Chapter DHS 109

DHS 109.11(6)(d) (d) When the department learns that the program enrollment fee payment has been returned for non-sufficient funds and the recipient fails to provide the enrollment fee within 10 days of the date the department sends a letter requesting payment.

DHS 109.11 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; correction in (4) (b) 2. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 21-067: cr. (6) (e) Register March 2022 No 795, eff. 4-1-22, r. (6) (e) eff. the first day of the month after the emergency period, as defined in 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (6) (e) made under s. 35.17, stats., Register March 2022 No. 795.

DHS 109.12 DHS 109.12 Calculation of eligible benefits and services. Persons the department determines to be eligible for SeniorCare benefits and services under s. DHS 109.11 may be subject to program deductible and spend-down amounts that participants must pay before the participant may receive the full SeniorCare benefits and services for the remainder of a benefit period. Whether and to what extent the deductibles and spend-down amounts under s. DHS 109.13 apply to a given participant depends on the annual income of the participant’s fiscal test group. The department shall calculate income for the participant’s fiscal test group as follows:

DHS 109.12(1) (1) SeniorCare fiscal test group. The SeniorCare fiscal test group shall consist solely of the applicant unless the applicant is residing with a spouse. If the applicant is residing with a spouse, the SeniorCare fiscal test group shall consist of the applicant and the applicant’s spouse, unless the spouse is an SSI recipient or the spouses are living together in a nursing home.

DHS 109.12(2) (2) Annual income. The department shall calculate annual income for SeniorCare applicants as follows:

DHS 109.12(2)(a) (a) Income shall be based on a prospective estimate of annual budgetable income under par. (c) for all persons in the SeniorCare fiscal test group.

DHS 109.12(2)(b) (b) The annual period used as the basis for the estimate shall be the 12 calendar months beginning with the month in which the SeniorCare application was filed.

DHS 109.12(2)(c) (c) Budgetable income shall consist of gross earned and unearned income with the following exceptions:

DHS 109.12(2)(c)1. 1. Self-employment income shall be calculated by deducting only estimated business expenses, losses, and depreciation from gross self-employment income.

DHS 109.12(2)(c)2. 2. Income from sources exempted under federal law from consideration for Medicaid eligibility will also be exempt for SeniorCare.

DHS 109.12 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.13 DHS 109.13 SeniorCare benefits and services.

DHS 109.13(1) (1) Conditions for receiving SeniorCare benefits and services. A person who meets the eligibility requirements under s. DHS 109.11 (1) may receive SeniorCare benefits or services, subject to the conditions under this section. Except during a period of program suspension under s. 49.688 (7) (b), Stats., SeniorCare benefits and services shall be available only for prescription drugs prescribed for the eligible person and dispensed with a date of service during the eligible person’s benefit period.

DHS 109.13(2) (2) Prescription benefit.

DHS 109.13(2)(a) (a) Income category applicability. A person may receive the prescription benefit in par. (b) under any of the following conditions:

DHS 109.13(2)(a)1. 1. The person is a member of a fiscal test group with an annual income less than or equal to 160% of the poverty line for a family the size of the fiscal test group.

DHS 109.13(2)(a)2. 2. The person is a member of a fiscal test group with an annual income greater than 160% but not in excess of 240% of the poverty line for a family the size of the fiscal test group and has met the deductible as described in sub. (3) (d) during the current benefit period.

DHS 109.13(2)(a)3. 3. The person is a member of a fiscal test group with an annual income greater than 240% of the poverty line for a family the size of the fiscal test group and has met both of the following thresholds during the current benefit period, in the following order:

DHS 109.13(2)(a)3.a. a. The spend-down as described in sub. (4) (c).

DHS 109.13(2)(a)3.b. b. The deductible as described in sub. (3) (d).

DHS 109.13(2)(b) (b) Copayment. Except as provided under sub. (3) (e), a person receiving the SeniorCare prescription benefit may purchase prescription drugs from participating SeniorCare providers for one of the following copayment amounts:

DHS 109.13(2)(b)1. 1. A copayment of $5 for each prescription drug that bears only a generic name.

DHS 109.13(2)(b)2. 2. A copayment of $15 for each prescription drug that does not bear only a generic name.

DHS 109.13(2)(bm) (bm) Exclusion of copayment. A copayment is not required for a vaccine or vaccine administration.

DHS 109.13(2)(c) (c) Exclusion for drugs. If a drug is covered by a third party and the participant makes a copayment to the SeniorCare provider, the department is not responsible for refunding the copayment amount to the participant.

DHS 109.13(2)(d) (d) Exclusion for vaccines and vaccine administration. The department will not cover reimbursement of a vaccine or vaccine administration in any of the following circumstances:

DHS 109.13(2)(d)1. 1. A vaccine is not on the federal centers for disease control and prevention’s advisory committee on immunization practices list of vaccines recommended for immunization to adults.

DHS 109.13(2)(d)2. 2. A vaccine is not administered by a SeniorCare provider in an allowed place of service.

