Chapter DHS 107

DHS 107.24(4)(c) (c) The services covered under this section are not covered for recipients who are nursing home residents except for:

DHS 107.24(4)(c)1. 1. Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters.

DHS 107.24(4)(c)2. 2. Durable medical equipment which is personalized in nature or custom-made for a recipient and is to be used by the recipient on an individual basis for hygienic or other reasons. These items are orthoses, prostheses including hearing aids or other assistive listening devices, orthopedic or corrective shoes, and complex rehabilitation technology. For coverage and reimbursement complex rehabilitation technology shall be prescribed by a physician, require prior authorization to establish medically necessity, and meet all complex rehabilitation standards under sub. (3) (i). In order to be covered for a recipient who is a nursing home resident, the complex rehabilitation technology shall do at least one of the following:

DHS 107.24(4)(c)2.a. a. Contribute to the recipient’s independent completion of activities of daily living.

DHS 107.24(4)(c)2.b. b. Support the recipient’s occupational, vocational, or psychosocial activities.

DHS 107.24(4)(c)2.c. c. Provide the recipient the independent ability to move about the facility, or to attain or retain self-care.

DHS 107.24(4)(d) (d) The provider shall weigh the costs and benefits of the equipment and supplies when considering purchase or rental of DME and medical supplies.

DHS 107.24 Note Note: The program’s listing of covered services and the maximum allowable reimbursement schedules are based on basic necessity. Although the program does not intend to exclude any manufacturer of equipment, reimbursement is based on the cost-benefit of equipment when comparable equipment is marketed at less cost. Several medical supply items are reimbursed according to generic pricing.

DHS 107.24(4)(e) (e) The department may determine whether an item is to be rented or purchased on behalf of a recipient. In most cases equipment shall be purchased; however, in those cases where short-term use only is needed or the recipient’s prognosis is poor, only rental of equipment shall be authorized.

DHS 107.24(4)(f) (f) Orthopedic or corrective shoes or foot orthoses shall be provided only for postsurgery conditions, gross deformities, or when attached to a brace or bar. These conditions shall be described in the prior authorization request.

DHS 107.24(4)(g) (g) Provision of hearing aid accessories shall be limited as follows:

DHS 107.24(4)(g)1. 1. For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;

DHS 107.24(4)(g)2. 2. For recipients over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per recipient per year; and

DHS 107.24(4)(g)3. 3. For all recipients: one harness, one contralateral routing of signals (CROS) fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per recipient per year.

DHS 107.24(4)(h) (h) If a prior authorization request is approved, the person shall be eligible for MA reimbursement for the service on the date the final ear mold is taken.

DHS 107.24(4)(i) (i) Reimbursement for complex rehabilitation technology is limited to qualified complex rehabilitation technology suppliers.

DHS 107.24(4)(j) (j) The cost of mailing or delivery, such as shipping and handling charges and fees, of diagnostic tools or equipment needed to assess, diagnose, repair or setup medical supplies, hearing aids, cochlear implants, or other equipment cannot be billed to the recipient.

DHS 107.24(5) (5) Non-covered services. The following services are not covered services:

DHS 107.24(5)(a) (a) Foot orthoses or orthopedic or corrective shoes for the following conditions:

DHS 107.24(5)(a)1. 1. Flattened arches, regardless of the underlying pathology;

DHS 107.24(5)(a)2. 2. Incomplete dislocation or subluxation metatarsalgia with no associated deformities;

DHS 107.24(5)(a)3. 3. Arthritis with no associated deformities; and

DHS 107.24(5)(a)4. 4. Hypoallergenic conditions;

DHS 107.24(5)(b) (b) Services denied by both Medicare and MA for lack of medical necessity.

DHS 107.24(5)(c) (c) Items which are not primarily medical in nature, such as dehumidifiers and air conditioners;

DHS 107.24(5)(d) (d) Items which are not appropriate for home usage, such as oscillating beds;

DHS 107.24(5)(e) (e) Items which are not generally accepted by the medical profession as being therapeutically effective, such as a heat and massage foam cushion pad;

DHS 107.24(5)(f) (f) Items which are for comfort and convenience, such as cushion lift power seats or elevators, or luxury features which do not contribute to the improvement of the recipient’s medical condition;

DHS 107.24(5)(g) (g) Repair, maintenance or modification of rented durable medical equipment;

DHS 107.24(5)(h) (h) Delivery or set-up charges for equipment as a separate service;

