DHS 104.01(5)(a)1.1. Applicants and recipients have the right to a fair hearing in accordance with procedures set out in this subsection when aggrieved by action or inaction of the agency or the department. This subsection does not apply to actions taken by a PRO or to adverse benefit determinations made by a care management organization or managed care organization under s. 46.287 (2) (a) 1m. or 49.45 (5) (ag), Stats. DHS 104.01(5)(a)2.2. Every applicant or recipient shall be informed in writing at the time of application for MA and at the time of any action affecting the recipient’s claim of the right to a fair hearing, of the manner by which a fair hearing may be obtained and of the right to be represented or to represent self at such a fair hearing. DHS 104.01(5)(a)3.3. The applicant or recipient shall be provided reasonable time, not to exceed 45 days, in which to appeal an agency action. The department shall take prompt, definitive, and final administrative action within 90 days of the date of the request for a hearing. DHS 104.01(5)(a)4.4. No fair hearing is required when the sole issue being petitioned involves an automatic grant adjustment or change which affects an entire class of recipients and is the result of a change in state or federal law. DHS 104.01(5)(b)(b) Purpose of hearing. The purpose of the fair hearing is to allow a recipient to appeal department actions which result in the denial, discontinuation, termination, suspension or reduction of the recipient’s MA benefits. The fair hearing process is not intended for recipients who wish to lodge complaints against providers concerning quality of services received, nor is it intended for recipients who wish to institute legal proceedings against providers. Recipients’ complaints about quality of care should be lodged with the appropriate channels established for this purpose, to include but not limited to provider peer review organizations, consumer advocacy organizations, regulatory agencies and the courts. DHS 104.01(5)(c)1.1. After the department has received a recipient’s request for a fair hearing and has set the date for the hearing, the department shall review and investigate the facts surrounding the recipient’s request for fair hearing in an attempt to resolve the problem informally. DHS 104.01(5)(c)2.2. If before the hearing date an informal resolution is proposed and is acceptable to the recipient, the recipient may withdraw the request for fair hearing. DHS 104.01(5)(c)3.3. If before the fair hearing date the concurrent review results in a proposed informal resolution not acceptable to the recipient, the fair hearing shall proceed as scheduled. DHS 104.01(5)(c)4.4. If the concurrent review has not resolved the recipient’s complaint satisfactorily by the fair hearing date but an informal resolution acceptable to the recipient appears imminent to all parties, the hearing may be dropped without prejudice and resumed at a later date. However, if the informal resolution proposed by the department is not acceptable to the recipient, the recipient may proceed with a fair hearing and a new hearing date shall be set promptly. DHS 104.01(5)(c)5.5. If before the fair hearing date the concurrent review has not been initiated, the fair hearing shall proceed as scheduled. DHS 104.01(5)(d)(d) Absence of petitioner. If the recipient does not appear at a scheduled hearing and does not contact the department of administration’s division of hearings and appeals with good cause for postponement, the hearing examiner may dismiss the petition. DHS 104.01(6)(6) Coverage while out-of-state. Medical assistance shall be furnished under any of the following circumstances to recipients who are Wisconsin residents but absent from the state provided that they are within the United States, Canada or Mexico: DHS 104.01(6)(b)(b) When the health of the recipient would be endangered if the care and services were postponed until the recipient returned to Wisconsin; DHS 104.01(6)(c)(c) When the recipient’s health would be endangered if the recipient undertook travel to return to Wisconsin; or DHS 104.01(6)(d)(d) When prior authorization has been granted for provision of a non-emergency service, except that prior authorization is not required for non-emergency services provided to Wisconsin recipients by border status providers certified by the Wisconsin MA program. DHS 104.01(7)(7) Free choice of family planning method. Recipients eligible for family planning services and supplies shall have freedom of choice of family planning method so that a recipient may choose in accordance with the dictates of conscience and shall neither be coerced nor pressured into choosing any particular method of family planning. DHS 104.01(8)(8) Continuation of benefits to community care organization clients. Recipients who were eligible for or receiving services from any of the local community care organization (CCO) projects in La Crosse county, Barron county, or Milwaukee county, in April 1976, shall be allowed to continue to receive any of the CCO services and these services shall be reimbursed under MA. DHS 104.01(9)(a)(a) Program manuals. Recipients may examine program manuals and policy issuances which affect the public, including rules and regulations governing eligibility, need and amount of assistance, recipients’ rights and responsibilities and services covered under MA, at the department’s state or regional offices, or an agency’s offices, during regular office hours. DHS 104.01(9)(b)1.1. Except when changes in the law require automatic grant adjustments for classes of recipients, in every instance in which the department intends to discontinue, terminate, suspend or reduce a recipient’s eligibility for MA or coverage of services to a general class of recipients, the department