Wisconsin Legislature: DHS 107.30(3)(c)

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4. Bronchoscopy;

5. Carpal tunnel;

6. Cervix biopsy or conization;

7. Circumcision;

8. Dilation and curettage;

9. Esophago-gastroduodenoscopy;

10. Ganglion resection;

11. Hernia repair;

12. Hernia — umbilical;

13. Hydrocele resection;

14. Laparoscopy, peritoneoscopy or other sterilization methods;

15. Pilonidal cystectomy;

16. Procto-colonoscopy;

17. Tympanoplasty;

18. Vasectomy;

19. Vulvar cystectomy; and

20. Any other surgical procedure that the department determines shall be covered and that the department publishes notice of in the MA provider handbook; and

(b) Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par. (a):

1. Complete blood count (CBC);

2. Hemoglobin;

3. Hematocrit;

4. Urinalysis;

5. Blood sugar;

6. Lee white coagulant; and

7. Bleeding time.

(2) Services requiring prior authorization. Any surgical procedure under s. DHS 107.06 (2) requires prior authorization.

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

(3) Other limitations.

(a) A sterilization is a covered service only if the procedures specified in s. DHS 107.06 (3) are followed.

1. Nursing, technician, and related services;

2. Use of ambulatory surgical center facilities;

3. Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;

4. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;

5. Administrative, recordkeeping and housekeeping items and services; and

6. Materials for anesthesia.

(4) Non-covered services.

(a) Ambulatory surgical center services and items for which payment may be made under other provisions of this chapter are not covered services. These include:

1. Physician services;

2. Laboratory services;

3. X-ray and other diagnostic procedures, except those directly related to performance of the surgical procedure;

4. Prosthetic devices;

5. Ambulance services;

6. Leg, arm, back and neck braces;

7. Artificial limbs; and

8. Durable medical equipment for use in the recipient’s home.

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 (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-039: r. (3) (b) Register October 2021 No. 790, eff. 11-1-21.

DHS 107.31 Hospice care services.

(1) Definitions.

(a) “Attending physician” means a physician who is a doctor of medicine or osteopathy certified under s. DHS 105.05 and identified by the recipient as having the most significant role in the determination and delivery of his or her medical care at the time the recipient elects to receive hospice care.

(b) “Bereavement counseling” means counseling services provided to the recipient’s family following the recipient’s death.

(d) “Interdisciplinary group” means a group of persons designated by a hospice to provide or supervise care and services and made up of at least a physician, a registered nurse, a medical worker and a pastoral counselor or other counselor, all of whom are employees of the hospice.

(e) “Medical director” means a physician who is an employee of the hospice and is responsible for the medical component of the hospice’s patient care program.

(f) “Respite care” means services provided by a residential facility that is an alternate place for a terminally ill recipient to stay to temporarily relieve persons caring for the recipient in the recipient’s home or caregiver’s home from that care.

(g) “Supportive care” means services provided to the family and other individuals caring for a terminally ill person to meet their psychological, social and spiritual needs during the final stages of the terminal illness, and during dying and bereavement, including personal adjustment counseling, financial counseling, respite care and bereavement counseling and follow-up.

(h) “Terminally ill” means that the medical prognosis for the recipient is that he or she is likely to remain alive for no more than 6 months.

(2) Covered services.

(a) General. Hospice services covered by the MA program effective July 1, 1988 are, except as otherwise limited in this chapter, those services provided to an eligible recipient by a provider certified under s. DHS 105.50 which are necessary for the palliation and management of terminal illness and related conditions. These services include supportive care provided to the family and other individuals caring for the terminally ill recipient.

(b) Conditions for coverage. Conditions for coverage of hospice services are:

1. Written certification by the hospice medical director, the physician member of the interdisciplinary team or the recipient’s attending physician that the recipient is terminally ill;

2. An election statement shall be filed with the hospice by a recipient who has been certified as terminally ill under subd. 1. and who elects to receive hospice care. The election statement shall designate the effective date of the election. A recipient who files an election statement waives any MA covered services pertaining to his or her terminal illness and related conditions otherwise provided under this chapter, except those services provided by an attending physician not employed by the hospice. However, the recipient may revoke the election of hospice care at any time and thereby have all MA services reinstated. A recipient may choose to reinstate hospice care services subsequent to revocation. In that event, the requirements of this section again apply;

3. A written plan of care shall be established by the attending physician, the medical director or physician designee and the interdisciplinary team for a recipient who elects to receive hospice service prior to care being provided. The plan shall include:

a. An assessment of the needs of the recipient;

b. The identification of services to be provided, including management of discomfort and symptom relief;

c. A description of the scope and frequency of services to the recipient and the recipient’s family; and

d. A schedule for periodic review and updating of the plan; and

4. A statement of informed consent. The hospice shall obtain the written consent of the recipient or recipient’s representative for hospice care on a consent form signed by the recipient or recipient’s representative that indicates that the recipient is informed about the type of care and services that may be provided to him or her by the hospice during the course of illness and the effect of the recipient’s waiver of regular MA benefits.

(c) Core services. The following services are core services which shall be provided directly by hospice employees unless the conditions of sub. (3) apply:

1. Nursing care by or under the supervision of a registered nurse;

2. Physician services;

3. Medical social services provided by a social worker under the direction of a physician. The social worker shall have at least a bachelor’s degree in social work from a college or university accredited by the council of social work education; and

4. Counseling services, including but not limited to bereavement counseling, dietary counseling and spiritual counseling.

(d) Other services. Other services which shall be provided as necessary are:

1. Physical therapy;

2. Occupational therapy;

3. Speech pathology;

4. Home health aide and homemaker services;

5. Durable medical equipment and supplies;

6. Drugs; and

7. Short-term inpatient care for pain control, symptom management and respite purposes.

(3) Other limitations.

(a) Short-term inpatient care.

1. General inpatient care necessary for pain control and symptom management shall be provided by a hospital, a skilled nursing facility certified under this chapter or a hospice providing inpatient care in accordance with the conditions of participation for Medicare under 42 CFR 418.98.

2. Inpatient care for respite purposes shall be provided by a facility under subd. 1. or by an intermediate care facility which meets the additional certification requirements regarding staffing, patient areas and 24 hour nursing service for skilled nursing facilities under subd. 1. An inpatient stay for respite care may not exceed 5 consecutive days at a time.

3. The aggregate number of inpatient days may not exceed 20% of the aggregate total number of hospice care days provided to all MA recipients enrolled in the hospice during the period beginning November 1 of any year and ending October 31 of the following year. Inpatient days for persons with acquired immune deficiency syndrome (AIDS) are not included in the calculation of aggregate inpatient days and are not subject to this limitation.

(b) Care during periods of crisis. Care may be provided 24 hours a day during a period of crisis as long as the care is predominately nursing care provided by a registered nurse. Other care may be provided by a home health aide or homemaker during this period. “Period of crisis” means a period during which an individual requires continuous care to achieve palliation or management of acute medical symptoms.