Chapter DHS 105

DHS 105.52(1)(h) (h) An independent physician association (IPA);

DHS 105.52(1)(i) (i) A hospital;

DHS 105.52(1)(j) (j) A physician’s office or clinic;

DHS 105.52(1)(k) (k) A private case management agency;

DHS 105.52(1)(L) (L) A registered nurse or nurse practitioner;

DHS 105.52(1)(m) (m) A rural health clinic certified under s. DHS 105.35;

DHS 105.52(1)(n) (n) A tribal agency health center; or

DHS 105.52(1)(o) (o) A women, infants, and children (WIC) program under 42 USC 1786.

DHS 105.52(2) (2) Qualified professionals.

DHS 105.52(2)(a) (a) Definition. In this subsection, “qualified professional” means any of the following:

DHS 105.52(2)(a)1. 1. A nurse practitioner licensed as a registered nurse pursuant to s. 441.06, Stats., and currently certified by the American nurses’ association, the national board of pediatric nurse practitioners and associates or the nurses’ association of the American college of obstetricians and gynecologists’ certification corporation;

DHS 105.52(2)(a)2. 2. A nurse midwife certified under s. DHS 105.201;

DHS 105.52(2)(a)3. 3. A public health nurse meeting the qualifications of s. DHS 139.08;

DHS 105.52(2)(a)4. 4. A physician licensed under ch. 448, Stats., to practice medicine or osteopathy;

DHS 105.52(2)(a)5. 5. A physician assistant certified under ch. 448, Stats.;

DHS 105.52(2)(a)6. 6. A dietitian certified or eligible for registration by the commission on dietetic registration of the American dietetic association with at least 2 years of community health experience;

DHS 105.52(2)(a)7. 7. A registered nurse with at least 2 years of experience in maternity nursing or community health services or a combination of maternity nursing and community health services;

DHS 105.52(2)(a)8. 8. An employee with at least a bachelor’s degree and 2 years of experience in a health care or family services program; or

DHS 105.52(2)(a)9. 9. A health educator with a master’s degree in health education and at least 2 years of experience in community health services.

DHS 105.52(2)(b) (b) Required qualified professionals. To be certified to provide prenatal care coordination services that are reimbursable under MA, the prenatal care coordination agency under sub. (1) shall:

DHS 105.52(2)(b)1. 1. Employ at least one qualified professional with at least 2 years of experience in coordinating services for at-risk or low income women;

DHS 105.52(2)(b)2. 2. Have on staff, under contract or available in a volunteer capacity a qualified professional to supervise risk assessment and ongoing care coordination and monitoring; and

DHS 105.52(2)(b)3. 3. Have on staff, under contract or available in a volunteer capacity one or more qualified professionals with the necessary expertise, based on education or at least one year of work experience, to provide health education and nutrition counseling.

DHS 105.52(3) (3) Sufficiency of agency certification. Individuals employed by or under contract with an agency that is certified to provide prenatal care coordination services under this section may provide prenatal care coordination services upon the department’s issuance of certification to the agency. The agency shall maintain a list of all persons who provide or supervise the provision of prenatal care coordination services. The list shall include the credentials of each named individual who is qualified to supervise risk assessment and ongoing care coordination under sub. (2) (b) 2. and to provide health education or nutrition counseling under sub. (2) (b) 3. Upon the department’s request, an agency shall promptly report to the department in writing the names of persons hired to provide prenatal care coordination services under MA and the termination of employees who have been providing prenatal care coordination services under MA.

DHS 105.52(4) (4) Administrative records and required documentation. To be certified to provide prenatal care coordination services reimbursable under MA, the prenatal care coordination agency under sub. (1) shall comply with s. DHS 106.02 (9) and shall submit a plan to the department documenting:

DHS 105.52(4)(a) (a) That the agency is located in the area it will serve;

DHS 105.52(4)(b) (b) That the agency has a variety of techniques to identify low-income pregnant women;

DHS 105.52(4)(c) (c) That, at a minimum, the agency has the name, location and telephone number of the following resources in the area to be served:

DHS 105.52(4)(c)1. 1. Women, infants, and children (WIC) programs;

DHS 105.52(4)(c)2. 2. Maternal and child health services;

DHS 105.52(4)(c)3. 3. The county, city, or combined city and county public health agency;

DHS 105.52(4)(c)4. 4. Child day care services;

DHS 105.52(4)(c)5. 5. Mental health and alcohol or other drug abuse prevention and treatment agencies;

DHS 105.52(4)(c)6. 6. The county protective service agency;

DHS 105.52(4)(c)7. 7. Domestic abuse agencies;

DHS 105.52(4)(c)8. 8. Translator and interpreter services including services for the hearing-impaired;

DHS 105.52(4)(c)9. 9. Family support services;

DHS 105.52(4)(c)10. 10. Transportation services; and

DHS 105.52(4)(c)11. 11. MA-certified primary care and obstetric providers, including health maintenance organizations participating in the medical assistance program’s HMO program.

DHS 105.52(4)(d) (d) That the agency, if located in a county with health maintenance organizations (HMO) participating in the medical assistance HMO program, has on file a signed copy of a memorandum of understanding with each HMO participating in the medical assistance HMO program in the county;

DHS 105.52(4)(e) (e) That the agency has contacted in writing MA-certified primary and obstetric care providers in its area and has identified the types of services the prenatal care coordination agency provides. These contacts and this information shall be documented and the documentation retained in the agency’s administrative records;

DHS 105.52(4)(f) (f) That the agency has the ability and willingness to deliver services in a manner that is sensitive to the particular characteristics of the racial or ethnic group or groups with which it intends to work. Documentation of that ability shall be maintained and kept up-to-date. Documentation shall consist of one or more of the following at all times:

DHS 105.52(4)(f)1. 1. Records showing the racial and ethnic composition of the population served in the past;

DHS 105.52(4)(f)2. 2. Records showing that the agency has developed, implemented and evaluated programs specifically targeted toward the racial or ethnic group or groups;

DHS 105.52(4)(f)3. 3. Records showing that the agency has provided health care services in a geographic area where a significant percentage of the population was the same as the agency’s targeted racial or ethnic group or groups;

DHS 105.52(4)(f)4. 4. Evidence that the agency’s board or administration has a significant amount of representation from the targeted group or groups;

DHS 105.52(4)(f)5. 5. Letters of support from minority health service organizations which represent the targeted group or groups; or

DHS 105.52(4)(f)6. 6. Evidence of the agency’s ability to address pertinent cultural issues such as cultural norms and beliefs, language, outreach networking and extended family relationships;

DHS 105.52(4)(g) (g) That the agency has the ability to arrange for supportive services provided by other funding sources such as county transportation, county protective services, interpreter services, child care services and housing. This description shall include the methods, techniques and contacts which will be used to offer and provide assistance in accessing those services;

DHS 105.52(4)(h) (h) That the agency has the capability to provide ongoing prenatal care coordination monitoring of high-risk pregnant women and to ensure that all necessary services are obtained; and

DHS 105.52(4)(i) (i) That the agency has on staff, under contract or available in a volunteer capacity, individuals who are qualified professionals under sub. (2) (a) with the expertise required under sub. (2) (b).

DHS 105.52(5) (5) Recipient record. The prenatal care coordination agency shall maintain a confidential prenatal care coordination file for each recipient receiving prenatal care coordination services, which includes the following items required or produced in connection with provision of covered services under s. DHS 107.34 (1):

DHS 105.52(5)(a) (a) Verification of the pregnancy;

DHS 105.52(5)(b) (b) Completed risk assessment document;

DHS 105.52(5)(c) (c) Care plan;

DHS 105.52(5)(d) (d) Completed consent documents for release of information;

DHS 105.52(5)(e) (e) A written record of all recipient-specific prenatal care coordination monitoring which includes, but is not limited to: the dates of service, description of service provided, the staff person doing the monitoring, the contacts made and the results;

DHS 105.52(5)(f) (f) Referrals and follow-up; and

DHS 105.52(5)(g) (g) All pertinent correspondence relating to coordination of the recipient’s prenatal care.

DHS 105.52 History History: Cr. Register, June, 1994, No. 462, eff. 7-1-94; CR 03-033: am. (1) (L), (2) (a) (intro.), 1., 6. to 8. Register December 2003 No. 576, eff. 1-1-04; corrections in (1) (intro.), (2) (a) 3., (4) (intro.) and (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 105.53 DHS 105.53 School-based service providers.

DHS 105.53(1) (1) Eligible providers. For MA certification, a school-based service provider shall be either a school district under ch. 120, Stats., or a cooperative educational service agency (CESA) under ch. 116, Stats.

