This is the preview version of the Wisconsin State Legislature site.
Please see http://docs.legis.wisconsin.gov for the production version.
Alert! This chapter may be affected by an emergency rule:
(L) Drugs included in the medicaid negative drug formulary maintained by the department; and
(m) Drugs produced by a manufacturer who does not meet the requirements of 42 USC 1396r-8, unless sub. (2) (e) or (3) (j) applies.
(n) Drugs provided for the treatment of males or females for infertility or to enhance the prospects of fertility;
(o) Drugs provided for the treatment of impotence;
(p) Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual anatomy or characteristics;
Note: In Flack v. Wisconsin Dep’t of Health Servs, 395 F. Supp. 3d 1001 (W.D. Wis. 2019), the United States District Court for the Western District of Wisconsin held that ss. DHS 107.03 (23) and (24) and 107.10 (4) (p) violated the Equal Protection Clause of the Fourteenth Amendment, s. 1557 of the Affordable Care Act, and the federal Medicaid Act. The court in Flack permanently enjoined the department from enforcing those provisions.
(q) Drugs or combinations of drugs that are administered to induce abortions, when the abortions do not comply with s. 20.927, Stats., and s. DHS 107.10 (3) (L).
(s) Infant formula, except when the product and recipient’s health condition meet the criteria established by the department under sub. (2) (c) to verify medical need; and
(t) Enteral nutritional products that do not meet the criteria established by the department under sub. (2) (c) to verify medical need, when an alternative nutrition source is available, or that are solely for the convenience of the caregiver or the recipient.
(5)Drug review, counseling and recordkeeping. In addition to complying with ch. Phar 7, a pharmacist shall fulfill the requirements of 42 USC 1396r-8 (g) (2) (A) as follows:
(a) The pharmacist shall review the drug therapy before each prescription is filled or delivered to an MA recipient. The review shall include screening for potential drug therapy problems including therapeutic duplication, drug–disease contraindications, drug–drug interactions, including serious interactions with non-legend drugs, incorrect drug dosage or duration of drug treatment, drug–allergy interactions and clinical abuse or misuse.
(b) The pharmacist shall offer to discuss with each MA recipient, the recipient’s legal representative or the recipient’s caregiver who presents the prescription, matters which, in the exercise of the pharmacist’s professional judgment and consistent with state statutes and rules governing provisions of this information, the pharmacist deems significant, including the following:
1. The name and description of the medication;
2. The route, dosage form, dosage, route of administration, and duration of drug therapy;
3. Specific directions and precautions for preparation, administration and use by the patient;
4. Common severe side effects or adverse effects or interactions and therapeutic contraindications that may be encountered, including how to avoid them, and the action required if they occur;
5. Techniques for self-monitoring drug therapy;
6. Proper storage;
7. Prescription refill information; and
8. Action to be taken in the event of a missed dose.
(c) The pharmacist shall make a reasonable effort to obtain, record and maintain at least the following information regarding each MA recipient for whom the pharmacist dispenses drugs under the MA program:
1. The individual’s name, address, telephone number, date of birth or age and gender;
2. The individual’s history where significant, including any disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices; and
3. The pharmacist’s comments relevant to the individual’s drug therapy.
(d) Nothing in this subsection shall be construed as requiring a pharmacist to provide consultation when an MA recipient, the recipient’s legal representative or the recipient’s caregiver refuses the consultation.
History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (3) (h), Register, February, 1988, No. 386, eff. 3-1-88; emerg. am. (2) (e) and (f), (4) (k), cr. (2) (g), (3) (j) and (k), (4) (L), eff. 4-27-91; r. and recr. Register, December, 1991, No. 432, eff. 1-1-92, r. and recr. (2) (c), am. (2) (d) and (e), cr. (2) (f) and (g), (3) (L) and (4) (n) to (t), Register, January, 1997, No. 493, eff. 2-1-97; CR 03-033: am. (1), (2) (d), (3) (b) to (d), (h) (intro.), (i), (4) (L) and (5) (a), r. (2) (a), cr. (3) (h) 8. Register December 2003 No. 576, eff. 1-1-04; correction in (1) made under s. 13.92 (4) (b)7., Stats., Register February 2014 No. 698; 2021 Wis. Act 125: am. (2) (c) Register February 2022 No. 794, eff. 2-6-22.
DHS 107.11Home health services.
(1)Definitions. In this section:
(a) “Community-based residential facility” has the meaning prescribed in s. 50.01 (1g), Stats.
