Chapter DHS 105

DHS 105.39 Note Note: For covered transportation services, see s. DHS 107.23.

DHS 105.39(7) (7) Denial of recertification. If a provider violates provisions of this chapter, s. DHS 106.06, 107.23 or any other instruction in MA program manuals, handbooks, bulletins or letters on provision of SMV services 3 times in a 36-month period, the department may deny that provider’s request for re-certification.

DHS 105.39 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1), (2) (a), (b) (intro.), 1., (3) (a), (b), (4) (a), (5) (a), renum. (2) (b) 2. and 3. to be 3. and 4., cr. (2) (b) 2., (h), (7), r. and recr. (4) (b), (c), Register, November, 1994, No. 467, eff. 12-1-94; reprinted to restore dropped copy in (3), Register, January, 1997, No. 493; emerg. am. (4) (b) 3., eff. 7-3-99; am. (4) (b) 3., Register, December, 1999, No. 528, eff. 1-1-00; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; CR 03-033: r. (4) (b) 2., renum. (4) (b) 3. to be (4) (b) 2. Register December 2003 No. 576, eff. 1-1-04; corrections in (3) (b), (4) (b) 2. and (7) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; correction in (4) (b) 2. made under s. 13.92 (4) (b) 7., Stats., Register July 2011 No. 667; CR 20-039: am. (4) (b) 2. Register October 2021 No. 790, eff. 11-1-21.

DHS 105.40 DHS 105.40 Durable medical equipment and medical supply vendors.

DHS 105.40(1) (1) Except as provided in sub. (2), vendors of durable medical equipment and medical supplies shall be eligible to participate in the MA program.

DHS 105.40(2) (2) Orthotists and prosthetists who develop and fit appliances for recipients shall be certified by the American board for certification in orthotics and prosthetics (A.B.C.). Certification shall be a result of successful participation in an A.B.C. examination in prosthetics, orthotics, or both, and shall be for:

DHS 105.40(2)(a) (a) Certified prosthetist (C.P.);

DHS 105.40(2)(b) (b) Certified orthotist (C.O.); or

DHS 105.40(2)(c) (c) Certified prosthetist and orthotist (C.P.O.)

DHS 105.40 Note Note: For covered durable medical equipment and medical supply services, see s. DHS 107.24.

DHS 105.40 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 105.41 DHS 105.41 Certification of hearing instrument specialists. For MA certification, hearing instrument specialists shall be licensed pursuant to ss. 459.01 to 459.14, Stats.

DHS 105.41 Note Note: For covered hearing aids and supplies, see s. DHS 107.24.

DHS 105.41 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; CR 03-033: am. Register December 2003 No. 576, eff. 1-1-04.

DHS 105.42 DHS 105.42 Physician office laboratories.

DHS 105.42(1) (1) Requirements. For MA certification, physician office laboratories, except as noted in sub. (2), shall be licensed pursuant to 42 CFR 493 (CLIA).

DHS 105.42(2) (2) Exception. Physician office laboratories servicing no more than 2 physicians, chiropractors or dentists, and not accepting specimens on referral from outside providers, are not required to be licensed under 42 CFR 493 (CLIA). These laboratories, however, shall submit an affidavit to the department declaring that they do not accept outside specimens.

DHS 105.42(3) (3) Medicare certification requirement. Physician office laboratories which accept referrals of 100 or more specimens a year in a specialty shall be certified to participate in medicare in addition to meeting the requirements under sub. (1).

DHS 105.42 Note Note: For covered diagnostic testing services, see s. DHS 107.25.

DHS 105.42 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) and (2) made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.43 DHS 105.43 Hospital and independent clinical laboratories. For MA certification, a clinical laboratory that is a hospital laboratory or an independent laboratory shall be licensed pursuant to 42 CFR 493 (CLIA). In addition, the laboratory shall be certified to participate in medicare and meet the requirements of 42 CFR 405.1310 to 405.1317.

DHS 105.43 Note Note: For covered diagnostic testing services, see s. DHS 107.25.

DHS 105.43 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.44 DHS 105.44 Portable x-ray providers. For MA certification, a portable x-ray provider shall be directed by a physician or group of physicians, registered pursuant to s. 254.35, Stats., and ch. DHS 157, certified to participate in medicare, and shall meet the requirements of 42 CFR 405.1411 to 405.1416.

DHS 105.44 Note Note: For covered diagnostic testing services, see s. DHS 107.25.

DHS 105.44 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528; correction made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.45 DHS 105.45 Dialysis facilities. For MA certification, dialysis facilities shall meet the requirements enumerated in ss. DHS 152.05 and 152.08, and shall be certified to participate in medicare.

DHS 105.45 Note Note: For covered dialysis services, see s. DHS 107.26.

DHS 105.45 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, November, 1994, No. 467; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.46 DHS 105.46 Blood banks. For MA certification, blood banks shall be licensed or registered with the U.S. food and drug administration and shall be approved pursuant to 42 CFR 493 (CLIA).

DHS 105.46 Note Note: For covered blood services, see s. DHS 107.27.

DHS 105.46 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1999, No. 528.

DHS 105.47 DHS 105.47 Health maintenance organizations and prepaid health plans.

DHS 105.47(1) (1) Contracts and licensing. Except as provided in sub. (3), for MA certification, a health maintenance organization or prepaid health plan shall enter into a written contract with the department to provide services to enrolled recipients and shall be licensed by the Wisconsin commissioner of insurance.

DHS 105.47(2) (2) Requirements for health maintenance organizations. For MA certification, an HMO shall:

DHS 105.47(2)(a) (a) Meet the requirements of 42 CFR 434.20 (c);

DHS 105.47(2)(b) (b) Make services it provides to individuals eligible under MA accessible to these individuals, within the area served by the organization, to the same extent that the services are made accessible under the MA state plan to individuals eligible for MA who are not enrolled with the organization; and

DHS 105.47(2)(c) (c) Make adequate provision against the risk of insolvency, which is satisfactory to the department and which ensures that individuals eligible for benefits under MA are not held liable for debts of the organization in case of the organization’s insolvency.

DHS 105.47 Note Note: For covered health maintenance organization and prepaid health plan services, see s. DHS 107.28.

DHS 105.47(3) (3) Care organizations providing the family care benefit. A care management organization under contract with the department under s. DHS 10.42 is not required to be licensed by the Wisconsin commissioner of insurance if both of the following apply:

DHS 105.47(3)(a) (a) The organization enrolls only individuals who are eligible under s. 46.286, Stats.

DHS 105.47(3)(b) (b) The services offered by the organization do not include hospital or physician services.

DHS 105.47 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (3), Register, October, 2000, No. 538, eff. 11-1-00; correction in (3) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.48 DHS 105.48 Out-of-state providers.

DHS 105.48(1) (1) When a provider in a state that borders on Wisconsin documents to the department’s satisfaction that it is common practice for recipients in a particular area of Wisconsin to go for medical services to the provider’s locality in the neighboring state, the provider may be certified as a Wisconsin border status provider, subject to the certification requirements in this chapter and the same rules and contractual agreements that apply to Wisconsin providers, except that nursing homes are not eligible for border status.

DHS 105.48(2) (2) Out-of-state independent laboratories, regardless of location, may apply for certification as Wisconsin border status providers.

DHS 105.48(2m) (2m) Out-of-state providers who meet the definition of a border-status provider as described in s. DHS 101.03 (19) and who provide services to Wisconsin members via telehealth, regardless of provider location, may apply for certification as Wisconsin border-status providers if they are licensed in Wisconsin under applicable Wisconsin statute and administrative code.

DHS 105.48(3) (3) Other out-of-state providers who do not meet the requirements of sub. (1) may be reimbursed for non-emergency services provided to a Wisconsin MA recipient upon approval by the department under s. DHS 107.04.

DHS 105.48(4) (4) The department may review border status certification of a provider annually. Border status certification may be canceled by the department if it is found to be no longer warranted by medical necessity, volume or other considerations.

DHS 105.48(5) (5) 

DHS 105.48(5)(a) (a) A provider certified in another state for services not covered in Wisconsin shall be denied border status certification for these services in the Wisconsin program.

DHS 105.48 Note Note: Examples of providers whose services are not covered in Wisconsin are music therapists and art therapists.

DHS 105.48(5)(b) (b) A provider denied certification in another state shall be denied certification in Wisconsin, except that a provider denied certification in another state because the provider’s services are not MA-covered in that state may be eligible for Wisconsin border status certification if the provider’s services are covered in Wisconsin.

DHS 105.48 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. Register, September, 1991, No. 429, eff. 10-1-91; correction in (3) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-043: cr. (2m) Register May 2023 No. 809, eff. 6-1-23.

DHS 105.49 DHS 105.49 Ambulatory surgical centers. For MA certification, an ambulatory surgical center shall be certified to participate in medicare as an ambulatory surgical center under 42 CFR 416.39.

DHS 105.49 Note Note: For covered ambulatory surgical center services, see s. DHS 107.30.