DHS 105.53(2) (2) Separate certification prohibited. No school district or CESA may be separately certified as a provider of nursing services under ss. DHS 105.19 and 105.20, physical therapy services under s. DHS 105.27, occupational therapy services under s. DHS 105.28, speech and language pathology services under ss. DHS 105.29 and 105.30, audiology services under s. DHS 105.31 or transportation services under s. DHS 105.39.

DHS 105.53(3) (3) Record-keeping requirements.

DHS 105.53(3)(a) (a) For each recipient of school-based services, the provider shall keep a record containing, at a minimum, all of the following:

DHS 105.53(3)(a)1. 1. The recipient’s first and last name and date of birth;

DHS 105.53(3)(a)2. 2. The prescription or, if referred, the referral for the service;

DHS 105.53(3)(a)3. 3. Documentation used to develop the recipient’s IEP and to annually revise the IEP; and

DHS 105.53(3)(a)4. 4. Annual documentation of the individual’s progress toward treatment goals identified in the IEP, changes in the individual’s physical or mental status and changes in the treatment plan identified in the IEP.

DHS 105.53(3)(b) (b) For each date of service, the provider shall keep a service record within the recipient’s record containing all of the following:

DHS 105.53(3)(b)1. 1. The date of service;

DHS 105.53(3)(b)2. 2. The general type of service provided;

DHS 105.53(3)(b)3. 3. A brief description of the specific service provided;

DHS 105.53(3)(b)4. 4. The unit of service delivered as defined through handbooks distributed by the department under s. DHS 108.02 (4);

DHS 105.53(3)(b)5. 5. A description and the cost of each durable medical equipment item with sufficient detail to allow the MA program to determine the reimbursement rate, when appropriate; and

DHS 105.53(3)(b)6. 6. Documentation of whether the procedure was provided in a group or individual setting, when appropriate.

DHS 105.53(3)(c) (c) Periodically, at least monthly, the provider shall include in the service record under par. (b) the following:

DHS 105.53(3)(c)1. 1. For each service provided, a brief description of the recipient’s response to the service and progress toward the treatment goals identified in the IEP; and

DHS 105.53(3)(c)2. 2. The service provider’s signature.

DHS 105.53(3)(d) (d) The provider shall include in the records other information identified by the department in publications in accordance with s. DHS 108.02 (4).

DHS 105.53(4) (4) Reporting requirements. The required annual audit of school district accounts under s. 120.14, Stats., and the audit of CESA receipts and expenditures under s. 115.28 (3m), Stats., shall include evidence, in accordance with instructions distributed by the department under s. DHS 108.02 (4), that requirements for billing and for paying expenses under s. 49.45 (39) (b), Stats., are being met. Sections of those annual audits shall be made available to the department upon request.

DHS 105.53(5) (5) Reimbursement.

DHS 105.53(5)(a) (a) School-based services shall be reimbursed when the services are provided by certified providers or their contractors to recipients eligible for school-based services.

DHS 105.53(5)(b) (b) Payment, based on the cost to provide the service, shall be made to certified providers of school-based services according to terms of reimbursement established by the department and stated in the medicaid state plan under 42 CFR 430.10.

DHS 105.53(5)(c) (c) Services provided between July 1, 1995 and June 30, 1996 may be billed through June 30, 1997, to the extent allowed by federal law, notwithstanding s. DHS 106.03 (3) (b) 1.

DHS 105.53(6) (6) Coordination with other MA-certified providers.

DHS 105.53(6)(a) (a) Memorandum of understanding with HMO. School-based services providers shall have on file a signed copy of a memorandum of understanding with each HMO participating in the medical assistance HMO program when the geographic service area of the HMO coincides with part or all of the geographic service area of the school-based services provider.

DHS 105.53(6)(b) (b) Coordination with fee-for-service providers. When a recipient receives similar services from both an MA fee-for-service provider and a school-based service provider, the school-based service provider shall document, at least annually, regular contacts with the MA fee-for-service provider, and provide the MA fee-for-service provider with copies of the recipient’s IEP and relevant components of the multidisciplinary team evaluation under s. 115.80 (3) and (5), Stats., upon request.

DHS 105.53 History History: Emerg. cr. eff. 6-15-96; cr. Register, January, 1997, No. 497, eff. 2-1-97; CR 03-033: am. (3) (a) 3., 4., (c) 1. and (6) (b) Register December 2003 No. 576, eff. 1-1-04; corrections in (3) (b) 4., (d), (4) and (5) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.