Wisconsin Legislature: DHS 108.01(2)(g)

Chapter DHS 108

GENERAL ADMINISTRATION

DHS 108.01 Safeguarded information.

DHS 108.02 Department rights and responsibilities.

DHS 108.03 County responsibilities.

Note: Chapter HSS 108 was renumbered Chapter HFS 108 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1997, No. 493. Chapter HFS 108 was renumbered to chapter DHS 108 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 108.01 Safeguarded information.

(1) Except for purposes directly related to direct program administration, the department may not use or disclose any information concerning past or present applicants and recipients of MA.

(2) In this section, “direct program administration” means:

(a) Determining initial eligibility of the applicant and continuing eligibility of the recipient;

(b) Determining appropriate services to be covered;

(d) Processing provider claims for reimbursement;

(e) Auditing provider claims for reimbursement;

(f) Investigating or prosecuting criminal or civil proceedings conducted in connection with program administration;

(g) Seeking third-party payment for services provided to a recipient; and

(h) Other activities determined by the department to be necessary for proper and efficient administration of MA.

(3) The department shall request the attorney general to institute appropriate action when necessary to enforce provisions of this section.

(4) Safeguarded information concerning an individual applicant or recipient shall include but not be limited to:

(a) Name and address;

(b) Social data, including but not limited to:

1. Marital status;

2. Age;

3. Race;

4. Names and MA numbers of family members;

5. Paternity status of children; and

6. Unique identifying characteristics;

1. Assets;

2. Amount of assistance received;

3. Amount of medical expenses incurred;

4. Sources of payment or support;

5. Past or present employment;

6. Income, regardless of source;

7. Social security number; and

8. Income expense deductions;

(d) Agency evaluation information, including but not limited to:

1. Verification of client information; and

2. Identity of verification sources; and

(e) Medical data, including but not limited to:

1. Past history and medical record content;

2. Diagnosis;

3. Drugs prescribed;

4. Course of treatment prescribed; and

5. Name of provider.

(5) For purposes of direct program administration, the department may permit disclosure to, or use of safeguarded information by, legally qualified persons or agency representatives outside the department. Governmental authorities, the courts, and law enforcement officers are persons outside the department who shall comply with sub. (6).

(6) Persons or agency representatives outside the department to whom the department may disclose or permit use of safeguarded information shall meet the following qualifications:

(a) The purpose for use or disclosure shall involve direct program administration; and

(b) The person or the person’s agency shall be bound by law or other legally enforceable obligation to observe confidentiality standards comparable to those observed by the department.

(7) Unless it is related to direct program administration, the department shall respond to a subpoena for a case record or for agency representative testimony regarding an applicant or recipient as follows:

(a) The department shall provide the court and all parties to the proceeding with a copy of this section;

(b) The department shall request that the attorney general intervene in the proceeding in a manner which will give effect to this section; and

(8) The department shall publicize this section as follows:

(a) Publication in the Wisconsin administrative code;

(b) Incorporation by reference in certification procedures for all providers; and

(9) The secretary or a designee shall determine the appropriate application of this section to circumstances not covered expressly by this section. Use or disclosure not expressly provided for in this section may not occur prior to this determination.

History: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 108.02 Department rights and responsibilities.

(1) Different benefits for different groups. The department may offer MA benefits to the categorically needy which are different from the benefits offered to the medically needy, subject to ss. 49.46 (2) (a) and 49.47 (6) (a), Stats. For the categorically needy, benefits shall meet federal minimum standards of coverage under 42 CFR 435.100-135. The department need not provide the same benefits that the categorically needy receive to individuals who are determined to be medically needy. The department is not required to provide the same amount, duration and scope of services to all the different groups who make up the medically needy population.

(2) Reimbursement methods and payment levels. The department may establish the reimbursement methods and payment levels for program services subject to the requirements of federal and state statutes, regulations and chs. DHS 101 to 107 and this chapter. Notice of specific changes or updates to payment levels shall be communicated to the service providers by the department through periodic publication of provider handbooks.

(3) Advisory committees. The department may appoint and make use of professional advisory committees on an ad hoc basis to provide expertise for development of service or reimbursement policies.

(4) Provider handbooks and bulletins. The department shall publish provider handbooks, bulletins and periodic updates to inform providers of changes in state or federal law, policy, reimbursement rates and formulas, departmental interpretation, and procedural directives such as billing and prior authorization procedures, specific reimbursement changes and items of general information. The department shall inform providers in a handbook, bulletin or other publication of specific services requiring collection of benefits from medicare or other health care plans under s. DHS 106.03 (7) before benefits are claimed from the MA program. Information regarding eligibility for medicare or for another health care plan as identified on the recipient’s MA identification card shall also be included in these publications.

(5) Notification of recipients. The department shall publish periodic notification to eligible recipients, as necessary, to provide general information regarding MA program benefits and procedural requirements, and to notify recipients of any benefit or eligibility changes.

(6) Notice of change in method or level of reimbursement.

(a) Except as provided in par. (b), the department shall publish a public notice in the Wisconsin administrative register of any significant proposed change in the statewide method or level of reimbursement for a service, in compliance with 42 CFR 447.205. This notice shall include information on the procedure for obtaining details of the proposed change, why the change is proposed and how to provide public comment to the department.

(b) Changes for which no public notice is required include the following:

1. Changes to conform with medicare methods and federally-invoked upper limits on reimbursement;

2. Changes required of the department by court order; and

3. Changes in wholesalers’ or manufacturers’ prices of drugs or materials, if the department’s method of reimbursement is based on direct or wholesale prices as reported in a national standard such as the American druggist blue book, plus a pharmacy dispensing fee.

(c) Notice in the Wisconsin administrative register shall constitute official notice by the department to its contracted health service providers of a contractual change.

(7) Mailings and distributions. The department shall mail or distribute materials to applicants, recipients or medical providers, as follows:

(a) All materials shall be limited to purposes directly related to program administration.

(b) Materials which may not be mailed or distributed include: