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.