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 NoteNote: 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. DHS 109.01DHS 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 HistoryHistory: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03. DHS 109.02DHS 109.02 Applicability. This chapter applies to all of the following: 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 HistoryHistory: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03. DHS 109.03DHS 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(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(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)(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(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)(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. DHS 109.03(18)(b)(b) A person born outside of the United States to at least one U.S. citizen parent. DHS 109.03 HistoryHistory: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (9) Register October 2004 No. 586, eff. 11-1-04; corrections in (intro.) and (2) made under s. 13.92 (4) (b) 6. and 7., Stats., Register December 2008 No. 636; CR 20-039: am. (12) Register October 2021 No. 790, eff. 11-1-21; CR 22-046: renum. (10) to (10) (intro.) and am., cr. (10) (a), (b) Register June 2023 No. 810, eff. 7-1-23. DHS 109.11DHS 109.11 Application and determining eligibility. DHS 109.11(1)(1) Conditions for eligibility. A person who meets all of the following requirements shall be eligible for SeniorCare and shall be issued a prescription drug card for use in purchasing prescription drugs: DHS 109.11(1)(a)(a) The person is a resident of the state of Wisconsin as defined in s. 27.01 (10) (a), Stats. The temporary absence of a resident from the state shall not be grounds for denying or terminating SeniorCare eligibility unless another state has determined the person is a resident in the other state for purposes of medical assistance. DHS 109.11(1)(c)(c) The person is not a recipient of medical assistance, or as a recipient, does not receive prescription drug coverage. Persons who only receive Medicare buy-in benefits under s. 49.468, Stats., 42 USC 1396a(a)(10)(E), or 42 USC 1396u-3, are not considered a medical assistance recipient under this chapter. DHS 109.11(1)(e)1.1. Except as provided in subd. 2., the person requesting SeniorCare benefits has a social security number and furnishes the number to the department. DHS 109.11(1)(e)2.a.a. If an applicant does not have a social security number, the applicant or a person acting on behalf of the applicant shall apply to the federal social security administration for a number. The department may not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual’s social security number. DHS 109.11(1)(e)2.b.b. If the applicant or a person acting on behalf of an applicant refuses to furnish a number or apply for a number, the applicant shall be ineligible for SeniorCare. DHS 109.11(1)(f)(f) The person is a U.S. national or an alien legally residing in the U.S. and whose status qualifies them for medical assistance under 8 USC 1611 through 8 USC 1613, except that an alien whose status would qualify them only for emergency medical assistance benefits under 42 USC 1396b(v)(3) is not eligible for SeniorCare. DHS 109.11(1)(g)(g) The applicant, participant, or person described in sub. (2) (d) who is acting on behalf of the applicant or participant provides correct and truthful information as specified under sub. (2) (c). DHS 109.11(2)(2) Application for SeniorCare. Application for SeniorCare shall be made pursuant to s. 49.688, Stats., and this chapter. Applications shall be made and reviewed by the department in accordance with the following provisions: DHS 109.11(2)(a)(a) Right to apply. Any person may apply to the department for SeniorCare on a form prescribed by the department. DHS 109.11 NoteNote: Application forms for SeniorCare are widely available through various local agencies. A copy of the application form is also available at the Department’s Internet web site at: http://dhs.wisconsin.gov. DHS 109.11(2)(b)(b) Access to information. The department shall provide information, in writing or orally, as appropriate, to persons inquiring about or applying for SeniorCare: coverage; conditions of eligibility; scope of the program and related services available; and applicant and participant rights and responsibilities. DHS 109.11(2)(c)(c) Providing correct and truthful information. The applicant, participant, or person described in par. (d) acting on behalf of the applicant or participant shall provide to the department full, correct and truthful information necessary for eligibility determination, redetermination, or for processing SeniorCare prescription claims, including health insurance policies or other health care plans and claims or causes of action against other parties on the part of the applicant or participant. The applicant, participant, or person described in par. (d) acting on behalf of the applicant or participant shall report changes in circumstances that may affect eligibility to the department within 10 calendar days of the change. DHS 109.11(2)(d)(d) Signing the application. The applicant or the legal guardian, authorized representative or, where the applicant is incompetent or incapacitated, someone acting responsibly for the applicant, shall sign each application. Two witnesses shall also sign the application when the applicant signs the application with a mark. DHS 109.11(3)(3) Refusal to provide information. If an applicant refuses or fails to provide information necessary for the determination of SeniorCare eligibility, the department shall deny eligibility to the applicant or participant and the spouse of the applicant or participant. DHS 109.11(4)(a)(a) The department may verify information provided by the applicant in the application under sub. (2) under any of the following circumstances: DHS 109.11(4)(a)2.2. The applicant is repaying aid determined to be previously owed by the applicant pursuant to an agreement with the district attorney’s office. DHS 109.11(4)(a)3.3. The applicant is known to have provided erroneous information on a previous SeniorCare or medical assistance application that resulted in an incorrect issuance of medical assistance or SeniorCare assistance. DHS 109.11(4)(b)(b) The department may verify the following information about the applicant, participant or an ineligible spouse who is in the fiscal test group: DHS 109.11(4)(c)(c) The department shall deny or terminate an applicant’s or participant’s SeniorCare eligibility if the applicant or participant is able to produce required verifications but refuses or fails to do so. If the applicant or participant cannot produce verifications, or requires assistance to do so, the department may not deny eligibility to the applicant or participant, but shall proceed immediately to verify the data elements in par. (b). DHS 109.11(5)(a)1.1. Except as provided in subd. 2., the department shall determine the applicant’s eligibility for SeniorCare as soon as possible, but not later than 30 days from the date the department receives a signed application that contains, at a minimum, the name and address of the applicant. DHS 109.11(5)(a)2.2. If a delay in processing the application occurs because of a delay in securing necessary information, the department shall notify the applicant in writing that there is a delay in processing the application, specify the reason for the delay, and inform the applicant of his or her right under s. DHS 109.17 to appeal the delay.
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Chs. DHS 101-109; Medical Assistance
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