Chapter DHS 154

DHS 154.06(2) (2) Timeliness.

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) (3) Payment.

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 Note Note: 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 History History: 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 DHS 154.07 Participant liability.

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) (3) Participant coinsurance.

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(3)(d)1. 1. For an income of up to $10,000, 3%;

DHS 154.07(3)(d)2. 2. For an income of $10,001 to $20,000, 4%;

DHS 154.07(3)(d)3. 3. For an income of $20,001 to $40,000, 5%;

DHS 154.07(3)(d)4. 4. For an income of $40,001 to $60,000, 6%;

DHS 154.07(3)(d)5. 5. For an income of $60,001 to $80,000, 7%;

DHS 154.07(3)(d)6. 6. For an income of $80,001 to $100,000, 9%; and

DHS 154.07(3)(d)7. 7. For an income of $100,001 and over, 10%.

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) (5) Estate recovery.

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) (b) For purposes of applying s. DHS 108.02 (12) (b) to (e) to this subsection the following definitions apply:

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)4. 4. “Recipient” means a participant who received reimbursement under s. 49.683, Stats.; and

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

- See PDF for table

DHS 154.07 Note Note: To illustrate how a patient’s coinsurance liability is calculated, assume that the family has 2 members and an annual income of $38,000, and that a bill has been received for treatment in the amount of $600. The patient would be liable for 16% of that bill, or $96.

DHS 154.07 History History: Cr. Register, December, 1994, No. 468, eff. 1-1-95; emerg. cr. (5), eff. 11-1-95; cr. (5), Register, April, 1996, No. 484, eff. 5-1-96; CR 02-070: am. (4) Register October 2002 No. 562, eff. 11-1-02; CR 04-051: am. (2) and (4), cr. (2) (f) to (h) Register November 2004 No. 587, eff. 12-1-04; corrections in (5) (a) and (b) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637; corrections in (5) (a), (b) 1., 5., (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2013 No. 696.