amount of a participant’s coinsurance shall be related to family size and to family income rounded to the nearest whole dollar, in accordance with the schedule in Table 154.07. DHS 154.07(3)(d)(d) The amount that a participant pays in coinsurance annually may not exceed the following applicable percentage of the family’s income, rounded to the nearest whole dollar: DHS 154.07(4)(4) Participant copayment. When a pharmacy directly bills the adult cystic fibrosis program for a prescription received by a program participant, the participant is responsible for a $7.50 copayment amount for each generic drug and a $15.00 copayment amount for each brand name drug. DHS 154.07(5)(a)(a) An heir or beneficiary of the estate of a participant or a participant’s surviving spouse may apply to the department for a waiver of an estate claim filed by the department pursuant to s. 49.682 or 49.849, Stats. The criteria for granting waivers in s. DHS 108.02 (12) (b) shall apply to applications under this subsection. All of the procedures and rights in s. DHS 108.02 (12) (b) to (e) shall apply to this subsection. DHS 154.07(5)(b)1.1. “Beneficiary” means any person nominated in a will to receive an interest in property other than in a fiduciary capacity; DHS 154.07(5)(b)2.2. “Decedent” means a deceased participant or the deceased surviving spouse of a participant who received benefits that are subject to recovery under s. 49.682 or 49.849, Stats.; DHS 154.07(5)(b)3.3. “Heir” means any person who is entitled under the statutes of intestate succession, ch. 852, Stats., to an interest in property of a decedent; DHS 154.07(5)(b)5.5. “Waiver applicant” means a beneficiary or heir of a decedent who requests the department to waive an estate claim filed by the department pursuant to s. 49.682 or 49.849, Stats. DHS 154.07(5)(c)(c) The department may make adjustments to and settle estate claims filed under s. 49.682 or 49.849, Stats., to obtain the fullest amount practicable. Table 154.07
Patient Coinsurance Liability for the Direct Cost of Treatment
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