(b) “Home health aide services” means medically oriented tasks, assistance with activities of daily living and incidental household tasks required to facilitate treatment of a recipient’s medical condition or to maintain the recipient’s health.
(c) “Home health visit” or “visit” means a period of time of any duration during which home health services are provided through personal contact by agency personnel of less than 8 hours a day in the recipient’s place of residence for the purpose of providing a covered home health service. The services are provided by a home health provider employed by a home health agency, by a home health provider under contract to a home health agency according to the requirements of s. DHS 133.19 or by arrangement with a home health agency. A visit begins when the home health provider starts to provide a covered service and ends when the service is complete.
(d) “Home health provider” means a person who is an RN, LPN, home health aide, physical or occupational therapist, speech pathologist, certified physical therapy assistant or certified occupational therapy assistant.
(e) “Initial visit” means the first home health visit of any duration in a calendar day provided by a registered nurse, licensed practical nurse, home health aide, physical or occupational therapist or speech and language pathologist for the purpose of delivering a covered home health service to a recipient.
(f) “Subsequent visit” means each additional visit of any duration following the initial visit in a calendar day provided by an RN, LPN or home health aide for the purpose of delivering a covered home health service to a recipient.
(g) “Unlicensed caregiver” means a home health aide or personal care worker.
(2)Covered home health services. Services provided by an agency certified under s. DHS 105.16 which are covered by MA are those reasonable and medically necessary services required to treat the recipient’s condition. Covered services must meet all of the following criteria:
(a) The services are performed according to the requirements of s. DHS 105.16.
(b) The services are provided in a place other than a hospital or nursing home.
(c) The services provided are any of the following:
1. Skilled nursing services provided under a plan of care which requires less than 8 hours of skilled nursing care per day and specifies which level of care the nurse is qualified to provide. Skilled nursing services are any of the following:
a. Nursing services performed by a registered nurse, or by a licensed practical nurse under the supervision of a registered nurse, according to the written plan of care and accepted standards of medical and nursing practice, in accordance with ch. N 6.
b. Services which, due to the recipient’s medical condition, may be only safely and effectively provided by an RN or LPN.
c. Assessments performed only by a registered nurse.
d. Teaching and training of the recipient, the recipient’s family or other caregivers requiring the skills on an RN or LPN.
2. Home health aide services and medical supplies, equipment, and appliances. Home health services are any of the following:
a. Medically oriented tasks which cannot be safely delegated by an RN as determined and documented by the RN to a personal care worker who has not received special training in performing tasks for the specific individual, and which may include, but are not limited to, medically oriented activities directly supportive of skilled nursing services provided to the recipient. These may include assistance with and administration of oral, rectal and topical medications ordinarily self-administered and supervised by an RN according to 42 CFR 483.36 (d), ch. DHS 133, and ch. N 6, and assistance with activities directly supportive of current and active skilled therapy and speech pathology services and further described in the Wisconsin medical assistance home health agency provider handbook.
b. Assistance with the recipient’s activities of daily living only when provided on conjunction with a medically oriented task that cannot be safely delegated to a personal care worker as determined and documented by the delegating RN. Assistance with the recipient’s activities of daily living consists of medically oriented tasks when a reasonable probability exists that the recipient’s medical condition will worsen during the period when assistance is provided, as documented by the delegating RN. A recipient whose medical condition has exacerbated during care activities sometime in the past 6 months is considered to have a condition which may worsen when assistance is provided. Activities of daily living include, but are not limited to, bathing, dressing, grooming and personal hygiene activities, skin, foot and ear care, eating, elimination, ambulation, and changing bed positions.
c. Household tasks incidental to direct care activities described in subd. 2. a. and b.
3. Therapy and speech pathology services which the agency is certified to provide.
(d) The services are included in the written plan of care.
(e) The services are provided with supervision from, and coordination of all nursing care by, a registered nurse.
(2m)Additional requirements for covered home health services.
(a) Covered services provided under sub. (2) must only be safely and effectively performed by a skilled therapist or speech pathologist or by a certified therapy assistant who receives supervision by the certified therapist according to 42 CFR 484.32.
(b) Based on the assessment by the recipient’s physician of the recipient’s rehabilitation potential, services provided under sub. (2) are expected to materially improve the recipient’s condition within a reasonable, predictable time period, or are necessary to establish a safe and effective maintenance program for the recipient.
(c) In conjunction with the written plan of care, a therapy evaluation shall be conducted prior to the provision of services under sub. (2) by the therapist or speech pathologist who will provide the services to the recipient.