shall send a written notice to the recipient’s last known address at least by the minimum time period required under 42 USC 601-613 and before the date upon which the action would become effective, informing the recipient of the following: DHS 104.01(9)(b)1.e.e. The circumstances under which assistance will be continued if a hearing is requested. DHS 104.01(9)(b)2.2. The department shall mail the individual written notice to be received no later than the date of intended action under any of the following circumstances: DHS 104.01(9)(b)2.a.a. The department receives a clear written statement signed by a recipient that states the recipient no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the recipient has indicated, in writing, that the recipient understands that the consequence of supplying the information will be termination or reduction of assistance; DHS 104.01(9)(b)2.c.c. The recipient has been admitted or committed to an institution and further payments to the recipient do not qualify for federal financial participation under the state plan for MA; DHS 104.01(9)(b)2.d.d. The recipient has been placed in skilled nursing care, intermediate care or long-term hospitalization; DHS 104.01(9)(b)2.e.e. The recipient’s whereabouts are unknown and departmental mail directed to the recipient has been returned by the post office indicating no known forwarding address; DHS 104.01(9)(b)2.f.f. A recipient has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance; DHS 104.01(9)(b)2.h.h. A change in level of medical care is prescribed by the recipient’s physician; DHS 104.01(9)(b)2.j.j. The recipient has received service during a period of ineligibility and the department is preparing to take recovery action, pursuant to s. DHS 108.03 (3). DHS 104.01(10)(10) Right to prompt decisions and assistance. Applicants have the right to prompt decisions on their applications. Eligibility decisions shall be made within 30 days of the date the application was signed. For individuals applying as disabled, where medical examination reports, determination of disability, and other additional medical and administrative information is necessary for the decision, eligibility decisions shall be made not more than 60 days after the date the application was signed. Health care shall be furnished promptly to eligible recipients without any delay attributable to the department’s administrative process and shall be continued as needed until the individual is found ineligible. DHS 104.01(11)(11) Right to request return of payments made for covered services during period of retroactive eligibility. If a person has paid all or part of the cost of health care services received and then becomes a recipient of MA benefits with retroactive eligibility for those covered services for which the recipient has previously made payment, then the recipient has the right to notify the certified provider of the retroactive eligibility period. At that time the certified provider shall submit claims to MA for covered services provided to the recipient during the retroactive period. Upon the provider’s receipt of the MA payment, the provider shall reimburse the recipient for the lesser of the amount received from MA or the amount paid by recipient or other person, minus any relevant copayment. In no case may the department reimburse the recipient directly. DHS 104.01(12)(a)1.1. Recipients of MA are liable for payment of any copayment or deductible amount established by the department pursuant to s. 49.45 (18), Stats., for the cost of a service, except as provided in this subsection. The recipient shall pay the copayment or deductible to the provider of service. Copayments or deductibles are not required in each of the following circumstances: DHS 104.01(12)(a)1.b.b. Former foster care youth also known as individuals under the age of 26 who were in foster care under the responsibility of any state when they turned 18 years old. DHS 104.01(12)(a)1.d.d. A recipient is a pregnant women and the services relate to the pregnancy, or to any medical condition which may complicate the pregnancy when it can be determined from the claim submitted that the recipient was pregnant. DHS 104.01(12)(a)1.e.e. Services provided are emergency hospital and ambulance services and emergency services related to the relief of dental pain. DHS 104.01(12)(a)1.h.h. Services provided are transportation services provided through or paid for by a county social services department. DHS 104.01(12)(a)1.i.i. Services provided are home health services or for home nursing services if a home health agency is not available. DHS 104.01(12)(a)1.j.j. Services provided are outpatient psychotherapy services received over 15 hours or $500, whichever comes first, during one calendar year. DHS 104.01(12)(a)1.k.k. Services provided are occupational, physical or speech therapy services received exceeding 30 hours or $1,500 for any one therapy, whichever occurs first, during one calendar year. DHS 104.01(12)(a)1.o.o. Services provided are alcohol and other drug abuse (AODA) day treatment services. DHS 104.01(12)(a)2.2. If the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs, the monthly amount of copayment a recipient is required to pay may not exceed $5. DHS 104.01(12)(b)(b) Freedom from having to pay for services covered by MA. Recipients may not be held liable by certified providers for covered services and items furnished under the MA program, except for copayments or deductibles under par. (a), if the patient identifies himself or herself as an MA recipient and shows the provider the MA identification card. DHS 104.01 NoteNote: Recipients seeking nonemergency services from noncertified providers are liable for all charges, unless the services were authorized by the department prior to service delivery.
DHS 104.01(12)(c)(c) Prior authorization of services. When a service must be authorized by the department in order to be covered, the recipient may not be held liable by the certified provider unless the prior authorization was denied by the department and the recipient was informed of the recipient’s personal liability before provision of the service. In that case the recipient may request a fair hearing. Negligence on the part of the certified provider in the prior authorization process shall not result in recipient liability. DHS 104.01 NoteNote: For example, if a provider does not inform a recipient that a procedure or service requires prior authorization, and performs the service before submitting a prior authorization request or receiving an approval and then submits a claim for services rendered which is rejected, the recipient may not be held liable.
DHS 104.01(12)(d)(d) Freedom from having to pay the difference between charges and MA payment. Providers may not charge recipients for the amount of the difference between charge for service and MA reimbursement, except in the case of recipients wishing to be in a private room in a nursing home or hospital, in which case the provisions of s. DHS 107.09 (4) (k) shall be met. DHS 104.01 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; am. (4) (b), cr. (4) (f) and (g), r. (12) (a) 1. j. and k., Register, February, 1988, No. 386, eff. 3-1-88; renum. (12) (a) 1. l. and m. under s. 13.93 (2m) (b) 1., Stats., Register, February, 1988, No. 386; emerg. am. (1) (k), cr. (1) (l) to (q), eff. 1-1-90; am. (1) (k), cr. (1) (l) to (q), Register, September, 1990, No. 417, eff. 10-1-90; correction in (4) (c) and (5) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, May, 1995, No. 473; correction in (5) (d) and (12) (d) made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, April, 1999, No. 520; corrections in (4) (c) and (5) (d) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; corrections in (4) (f), (g), (5) (a) 1., (9) (b) 2. j., (12) (a) 1. L., m., p., q. and (d) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-039: am. (3), r. (9) (b) 2. g. Register October 2021 No. 790, eff. 11-1-21; CR 20-068: am. (2) Register December 2021 No. 792, eff. 1-1-22; CR 22-026: am. (5) (a) 1. Register May 2023 No. 809, eff. 6-1-23; CR 23-046: am. (12) (a) 1. (intro.), r. and recr. (12) (a) 1. a., b., am. (12) (a) 1. c. to q. Register April 2024 No. 820, eff. 5-1-24. DHS 104.02(1)(1) Not to seek duplication of services. A recipient may not seek the same or similar services from more than one provider. DHS 104.02(2)(2) Prior identification of eligibility. Except in emergencies that preclude prior identification, the recipient shall, before receiving services, inform the provider that the recipient is receiving benefits under MA and shall present to the provider a current valid MA identification card. DHS 104.02(3)(3) Review of benefits notice. Recipients shall review the monthly explanation of benefits (EOB) notice sent to them by the department and shall report to the department any payments made for services not actually provided. The explanation of benefits notice may not specify confidential services, such as family planning, and may not be sent if the only service furnished is confidential. DHS 104.02(4)(4) Informational cooperation with providers. Recipients shall give providers full, correct and truthful information requested by providers and necessary for the submission of correct and complete claims for MA reimbursement. This information shall include but is not limited to: DHS 104.02(4)(a)(a) Information concerning the recipient’s eligibility status, accurate name, address and MA identification number; DHS 104.02(4)(c)(c) Information concerning the recipient’s use of MA benefits; and DHS 104.02(4)(d)(d) Information concerning the recipient’s coverage under other insurance programs. DHS 104.02(5)(5) Not to abuse or misuse the MA card or benefits. If a recipient abuses or misuses the MA card or benefits in any manner, the department or agency, as appropriate, may limit or terminate benefits. For purposes of this subsection,“abuses or misuses” includes, but is not limited to, any of the following actions: DHS 104.02(5)(b)(b) Permitting the use of the MA card by any unauthorized individual for the purpose of obtaining health care through MA; DHS 104.02(5)(d)(d) Using the MA card to obtain any covered service for another individual; DHS 104.02(5)(f)(f) Knowingly misrepresenting material facts as to medical symptoms for the purpose of obtaining any covered service; DHS 104.02(5)(g)(g) Knowingly furnishing incorrect eligibility status or other information to a provider; DHS 104.02(5)(h)(h) Knowingly furnishing false information to a provider in connection with health care previously rendered which the recipient has obtained and for which MA has been billed; DHS 104.02(5)(i)(i) Knowingly obtaining health care in excess of established program limitations, or knowingly obtaining health care which is clearly not medically necessary; DHS 104.02(5)(j)(j) Knowingly obtaining duplicate services from more than one provider for the same health care condition, excluding confirmation of diagnosis or a second opinion on surgery; or
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Department of Health Services (DHS)
Chs. DHS 101-109; Medical Assistance
administrativecode/DHS 104.01(9)(b)1.e.
administrativecode/DHS 104.01(9)(b)1.e.
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