DHS 107.24(5)(i) (i) Fitting, adapting, adjusting or modifying a prosthetic or orthotic device or corrective or orthopedic shoes as a separate service;

DHS 107.24(5)(j) (j) All repairs of a hearing aid or other assistive listening device performed by a dealer within 12 months after the purchase of the hearing aid or other assistive listening device. These are included in the purchase payment and are not separately reimbursable;

DHS 107.24(5)(k) (k) Hearing aid or other assistive listening device batteries which are provided in excess of the guidelines enumerated in the MA speech and hearing provider handbook;

DHS 107.24(5)(L) (L) Items that are provided for the purpose of enhancing the prospects of fertility in males or females;

DHS 107.24(5)(m) (m) Impotence devices, including but not limited to penile prostheses;

DHS 107.24(5)(n) (n) Testicular prosthesis;

DHS 107.24(5)(o) (o) Food; and

DHS 107.24(5)(p) (p) Infant formula and enteral nutritional products except as allowed under s. DHS 107.10 (2) (c).

DHS 107.24 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (3) (h) 1. and 2., eff. 7-1-89; am. (2) (d) 6., (3) (e), (h) 4., (4) (c) 2., (5) (j) and (k), r. and recr. (3) (h) (intro.), 1. and 2. and (4) (g), cr. (4) (h), Register, May, 1990, No. 413, eff. 6-1-90; r. and recr. (4) (a), Register, September, 1991, No. 429, eff. 10-1-91; am. (5) (j) to (k), cr. (5) (L) to (p), Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (b) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; CR 03-033: am. (2) (a), (3) (h) 1. (intro.), 2., and (5) (j) Register December 2003 No. 576, eff. 1-1-04; CR 20-012: renum. (1) to (1) (intro.) and am., cr. (1) (b), am. (2) (a), cr. (2) (a) 2., am. (2) (c) 1., 4., 6., cr. (2) (c) 9., am. (3) (intro.), (a) to (g), (h) 1. to 3., cr. (3) (i), (j), (4) (i), am. (5) (b) Register October 2021 No. 790, eff. 11-1-21; correction in (3) (g) made under s. 35.17, Stats., Register October 2021 No. 790; CR 20-039: am. (2) (c) 1., 4. to 6. Register October 2021 No. 790, eff. 11-1-21; merger of (2) (c) 1., 4., 6. treatments by CR 20-012 and CR 20-039 made under s. 13.92 (4) (bm), Stats., Register October 2021 No. 790; correction in (2) (a) 1. made under s. 35.17, Stats., Register December 2021, No. 792; CR 22-043: Register May 2023 No. 809, eff. 6-1-23; CR 23-005: am. (4) (c) 1., renum. (4) (c) 2. to (4) (c) 2. (intro.) and am., cr. (4) (c) 2. a. to c., r. (4) (c) 3. Register April 2024 No. 820, eff. 5-1-24; merger of (2) (c) 1., 4., 6. treatments by CR 20-012 and CR 23-046 and merger of (2) (c) 1., 4. to 6. treatments by CR 20-012, CR 20-039, and CR 23-046 made under s. 13.92 (4) (bm), Stats., Register April 2024 No. 820.

DHS 107.25 DHS 107.25 Diagnostic testing services.

DHS 107.25(1) (1) Covered services. Professional and technical diagnostic services covered by MA are laboratory services provided by a certified physician or under the physician’s supervision, or prescribed by a physician and provided by an independent certified laboratory, and x-ray services prescribed by a physician and provided by or under the general supervision of a certified physician.

DHS 107.25(2) (2) Other limitations.

DHS 107.25(2)(a) (a) All diagnostic services shall be prescribed or ordered by a physician or dentist.

DHS 107.25(2)(b) (b) Laboratory tests performed which are outside the laboratory’s certified areas are not covered.

DHS 107.25(2)(c) (c) Portable x-ray services are covered only for recipients who reside in nursing homes and only when provided in a nursing home.

DHS 107.25(2)(d) (d) Reimbursement for diagnostic testing services shall be in accordance with limitations set by P.L. 98-369, Sec. 2303.

DHS 107.25 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 107.26 DHS 107.26 Dialysis services. Dialysis services are covered services when provided by facilities certified pursuant to s. DHS 105.45.

DHS 107.26 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.27 DHS 107.27 Blood. The provision of blood is a covered service when provided to a recipient by a physician certified pursuant to s. DHS 105.05, a blood bank certified pursuant to s. DHS 105.46 or a hospital certified pursuant to s. DHS 105.07.