DHS 109.13(2)(e) (e) Exclusion for vaccines. The department will not cover reimbursement of a vaccination when the vaccine is allocated through the federal government at no cost to the provider.

DHS 109.13(3) (3) Deductible benefit and services.

DHS 109.13(3)(a) (a) Income category applicability. A person may receive the SeniorCare benefit and services under par. (b) under any of the following conditions:

DHS 109.13(3)(a)1. 1. The person is a member of a fiscal test group with an annual income greater than 160%, but not in excess of 240% of the poverty line for a family the size of the fiscal test group.

DHS 109.13(3)(a)2. 2. The person is a member of a fiscal test group with an annual income greater than 240% of the federal poverty line for a family the size of the fiscal test group, but only for the remainder of the benefit period after he or she has met the spend-down as described in sub. (4) (c).

DHS 109.13(3)(b) (b) Benefit and services.

DHS 109.13(3)(b)1. 1. Except as provided under sub. (4) (d), a person receiving the SeniorCare deductible benefit and services may purchase prescription drugs from participating SeniorCare providers at the program payment rate.

DHS 109.13(3)(b)2. 2. The department shall maintain a record of the prescription drug purchases of each person receiving the SeniorCare deductible services and shall inform participating SeniorCare providers when the person receiving the SeniorCare deductible benefits and services has met the deductible within the benefit period as described in par. (d).

DHS 109.13(3)(c) (c) Amount. The amount of the SeniorCare deductible is based on a fiscal test group’s income as a percentage of the federal poverty line for a family the size of the fiscal test group, as follows:

DHS 109.13(3)(c)1. 1. If the fiscal test group’s income is more than 160% of the federal poverty line, but not more than 200%, the deductible is $500.

DHS 109.13(3)(c)2. 2. If the fiscal test group’s income is more than 200% of the federal poverty line, the deductible is $850.

DHS 109.13(3)(d) (d) Meeting the deductible. The deductible is considered met and the person shall receive the prescription benefit under sub. (2) (b) when, under the following conditions, the person has spent the dollar amount specified in par. (c) in purchasing prescription drugs:

DHS 109.13(3)(d)1. 1. Only purchases of prescription drugs prescribed for the eligible individual count toward meeting the deductible.

DHS 109.13(3)(d)2. 2. Each spouse has a deductible. When both persons in a 2-person fiscal test group are eligible for SeniorCare, each person’s purchases of prescription drugs shall only be counted toward meeting the deductible of the person for whom the drugs are prescribed.

DHS 109.13(3)(d)3. 3. Only prescription drugs dispensed with a date of service during the current benefit period described in s. DHS 109.14 may count toward meeting the deductible.

DHS 109.13(3)(d)4. 4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person’s other available coverage may count toward meeting the deductible.

DHS 109.13(3)(d)5. 5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied toward meeting the deductible.

DHS 109.13(3)(d)6. 6. Only claims submitted by a SeniorCare provider shall be considered in determining whether or not the participant has met the deductible.

DHS 109.13(3)(e) (e) Carryover of deductible. When the cost of a prescription applied towards meeting the deductible under par. (d) exceeds the remaining deductible amount, the excess prescription costs shall be applied to the prescription benefit. No participant may be required to pay the copayment under sub. (2) (b) for that prescription.

DHS 109.13(4) (4) Spend-down services.

DHS 109.13(4)(a) (a) Income category applicability.

DHS 109.13(4)(a)1. 1. A person may receive the SeniorCare spend-down services under this subsection when he or she is in a fiscal test group with an annual income that exceeds 240% of the poverty line for a family the size of the fiscal test group.

DHS 109.13(4)(a)2. 2. The department shall maintain an accounting of the prescription drug purchases of each person receiving the SeniorCare spend-down services and shall inform participating SeniorCare providers when he or she has met the spend-down within the benefit period as described in par. (c).

DHS 109.13(4)(b) (b) Amount. The amount of a person’s SeniorCare spend-down is the difference between the SeniorCare fiscal test group’s annual income and 240% of the poverty line for a family the size of the fiscal test group.

DHS 109.13(4)(c) (c) Meeting a spend-down. A SeniorCare spend-down shall be met and the person’s subsequent prescription purchases shall count toward meeting the deductible under sub. (3) (c) and (d) when the member or members of the fiscal test group, under the following conditions, have spent the amount of the spend-down in purchasing prescription drugs at the retail price:

DHS 109.13(4)(c)1. 1. When only one person is an eligible member of the SeniorCare fiscal test group in a calendar month, only purchases of prescription drugs prescribed for that person may be counted toward meeting the spend-down in that calendar month.

DHS 109.13(4)(c)2. 2. When 2 spouses are both eligible members of the same SeniorCare fiscal test group in a calendar month, purchases of prescription drugs prescribed for either person may be counted toward meeting the spend-down in that month.

DHS 109.13(4)(c)3. 3. Only prescription drugs dispensed with a date of service during the benefit period described in s. DHS 109.14 may count toward meeting the spend-down.

DHS 109.13(4)(c)4. 4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person’s other available coverage may be counted toward meeting the spend-down.

