Chapter DHS 107

DHS 107.21(1)(c)1. 1. Routinely performed procedures:

DHS 107.21(1)(c)1.a. a. CBC, or hematocrit or hemoglobin;

DHS 107.21(1)(c)1.b. b. Urinalysis;

DHS 107.21(1)(c)1.c. c. Papanicolaou smear for females between the ages of 12 and 65;

DHS 107.21(1)(c)1.d. d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and

DHS 107.21(1)(c)1.e. e. Serology;

DHS 107.21(1)(c)2. 2. Procedures covered if indicated by the recipient’s health history:

DHS 107.21(1)(c)2.a. a. Skin test for TB;

DHS 107.21(1)(c)2.b. b. Vaginal smears and wet mounts for suspected vaginal infection;

DHS 107.21(1)(c)2.c. c. Pregnancy test;

DHS 107.21(1)(c)2.d. d. Rubella titer;

DHS 107.21(1)(c)2.e. e. Sickle-cell screening;

DHS 107.21(1)(c)2.f. f. Post-prandial blood glucose; and

DHS 107.21(1)(c)2.g. g. Blood test for cholesterol, and triglycerides when related to oral contraceptive prescription;

DHS 107.21(1)(c)3. 3. Diagnostic and other procedures not for the purpose of enhancing the prospects of fertility in males or females;

DHS 107.21(1)(c)3.a. a. Endometrial biopsy when performed after a hormone blood test;

DHS 107.21(1)(c)3.b. b. Laparoscopy;

DHS 107.21(1)(c)3.c. c. Cervical mucus exam;

DHS 107.21(1)(c)3.d. d. Vasectomies;

DHS 107.21(1)(c)3.e. e. Culdoscopy; and

DHS 107.21(1)(c)3.f. f. Colposcopy;

DHS 107.21(1)(c)4. 4. Procedures relating to genetics, including:

DHS 107.21(1)(c)4.a. a. Ultrasound;

DHS 107.21(1)(c)4.b. b. Amniocentesis;

DHS 107.21(1)(c)4.c. c. Tay-Sachs screening;

DHS 107.21(1)(c)4.d. d. Hemophilia screening;

DHS 107.21(1)(c)4.e. e. Muscular dystrophy screening; and

DHS 107.21(1)(c)4.f. f. Sickle-cell screening; and

DHS 107.21(1)(c)5. 5. Colposcopy, culdoscopy, and laparoscopy procedures which may be either diagnostic or treatment procedures.

DHS 107.21(1)(d) (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:

DHS 107.21(1)(d)1. 1. Instruction on reproductive anatomy and physiology;

DHS 107.21(1)(d)2. 2. Overview of available methods of contraception, including natural family planning. An explanation of the medical ramifications and effectiveness of each shall be provided;

DHS 107.21(1)(d)3. 3. Counseling about venereal disease;

DHS 107.21(1)(d)4. 4. Counseling about sterilization accompanied by a full explanation of sterilization procedures including associated discomfort and risks, benefits, and irreversibility;

DHS 107.21(1)(d)5. 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;

DHS 107.21(1)(d)6. 6. Information regarding teratologic evaluations; and

DHS 107.21(1)(d)7. 7. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.

DHS 107.21(1)(e) (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:

DHS 107.21(1)(e)1. 1. Those related to intrauterine devices (IUD):

DHS 107.21(1)(e)1.a. a. Furnishing and fitting of the device;

DHS 107.21(1)(e)1.b. b. Localization procedures limited to sonography, and up to 2 x-rays with interpretation;

DHS 107.21(1)(e)1.c. c. A follow-up office visit once within the first 90 days of insertion; and

DHS 107.21(1)(e)1.d. d. Extraction;

DHS 107.21(1)(e)2. 2. Those related to diaphragms:

DHS 107.21(1)(e)2.a. a. Furnishing and fitting of the device; and

DHS 107.21(1)(e)2.b. b. A follow-up office visit once within 90 days after furnishing and fitting;

DHS 107.21(1)(e)3. 3. Those related to contraceptive pills:

DHS 107.21(1)(e)3.a. a. Furnishing and instructions for taking the pills; and

DHS 107.21(1)(e)3.b. 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.

DHS 107.21(1)(f) (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.

DHS 107.21(1)(g) (g) Supplies. The following supplies are covered when prescribed:

DHS 107.21(1)(g)1. 1. Oral contraceptives;

DHS 107.21(1)(g)2. 2. Diaphragms;

DHS 107.21(1)(g)3. 3. Jellies, creams, foam and suppositories;

DHS 107.21(1)(g)4. 4. Condoms; and

DHS 107.21(1)(g)5. 5. Natural family planning supplies such as charts.

