[To be taken from EIA]
Agency contact person
Statement on quality of agency data
See summary of factual data and analytical methodologies.
Place where comments are to be submitted and deadline for submission
Comments may be submitted to the agency contact person that is listed above until the deadline given in the upcoming notice of public hearing. The notice of public hearing and deadline for submitting comments will be published in the Wisconsin Administrative Register and to the department’s website, at https://www.dhs.wisconsin.gov/rules/permanent.htm. Comments may also be submitted through the Wisconsin Administrative Rules Website, at: https://docs.legis.wisconsin.gov/code/chr/active. RULE TEXT
SECTION 1. DHS 109.03 (10) is renumbered DHS 109.03 (intro) and amended to read:
DHS 109.03 (10) “Prescription drug” has the meaning given in s. 450.01 (20), Stats., that is included in the drugs specified under s. 49.46 (2) (b) 6. h., Stats., and s. DHS 109.31 and is manufactured by a drug manufacturer that enters into a rebate agreement in force under s. DHS 109.71. means any of the following: SECTION 2. DHS 109.03 (10) (a) and (b) are created to read:
DHS 109.03 (10) (a) A drug under s. 450.01 (20), Stats., that is included in the drugs specified under s. 49.46 (2) (b) 6. h., Stats., and s. DHS 109.31 and is manufactured by a drug manufacturer that enters into a rebate agreement in force under s. DHS 109.71.
(b) A vaccine recommended and approved for administration to adults by the federal centers for disease control and prevention’s advisory committee on immunization practices. SECTION 3. DHS 109.13 (2) (c) is amended to read:
DHS 109.13 (2) (c) Exclusion for drugs. If a drug is covered by a third party and the participant makes a copayment to the SeniorCare provider, the department is not responsible for refunding the copayment amount to the participant.
SECTION 4. DHS 109.13 (2) (bm), (d) and (e) are created to read:
DHS 109.13 (2) (bm) Exclusion of copayment. A copayment is not required for a vaccine or vaccine administration.
DHS 109.13 (2) (d) Exclusion for vaccines and vaccine administration. The department will not cover reimbursement of a vaccine or vaccine administration in any of the following circumstances.
1. If a vaccine is not on the federal centers for disease control and prevention’s advisory committee on immunization practices list of vaccines recommended for immunization to adults.
2. A vaccine is not administered by a SeniorCare provider in an allowed place of service.
DHS 109.13 (2) (e) Exclusion for vaccines. The department will not cover reimbursement of a vaccination when the vaccine is allocated through the federal government at no cost to the provider.
SECTION 5. DHS 109.31 (3) (h) is created to read:
DHS 109.31 (3) (h) SeniorCare shall only cover vaccines that are recommended for immunization to adults by the federal centers for disease control and prevention’s advisory committee on immunization practices and administered by a SeniorCare provider in an allowed place of service.
SECTION 6. DHS 109.51 (5) is amended to read:
DHS 109.51 (5) Submission of claims. A SeniorCare provider shall submit all claims for prescription drugs purchased by a participant during spend-down and deductible periods.
SECTION 7. DHS 109.52 (8) (d) and (11) (b) are amended to read:
DHS 109.52 (8) (d) Prescriptions that support SeniorCare billings, including records of SeniorCare covered vaccines and vaccine administration.
DHS 109.52 (11) (b) Reimbursement. A SeniorCare provider may not claim reimbursement for prescription drugs provided to participants on or after the effective date specified in the termination notice. If the SeniorCare provider’s notice of termination fails to specify an effective date, the department shall terminate the SeniorCare provider's certification to provide and claim reimbursement for services under the program on the date on which the department receives notice of termination.
SECTION 8. DHS 109.61 (2) is amended to read:
DHS 109.61 (2) Prior identification of eligibility. Except in emergencies that preclude prior identification, the participant shall, before receiving prescription drugs, inform the SeniorCare provider that the participant is receiving benefits under SeniorCare and shall present to the SeniorCare provider a current valid SeniorCare identification card.
SECTION 9. DHS 109.73 is amended to read:
DHS 109.73 Program suspension. During any period in which funding under s. 20.435 (4) (bv), Stats., is completely expended for the payments to SeniorCare providers, the requirements of ss. DHS 109.71 and 109.72 do not apply to prescription drugs purchased during that period. However, the department shall continue to accept applications and determine eligibility under subchapter II and shall indicate to applicants that the eligibility of program participants to purchase prescription drugs as specified in this chapter, under the requirements of s. DHS 109.72, is conditioned on the availability of funding under s. 20.435 (4) (bv), Stats. SECTION 10. EFFECTIVE DATE: This rule takes effect on the first day of the month following publication in the Wisconsin Administrative Register as provided in s. 227.22 (2) (intro.), Stats.
