Wisconsin Legislature: DHS 107.21(1)(b)5.d.

Alert! This chapter may be affected by an emergency rule:

EmR2421

Note: Under the department’s vision care volume purchase plan, MA-certified vision care providers must order all eyeglasses and component parts prescribed for MA recipients directly from a supplier under contract with the department to supply those items.

(e) All contact lenses and all contact lens therapy, including related materials and services, except where the recipient’s diagnosis is aphakia or keratoconus;

(f) Ptosis crutch services and materials;

(g) Eyeglass frames or lenses beyond the original and one unchanged prescription replacement pair from the same provider in a 12-month period; and

(h) Low vision services.

Note: For more information on prior authorization, see s. DHS 107.02 (3).

(3) Other limitations.

(a) Eyeglass frames, lenses, and replacement parts shall be provided by dispensing opticians, optometrists and ophthalmologists in accordance with the department’s vision care volume purchase plan. The department may purchase from one or more optical laboratories some or all ophthalmic materials for dispensing by opticians, optometrists or ophthalmologists as benefits of the program.

(b) Lenses and frames shall comply with ANSI standards.

(d) The department may define minimal prescription levels for lenses covered by MA. These limitations shall be published by the department in the MA vision care provider handbook.

(4) Non-covered services. The following services and materials are not covered services:

(a) Anti-glare coating;

(b) Spare eyeglasses or sunglasses; and

(c) Services provided principally for convenience or cosmetic reasons, including but not limited to gradient focus, custom prosthesis, fashion or cosmetic tints, engraved lenses and anti-scratch coating.

Note: For more information on non-covered services, see s. DHS 107.03.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.21 Family planning services.

(1) Covered services.

(a) General. Covered family planning services are the services included in this subsection when prescribed by a physician and provided to a recipient, including initial physical exam and health history, annual office visits and follow-up office visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services and prescribing medication for specific treatments. All family planning services performed in family planning clinics shall be prescribed by a physician, and furnished, directed or supervised by a physician, registered nurse, nurse practitioner, licensed practical nurse or nurse midwife under s. 441.15 (1) and (2) (b), Stats.

(b) Physical examination. An initial physical examination with health history is a covered service and shall include the following:

1. Complete obstetrical history including menarche, menstrual, gravidity, parity, pregnancy outcomes and complications of pregnancy or delivery, and abortion history;

2. History of significant illness-morbidity, hospitalization and previous medical care, particularly in relation to thromboembolic disease, any breast or genital neoplasm, any diabetic or prediabetic condition, cephalalgia and migraine, pelvic inflammatory disease, gynecologic disease and venereal disease;

3. History of previous contraceptive use;

4. Family, social, physical health, and mental health history, including chronic illnesses, genetic aberrations and mental depression;

5. Physical examination. Recommended procedures for examination are:

a. Thyroid palpation;

b. Examination of breasts and axillary glands;

c. Auscultation of heart and lungs;

d. Blood pressure measurement;

e. Height and weight measurement;

f. Abdominal examination;

g. Pelvic examination; and

h. Examination of extremities.

(c) Laboratory and other diagnostic services. Laboratory and other diagnostic services are covered services as indicated in this paragraph. These services may be performed in conjunction with an initial examination with health history, and are the following:

1. Routinely performed procedures:

a. CBC, or hematocrit or hemoglobin;

b. Urinalysis;

c. Papanicolaou smear for females between the ages of 12 and 65;

d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and

e. Serology;

2. Procedures covered if indicated by the recipient’s health history:

a. Skin test for TB;

b. Vaginal smears and wet mounts for suspected vaginal infection;

c. Pregnancy test;

d. Rubella titer;

e. Sickle-cell screening;

f. Post-prandial blood glucose; and

g. Blood test for cholesterol, and triglycerides when related to oral contraceptive prescription;

3. Diagnostic and other procedures not for the purpose of enhancing the prospects of fertility in males or females;

a. Endometrial biopsy when performed after a hormone blood test;

b. Laparoscopy;

c. Cervical mucus exam;

d. Vasectomies;

e. Culdoscopy; and

f. Colposcopy;

4. Procedures relating to genetics, including:

a. Ultrasound;

b. Amniocentesis;

c. Tay-Sachs screening;

d. Hemophilia screening;

e. Muscular dystrophy screening; and

f. Sickle-cell screening; and

5. Colposcopy, culdoscopy, and laparoscopy procedures which may be either diagnostic or treatment procedures.

(d) Counseling services. Counseling services in the clinic are covered as indicated in this paragraph. These services may be performed or supervised by a physician, registered nurse or licensed practical nurse. Counseling services may be provided as a result of request by a recipient or when indicated by exam procedures and health history. These services are limited to the following areas of concern:

1. Instruction on reproductive anatomy and physiology;

2. Overview of available methods of contraception, including natural family planning. An explanation of the medical ramifications and effectiveness of each shall be provided;

3. Counseling about venereal disease;

4. Counseling about sterilization accompanied by a full explanation of sterilization procedures including associated discomfort and risks, benefits, and irreversibility;

5. Genetic counseling accompanied by a full explanation of procedures utilized in genetic assessment, including information regarding the medical ramifications for unborn children and planning of care for unborn children with either diagnosed or possible genetic abnormalities;

6. Information regarding teratologic evaluations; and

7. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

(e) Contraceptive methods. Procedures related to the prescription of a contraceptive method are covered services. The contraceptive method selected shall be the choice of the recipient, based on full information, except when in conflict with sound medical practice. The following procedures are covered:

1. Those related to intrauterine devices (IUD):

a. Furnishing and fitting of the device;

b. Localization procedures limited to sonography, and up to 2 x-rays with interpretation;

c. A follow-up office visit once within the first 90 days of insertion; and

d. Extraction;

2. Those related to diaphragms:

a. Furnishing and fitting of the device; and

b. A follow-up office visit once within 90 days after furnishing and fitting;

3. Those related to contraceptive pills:

a. Furnishing and instructions for taking the pills; and

b. A follow-up office visit once during the first 90 days after the initial prescription to assess physiological changes. This visit shall include taking blood pressure and weight, interim history and laboratory examinations as necessary.

(f) Office visits. Follow-up office visits performed by either a nurse or a physician and an annual physical exam and health history are covered services.

(g) Supplies. The following supplies are covered when prescribed:

1. Oral contraceptives;

2. Diaphragms;

3. Jellies, creams, foam and suppositories;