DHS 107.21(2) (2) Services requiring prior authorization. All sterilization procedures require prior authorization by the medical consultant to the department, as well as the informed consent of the recipient. Informed consent requests shall be in accordance with s. DHS 107.06 (3).

DHS 107.21 Note Note: For more information on prior authorization, see DHS 107.02 (3).

DHS 107.21(3) (3) Non-covered services. The following services are not covered services:

DHS 107.21(3)(a) (a) The sterilization of a recipient under the age of 21 or of a recipient declared legally incapable of consenting to such a procedure;

DHS 107.21(3)(b) (b) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to:

DHS 107.21(3)(b)1. 1. Artificial insemination, including but not limited to intra-cervical or intra-uterine insemination;

DHS 107.21(3)(b)2. 2. Infertility counseling;

DHS 107.21(3)(b)3. 3. Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;

DHS 107.21(3)(b)4. 4. Reversal of female sterilizations, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;

DHS 107.21(3)(b)5. 5. Fertility-enhancing drugs provided for the treatment of infertility;

DHS 107.21(3)(b)6. 6. Reversal of vasectomies;

DHS 107.21(3)(b)7. 7. Office visits, consultations and other encounters to enhance fertility; and

DHS 107.21(3)(b)8. 8. Other fertility-enhancing services and items;

DHS 107.21(3)(c) (c) Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services;

DHS 107.21(3)(d) (d) Testicular prosthesis; and

DHS 107.21(3)(e) (e) Services that are not covered under ss. DHS 107.03 and 107.06 (5).

DHS 107.21 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.21 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) (c) 3., (3), r. (1) (d) 4., renum. (1) (d) 5. to 8. to be (1) (d) 4. to 7; Register, January, 1997, No. 493, eff. 2-1-97.

DHS 107.22 DHS 107.22 Early and periodic screening, diagnosis and treatment (EPSDT) services.

DHS 107.22(1) (1) Covered services. Early and periodic screening and diagnosis to ascertain physical and mental defects, and the provision of treatment as provided in sub. (4) to correct or ameliorate the defects shall be covered services for all recipients under 21 years of age when provided by an EPSDT clinic, a physician, a private clinic, an HMO or a hospital certified under s. DHS 105.37.

DHS 107.22(2) (2) EPSDT health assessment and evaluation package. The EPSDT health assessment and evaluation package shall include at least those procedures and tests required by 42 CFR 441.56. The package shall include the following:

DHS 107.22(2)(a) (a) A comprehensive health and developmental history;

DHS 107.22(2)(b) (b) A comprehensive unclothed physical examination;

DHS 107.22(2)(c) (c) A vision test appropriate for the person being assessed;

DHS 107.22(2)(d) (d) A hearing test appropriate for the person being assessed;

DHS 107.22(2)(e) (e) Dental assessment and evaluation services furnished by direct referral to a dentist for children beginning at 3 years of age;

DHS 107.22(2)(f) (f) Appropriate immunizations; and

DHS 107.22(2)(g) (g) Appropriate laboratory tests.

DHS 107.22(3) (3) Supplemental tests. Selection of additional tests to supplement the health assessment and evaluation package shall be based on the health needs of the target population. Consideration shall be given to the prevalence of specific diseases and conditions, the specific racial and ethnic characteristics of the population, and the existence of treatment programs for each condition for which assessment and evaluation is provided.

DHS 107.22(4) (4) Other needed services. In addition to diagnostic and treatment services covered by Wisconsin MA under applicable provisions of this chapter, any services described in the definition of “medical assistance” under federal law, 42 USC 1396d(a), when provided to EPSDT patients, are covered if the EPSDT health assessment and evaluation indicates that they are needed. Prior authorization under s. DHS 107.02 (3) is required for coverage of services under this subsection.

DHS 107.22(5) (5) Reasonable standards of practice. Services under this section shall be provided in accordance with reasonable standards of medical and dental practice determined by the department after consultation with the medical society of Wisconsin and the Wisconsin dental association.

DHS 107.22(6) (6) Referral. When EPSDT assessment and evaluation indicates that a recipient needs a treatment service not available under MA, the department shall refer the recipient to a provider willing to perform the service at little or no expense to the recipient’s family.

DHS 107.22(7) (7) No charge for services. EPSDT services shall be provided without charge to recipients under 18 years of age.