(d) The therapist or speech pathologist shall provide a summary of activities, including goals and outcomes, to the physician at least every 62 days, and upon conclusion of therapy services
(3)Prior authorization. Prior authorization is required to review utilization of services and assess the medical necessity of continuing services for:
(a) All home health visits when the total of any combination of skilled nursing, home health aide, physical and occupational therapist and speech pathologist visits by all providers exceeds 30 visits in a calendar year, including situations when the recipient’s care is shared among several certified providers;
(b) All home health aide visits when the services are provided in conjunction with private duty nursing under s. DHS 107.12 or the provision of respiratory care services under s. DHS 107.113;
(c) All medical supplies and equipment for which prior authorization is required under s. DHS 107.24;
(d) All home health aide visits when 4 or more hours of continuous care is medically necessary; and
(e) All subsequent skilled nursing visits.
(4)Other limitations.
(a) The written plan of care shall be developed and reviewed concurrently with and in support of other health sustaining efforts for the recipient in the home.
(b) All durable medical equipment and disposable medical supplies shall meet the requirements of s. DHS 107.24.
(c) Services provided to a recipient who is a resident of a community-based residential facility shall be rendered according to the requirements of ch. DHS 83 and shall not duplicate services that the facility has agreed to provide.
1. Except as provided in subd. 2., home health skilled nursing services provided by one or more providers are limited to less than 8 hours per day per recipient as required by the recipient’s medical condition.
2. If the recipient’s medical condition worsens so that 8 or more hours of direct, skilled nursing services are required in a calendar day, a maximum of 30 calendar days of skilled nursing care may continue to be reimbursed as home health services, beginning on the day 8 hours or more of skilled nursing services became necessary. To continue medically necessary services after 30 days, prior authorization for private duty nursing is required under s. DHS 107.12 (2).
(e) An intake evaluation is a covered home health skilled nursing service only if, during the course of the initial visit to the recipient, the recipient is admitted into the agency’s care and covered skilled nursing services are performed according to the written physician’s orders during the visit.
(f) A skilled nursing ongoing assessment for a recipient is a covered service:
1. When the recipient’s medical condition is stable, the recipient has not received a covered skilled nursing service, covered personal care service, or covered home visit by a physician service within the past 62 days, and a skilled assessment is required to re-evaluate the continuing appropriateness of the plan of care. In this paragraph, “medically stable” means the recipient’s physical condition is non-acute, without substantial change or fluctuation at the current time.
2. When the recipient’s medical condition requires skilled nursing personnel to identify and evaluate the need for possible modification of treatment;
3. When the recipient’s medical condition requires skilled nursing personnel to initiate additional medical procedures until the recipient’s treatment regimen stabilizes, but is not part of a longstanding pattern of care; or
4. If there is a likelihood of complications or an acute episode.
(g) Teaching and training activities are covered services only when provided to the recipient, recipient’s family or other caregiver in conjunction with other covered skilled nursing care provided to the recipient.
(h) A licensed nurse shall administer medications to a minor child or to an adult who is not self-directing, as determined by the physician, to direct or administer his or her own medications, when a responsible adult is not present to direct the recipient’s medication program.
(i) Services provided by an LPN which are not delegated by an RN under s. N 6.03 are not covered services.
(j) Skilled physical and occupational therapy and speech pathology services are not to include activities provided for the general welfare of the recipient or activities to provide diversion for the recipient or to motivate the recipient.
(k) Skilled nursing services may be provided for a recipient by one or more home health agencies or by an agency contracting with a nurse or nurses only if the agencies meet the requirements of ch. DHS 133 and are approved by the department.
(L) RN supervision and administrative costs associated with the provision of services under this section are not separately reimbursable MA services.
(m) Home health aide service limitations are the following:
1. A home health aide may provide assistance with a recipient’s medications only if the written plan of care documents the name of the delegating registered nurse and the recipient is aged 18 or more;
2. Home health aide services are primarily medically oriented tasks, as determined by the delegating RN, when the instability of the recipient’s condition as documented in the medical record is such that the recipient’s care cannot be safely delegated to a personal care worker under s. DHS 107.112;
3. A home health aide visit which is a covered service shall include at least one medically oriented task performed during a visit which cannot, in the judgment of the delegating RN, be safely delegated to a personal care worker; and
4. A home health aide, rather than a personal care worker, shall always provide medically oriented services for recipients who are under age 18.
(5)Non-covered services. The following services are not covered home health services:
(a) Services that are not medically necessary;
Loading...
Loading...
Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.