DHS 107.27 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.28 DHS 107.28 Health maintenance organization and prepaid health plan services.

DHS 107.28(1) (1) Covered services.

DHS 107.28(1)(a) (a) HMOs.

DHS 107.28(1)(a)1. 1. Except as provided in subd. 2., all health maintenance organizations (HMOs) that contract with the department shall provide to enrollees all MA services that are covered services at the time the medicaid HMO contract becomes effective with the exception of the following:

DHS 107.28(1)(a)1.a. a. EPSDT outreach services;

DHS 107.28(1)(a)1.b. b. County transportation by common carrier;

DHS 107.28(1)(a)1.c. c. Dental services; and

DHS 107.28(1)(a)1.d. d. Chiropractic services.

DHS 107.28(1)(a)2. 2. The department may permit an HMO to provide less than comprehensive coverage, but only if there is adequate justification and only if commitment is expressed by the HMO to progress to comprehensive coverage.

DHS 107.28(1)(b) (b) Prepaid health plans. Prepaid health plans shall provide one or more of the services covered by MA.

DHS 107.28(1)(c) (c) Family care benefit. A care management organization under contract with the department to provide the family care benefit under s. DHS 10.41 shall provide those MA services specified in its contract with the department and shall meet all applicable requirements under ch. DHS 10.

DHS 107.28(2) (2) Contracts. The department shall establish written contracts with qualified HMOs and prepaid health plan organizations which shall:

DHS 107.28(2)(a) (a) Specify the contract period;

DHS 107.28(2)(b) (b) Specify the services provided by the contractor;

DHS 107.28(2)(c) (c) Identify the MA population covered by the contract;

DHS 107.28(2)(d) (d) Specify any procedures for enrollment or reenrollment of the recipients;

DHS 107.28(2)(e) (e) Specify the amount, duration and scope of medical services to be covered;

DHS 107.28(2)(f) (f) Provide that the department may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed under the contract;

DHS 107.28(2)(g) (g) Provide that the department may audit and inspect any of the contractor’s records that pertain to services performed and the determination of amounts payable under the contract and stipulate the required record retention procedures;

DHS 107.28(2)(h) (h) Provide that the contractor safeguards recipient information;

DHS 107.28(2)(i) (i) Specify activities to be performed by the contractor that are related to third-party liability requirements; and

DHS 107.28(2)(j) (j) Specify which functions or services may be subcontracted and the requirements for subcontracts.

DHS 107.28(3) (3) Other limitations. Contracted organizations shall:

DHS 107.28(3)(a) (a) Allow each enrolled recipient to choose a health professional in the organization to the extent possible and appropriate;

DHS 107.28(3)(b) (b)

DHS 107.28(3)(b)1. 1. Provide that all medical services that are covered under the contract and that are required on an emergency basis are available on a 24-hour basis, 7 days a week, either in the contractor’s own facilities or through arrangements, approved by the department, with another provider; and

DHS 107.28(3)(b)2. 2. Provide for prompt payment by the contractor, at levels approved by the department, for all services that are required by the contract, furnished by providers who do not have arrangements with the contractor to provide the services, and are medically necessary to avoid endangering the recipient’s health or causing severe pain and discomfort that would occur if the recipient had to use the contractor’s facilities;

DHS 107.28(3)(c) (c) Provide for an internal grievance procedure that:

DHS 107.28(3)(c)1. 1. Is approved in writing by the department;

DHS 107.28(3)(c)2. 2. Provides for prompt resolution of the grievance; and

DHS 107.28(3)(c)3. 3. Assures the participation of individuals with authority to require corrective action;

DHS 107.28(3)(d) (d) Provide for an internal quality assurance system that:

DHS 107.28(3)(d)1. 1. Is consistent with the utilization control requirements established by the department and set forth in the contract;

DHS 107.28(3)(d)2. 2. Provides for review by appropriate health professionals of the process followed in providing health services;

DHS 107.28(3)(d)3. 3. Provides for systematic data collection of performance and patient results;

DHS 107.28(3)(d)4. 4. Provides for interpretation of this data to the practitioners; and

DHS 107.28(3)(d)5. 5. Provides for making needed changes;

DHS 107.28(3)(e) (e) Provide that the organization submit marketing plans, procedures and materials to the department for approval before using the plans;