DHS 105.49 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.50 DHS 105.50 Hospices. For MA certification, a hospice shall be certified to participate in medicare as a hospice under 42 CFR 418.50 to 418.100.

DHS 105.50 History History: Cr. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.51 DHS 105.51 Case management agency providers.

DHS 105.51(1) (1) Agency. For MA certification, a provider of case management services shall be an agency with state statutory authority to operate one or more community human service programs. A case management agency may be a county or Indian tribal department of community programs, a department of social services, a department of human services, or a county or tribal aging unit. Each applicant agency shall specify each population eligible for case management under s. DHS 107.32 (1) (a) 2. for which it will provide case management services. Each certified agency shall offer all 3 case management components described under s. DHS 107.32 (1) so that a recipient can receive the component or components that meet his or her needs.

DHS 105.51(2) (2) Employed personnel.

DHS 105.51(2)(a) (a) To provide case assessment or case planning services reimbursable under MA, persons employed by or under contract to the case management agency under sub. (1) shall:

DHS 105.51(2)(a)1. 1. Possess a degree in a human services-related field, possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed, and have acquired at least one year of supervised experience with the type of recipients with whom he or she will work; or

DHS 105.51(2)(a)2. 2. Possess 2 years of supervised experience or an equivalent combination of training and experience.

DHS 105.51 Note Note: The knowledge required in subd. 1. is typically gained through supervised experience working with persons in the target population.

DHS 105.51(2)(b) (b) To provide ongoing monitoring and service coordination reimbursable under MA, personnel employed by a case management agency under sub. (1) shall possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed.

DHS 105.51(3) (3) Sufficiency of agency certification for employed personnel. Individuals employed by or under contract to an agency certified to provide case management services under this section may provide case management services upon the department’s issuance of certification to the agency. The agency shall maintain a list of the names of individuals employed by or under contract to the agency who are performing case management services for which reimbursement may be claimed under MA. This list shall certify the credentials possessed by the named individuals which qualify them under the standards specified in sub. (2). Upon request, an agency shall promptly advise the department in writing of the employment of persons who will be providing case management services under MA and the termination of employees who have been providing case management services under MA.

DHS 105.51(4) (4) Contracted personnel. Persons under contract with a certified case management agency to provide assessments or case plans shall meet the requirements of sub. (2) (a), and to provide ongoing monitoring and service coordination, shall meet the requirements of sub. (2) (b).

DHS 105.51(5) (5) Recordkeeping. The case manager under s. DHS 107.32 (1) (d) shall maintain a file for each recipient receiving case management services which includes the following:

DHS 105.51(5)(a) (a) The assessment document;

DHS 105.51(5)(b) (b) The case plan;

DHS 105.51(5)(c) (c) Service contracts;

DHS 105.51(5)(d) (d) Financial forms;

DHS 105.51(5)(e) (e) Release of information forms;

DHS 105.51(5)(f) (f) Case reviews;

DHS 105.51(5)(g) (g) A written record of all monitoring and quality assurance activities; and

DHS 105.51(5)(h) (h) All pertinent correspondence relating to the recipient’s case management.

DHS 105.51(6) (6) Reimbursement.

DHS 105.51(6)(a) (a) Case management services shall be reimbursed when the services are provided by certified providers or their subcontractors to recipients eligible for case management.

DHS 105.51(6)(b) (b) Payment shall be made to certified providers of case management services according to terms of reimbursement established by the department.

DHS 105.51(7) (7) County election to participate.

DHS 105.51(7)(a) (a) The department may not certify a case management agency for a target population unless the county board or tribal government of the area in which the agency will operate has elected to participate in providing benefits under s. DHS 107.32 through providers operating in the county or tribal area. The county board or tribal government may terminate or modify its participation by giving a 30 day written notice to the department. This election is binding on any case management agencies providing services within the affected county or tribal area.

DHS 105.51(7)(b) (b) Any case management agency provider requesting certification under this section shall provide written proof of the election of the county or tribal government to participate under this subsection.

DHS 105.51 History History: Cr. Register, February, 1988, No. 386, eff. 3-1-88; corrections in (1) (a), (5) (intro.) and (7) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.52 DHS 105.52 Prenatal care coordination providers.

DHS 105.52(1) (1) Agency. For MA certification, an agency that provides prenatal care coordination services under s. DHS 107.34 (1) may be:

DHS 105.52(1)(a) (a) A community-based health organization;

DHS 105.52(1)(b) (b) A community-based social services agency or organization;