Chapter DHS 109

Chapter DHS 109

SENIOR CARE

Subchapter I — General Provisions

DHS 109.01   Authority and purpose.

DHS 109.02   Applicability.

DHS 109.03   Definitions.

Subchapter II — Eligibility for SeniorCare Benefits and Services

DHS 109.11   Application and determining eligibility.

DHS 109.12   Calculation of eligible benefits and services.

DHS 109.13   SeniorCare benefits and services.

DHS 109.14   SeniorCare benefit period.

DHS 109.15   Treatment of spouses.

DHS 109.16   Fees.

DHS 109.17   Applicant appeals.

Subchapter III — Drug Benefits

DHS 109.31   Covered drugs and limitations on coverage.

DHS 109.32   Coverage while out-of-state.

Subchapter IV — Program Integrity

DHS 109.41   Annual report to legislature.

DHS 109.42   Prohibition on fraud.

Subchapter V — Provider Rights and Responsibilities

DHS 109.51   Provider responsibility.

DHS 109.52   Provider certification.

DHS 109.53   Department recovery of overpayments from SeniorCare providers.

DHS 109.54   Incorporation of Medicaid standards.

Subchapter VI — Participant Rights and Responsibilities

DHS 109.61   Participant duties.

DHS 109.62   Recovery of incorrect payments from participants.

DHS 109.63   Participant appeals.

Subchapter VII — Program Administration

DHS 109.71   Rebate agreement.

DHS 109.72   Payment for drugs.

DHS 109.73   Program suspension.

DHS 109.74   Safeguarded information.

Ch. DHS 109 Note Note: Chapter HFS 109 was created as an emergency rule effective September 1, 2002. Chapter HFS 109 was renumbered to chapter DHS 109 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

subch. I of ch. DHS 109 Subchapter I — General Provisions

DHS 109.01 DHS 109.01 Authority and purpose. This chapter is promulgated under the authority of ss. 49.688 and 227.11 (2), Stats., to implement a program called SeniorCare that is designed to provide prescription drug assistance for Wisconsin residents aged 65 years or older and who meet the program’s eligibility criteria. The chapter does all of the following:

DHS 109.01(1) (1) Establishes the application process for SeniorCare.

DHS 109.01(2) (2) Describes how the department will determine eligibility for SeniorCare benefits and services.

DHS 109.01(3) (3) Identifies SeniorCare benefits, services and fees.

DHS 109.01(4) (4) Establishes requirements of SeniorCare participants and providers.

DHS 109.01(5) (5) Identifies the applicability of other department rules.

DHS 109.01 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.02 DHS 109.02 Applicability. This chapter applies to all of the following:

DHS 109.02(1) (1) The department.

DHS 109.02(2) (2) All persons applying to receive SeniorCare benefits and services.

DHS 109.02(3) (3) All persons found eligible to receive SeniorCare benefits and services.

DHS 109.02(4) (4) All persons prescribing or providing drugs to SeniorCare participants.

DHS 109.02(5) (5) All drug manufacturers who sell drugs for prescribed use in Wisconsin by SeniorCare participants.

DHS 109.02 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.03 DHS 109.03 Definitions. Unless otherwise defined in this chapter, the definitions in s. DHS 101.03 apply to this chapter. In addition, in this chapter:

DHS 109.03(1) (1) “Deductible benefits and services” means both of the following:

DHS 109.03(1)(a) (a) The prescription drugs which may be purchased by a SeniorCare participant with income over 160% of the poverty line for amounts no greater than the program payment rate.

DHS 109.03(1)(b) (b) The department’s tracking of prescription drug purchases by a SeniorCare participant with income over 160% of the poverty line so SeniorCare providers know when the participant may receive the SeniorCare prescription benefit.

DHS 109.03(2) (2) “Department” means the department of health services, or its agent.

DHS 109.03(3) (3) “Fiscal test group” means the person or persons in a household whose income and need is included in determining which SeniorCare benefits or services an applicant may receive.

DHS 109.03(4) (4) “Generic name” has the meaning given in s. 450.12 (1) (b), Stats.

DHS 109.03(5) (5) “Innovator multiple-source drug” means a multiple source drug that was originally marketed under an original new drug application approved by the U.S. food and drug administration.

DHS 109.03(6) (6) “Lock-in provider” means a single, SeniorCare-certified provider, selected by the participant or designated by the department in the event the participant is unwilling or unable to identify a provider, who is responsible for either personally providing all non-emergency care received by the participant under the MA program, or referring the participant to a specific provider for such needed non-emergency care.

DHS 109.03(7) (7) “Participant” means a person who has applied for SeniorCare and meets the eligibility criteria under s. DHS 109.11 (1) and may receive benefits and services during the benefit period under s. DHS 109.14.

DHS 109.03(8) (8) “Pharmacist” has the meaning given in s. 450.01 (15), Stats.

DHS 109.03(9) (9) “Prescription benefit” means the prescription drugs that may be purchased with a $5 or $15 payment by a SeniorCare participant with low income or who has spent at least the dollar amount specified in s. DHS 109.13 (3) on the purchase of prescription drugs during the current benefit period.

DHS 109.03(10) (10) “Prescription drug” or “drug” means any of the following:

DHS 109.03(10)(a) (a) A drug under s. 450.01 (20), Stats., that is included in the drugs specified under s. 49.46 (2) (b) 6. h., Stats., and s. DHS 109.31 and is manufactured by a drug manufacturer that enters into a rebate agreement in force under s. DHS 109.71.

DHS 109.03(10)(b) (b) A vaccine recommended and approved for administration to adults by the federal centers for disease control and prevention’s advisory committee on immunization practices.

DHS 109.03(11) (11) “Prescription order” has the meaning given in s. 450.01 (21), Stats.

DHS 109.03(12) (12) “Program payment rate” means the rate of payment made for the identical drug specified under s. 49.46 (2) (b) 6. h., Stats., plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h., Stats.

DHS 109.03(13) (13) “Retail price” means the provider’s charge for providing the same service to private paying customers.

DHS 109.03(14) (14) “SeniorCare” means the program of prescription drug assistance for eligible elderly persons under s. 49.688, Stats.

DHS 109.03(15) (15) “SeniorCare provider” means an MA certified pharmacist, pharmacy or dispensing physician.

DHS 109.03(16) (16) “Spend-down” means the amount of money a SeniorCare participant must spend on prescription drugs before the participant becomes eligible for SeniorCare deductible and copayment benefits and services.

DHS 109.03(17) (17) “Spend-down services” means the department’s monitoring of participant prescription drug purchases to determine when the participant’s SeniorCare fiscal test group’s purchases have equaled the difference between the fiscal test group’s annual income and 240% of the poverty line for a family the size of the fiscal test group.

DHS 109.03(18) (18) “U.S. national” means any of the following:

DHS 109.03(18)(a) (a) A person born in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), America Samoa, Swain’s Island or the Northern Mariana Islands.