Chapter DHS 104

DHS 104.01 Note Note: 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 Note Note: 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 History History: 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 DHS 104.02 Recipient duties.

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)(b) (b) Information concerning the recipient’s use of the MA card;

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)(a) (a) Altering or duplicating the MA card in any manner;

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)(c) (c) Using an MA card that belongs to another recipient;

DHS 104.02(5)(d) (d) Using the MA card to obtain any covered service for another individual;

DHS 104.02(5)(e) (e) Duplicating or altering prescriptions;

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

DHS 104.02(5)(k) (k) Otherwise obtaining health care by false pretenses.

DHS 104.02(6) (6) Notification of personal or financial status changes. Recipients shall inform the agency within 10 days of any change in address, income, assets, need, or living arrangements which may affect eligibility. In addition, the department may require as a condition for continuation of MA coverage that certain recipients report each month whether there has been any change of circumstances that may affect eligibility.

DHS 104.02(7) (7) Financial responsibility of spouse or responsible relative. Within the limitations provided by s. 49.90, Stats., and this chapter, the spouse of an applicant of any age or the parent of an applicant under 18 years of age shall be charged with the cost of medical services before MA payments shall be made. However, eligibility may not be withheld, delayed or denied because a responsible relative fails or refuses to accept financial responsibility. When the agency determines that a responsible relative is able to contribute without undue hardship to self or immediate family but refuses to contribute, the agency shall exhaust all available administrative procedures to obtain that relative’s contribution. If the responsible relative fails to contribute support after the agency notifies the relative of the obligation to do so, the agency shall notify the district attorney in order to commence legal action against that relative.

DHS 104.02 History History: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; corrections in (6) and (7) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; CR 20-039: am. (1) Register October 2021 No. 790, eff. 11-1-21.

DHS 104.03 DHS 104.03 Primary provider.

DHS 104.03(1) (1) Required designation.

DHS 104.03(1)(a) (a) Required when program is abused. If the department discovers that a recipient is abusing the program, including abuse under s. DHS 104.02 (5), the department may require the recipient to designate, in any or all categories of health care provider, a primary health care provider of the recipient’s choice, except when free choice is limited under s. DHS 104.035.

DHS 104.03(1)(b) (b) Selection of provider. The department shall allow a recipient to choose a primary provider from the department’s current list of certified providers, except when free choice is limited under s. DHS 104.035. The recipient’s choice shall become effective only with the concurrence of the designated primary provider. The type of service and identification number of the primary provider shall be endorsed on the recipient’s MA card.

DHS 104.03(1)(c) (c) Failure to cooperate. If the recipient fails to designate a primary provider after receiving a formal request from the department, the department shall designate a primary provider for the recipient in the proximity of the recipient’s residence.

DHS 104.03(2) (2) Referral to other providers. A primary provider may, within the scope of the provider’s practice, make referrals to other providers of medical services for which reimbursement will be made if the referral can be documented as medically necessary and the services are covered by MA. This documentation shall be made by the primary provider in the recipient’s medical record.

DHS 104.03(3) (3) Alternative primary provider. The department may allow the designation of an alternate primary provider. When approval is given by the department to select an alternate primary provider, the recipient may designate an alternate primary provider in the same manner a primary provider is designated.

DHS 104.03(4) (4) Exception. The limitations imposed in this section do not apply in the case of an emergency. Emergency health care provided by any provider to a recipient restricted under this section shall be eligible for reimbursement if the claim for reimbursement is accompanied by a full explanation of the emergency circumstances.

DHS 104.03 History History: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 104.035 DHS 104.035 Prudent buyer limitations. Free choice of a provider may be limited by the department if the department contracts for alternate service arrangements which are economical for the MA program and are within state and federal law, and if the recipient is assured of reasonable access to health care of adequate quality.

DHS 104.035 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 104.05 DHS 104.05 Preferred enrollment.

DHS 104.05(1) (1) Contracts for services from group plans. The department may enter into contracts for MA services with health maintenance organizations (HMOs) or prepaid health plans (PHPs). Each contract shall include specific information about services to be provided by the group, the number and types of practitioners who will provide the services, the geographic service area covered by the group plan, the period of time in which recipients are enrolled, the procedures for recipient enrollment, additional services which may be available, and the cost of services for each enrollee.

DHS 104.05(2) (2) Enrollment responsibility. MA recipients within the geographic area stipulated in a group plan service contract shall have the choice of enrolling for service membership under the following conditions:

DHS 104.05(2)(a) (a) Minimum enrollment period. The department may enter into arrangements with HMOs or PHPs which establish minimum enrollment periods for MA recipients.

DHS 104.05(2)(b) (b) Disenrollment period. In geographic areas where there is only one certified group plan provider, each recipient may be automatically enrolled in the group plan. A recipient may disenroll from the group plan, and the effective date of the disenrollment shall be no later than one month from the month in which the recipient disenrolls.

DHS 104.05(3) (3) Control of services. Enrollees in an HMO or PHP shall obtain services paid for by MA from that organization’s providers, except for referrals or emergencies. Recipients who obtain services in violation of this section shall pay for these services.

DHS 104.05(4) (4) Identification of covered services. Services available to MA recipients shall be identified in the provider’s contract with the department and shall be made known to all MA enrollees.

DHS 104.05 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.