DHS 109.13(4)(c)5. 5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied to meeting the spend-down.

DHS 109.13(4)(c)6. 6. Only claims submitted by a SeniorCare provider may be considered in determining whether the participant has met the spend-down.

DHS 109.13(4)(d) (d) Carryover of spend-down. When the cost of a prescription applied towards meeting the spend-down under par. (c) exceeds the remaining spend-down amount, the excess prescription costs shall be applied towards meeting the deductible under sub. (3) (d). The program payment rate may not apply to that portion of the prescription counted for the deductible.

DHS 109.13(5) (5) Review of benefits. After the department learns of an error or omission in the information on the application form or other information provided by the recipient used to determine the benefits and services, the department shall promptly redetermine which SeniorCare benefits and services a participant may receive under this section. The benefits and services may only be changed if the error or omission is of factual information available to the recipient at the time he or she filed the application.

DHS 109.13(6) (6) Correction of benefits. The department shall correct in the following ways the benefits and services received in error under this section:

DHS 109.13(6)(a) (a) For underpayment errors caused by the department, benefits will be corrected back to the beginning of the benefit period.

DHS 109.13(6)(b) (b) For underpayment errors caused by the recipient when the recipient reports the error within 45 days after the date of the initial eligibility notice, benefits will be corrected back to the beginning of the benefit period.

DHS 109.13(6)(c) (c) For underpayment errors caused by the recipient when the recipient reports the error more than 45 days after the date of the initial eligibility notice, benefits will be corrected back to the first of the month in which the error was reported.

DHS 109.13(6)(d) (d) For overpayment errors, benefits will be corrected beginning the first of the month following the issuance by the department of a timely notice of decision under s. DHS 109.11 (5) (b). Recovery of benefits issued in error shall be in accordance with s. DHS 109.62.

DHS 109.13 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (3) (c) and (d) (intro) and 2. Register October 2004 No. 586, eff. 11-1-04; CR 22-046: cr. (2) (bm), am. (2) (c) (title), cr. (2) (d), (e) Register June 2023 No. 810, eff. 7-1-23; correction in (2) (d) (intro.), 1. made under s. 35.17, Stats., Register June 2023 No. 810.

DHS 109.14 DHS 109.14 SeniorCare benefit period.

DHS 109.14(1) (1) Duration. Except as provided in subs. (3) to (5), and in s. DHS 109.15 and s. 49.688 (7) (a), Stats., the benefit period for SeniorCare eligibility shall be 12 consecutive calendar months.

DHS 109.14(2) (2) Eligibility begin date. Except as provided in sub. (3), a person’s SeniorCare eligibility begins on the first day of the month after the date the department receives a complete application and the person meets all of the eligibility requirements.

DHS 109.14(3) (3) Exception for medicaid recipients. If the department receives a complete application and determines that the person meets all other eligibility requirements prior to the date medical assistance eligibility ends, the person’s SeniorCare eligibility begins the day after the person’s medical assistance eligibility ends.

DHS 109.14(4) (4) Termination of SeniorCare benefit period.

DHS 109.14(4)(a) (a) Except as provided in sub. (5), the department shall terminate the SeniorCare benefit period of a SeniorCare participant who no longer meets the eligibility conditions in s. DHS 109.11, or who requests a withdrawal from the program under s. DHS 109.11 (5) (d).

DHS 109.14(4)(b) (b) The department shall restore the SeniorCare benefit period for a person terminated from SeniorCare without a break in coverage if, within one calendar month of the effective termination date, he or she does both of the following:

DHS 109.14(4)(b)1. 1. Meets all of the eligibility criteria under s. DHS 109.11.

DHS 109.14(4)(b)2. 2. Notifies the department of the change in circumstances.

DHS 109.14(4)(c) (c) The department shall reinstate the SeniorCare benefit period for a person who has requested a withdrawal from the program under s. DHS 109.11 (5) (d) if within 30 calendar days of the effective date of the withdrawal both of the following occur:

DHS 109.14(4)(c)1. 1. The department receives the person’s request to have SeniorCare benefits restored.

DHS 109.14(4)(c)2. 2. The person meets all of the eligibility criteria under s. DHS 109.11, including a new payment of the program enrollment fee specified in s. DHS 109.16 for persons who were issued a refund under s. DHS 109.11 (5) (d) 1.

DHS 109.14(5) (5) Continuation of benefit period for medical assistance recipients. The department may not terminate the benefit period of SeniorCare participants who lose eligibility solely due to receipt of medical assistance benefits. A SeniorCare participant is not eligible for any SeniorCare benefits or services under s. DHS 109.13 for any calendar months in which he or she receives medical assistance benefits.

DHS 109.14(6) (6) Request for new benefit period. A SeniorCare participant may request a new benefit period for SeniorCare at any time. Upon receipt of a new application, the department shall determine the participant’s eligibility for a new benefit period in the following manner unless the application is from the spouse of a participant and meets the conditions under s. DHS 109.15:

DHS 109.14(6)(a) (a) The person shall submit a new application as required under s. DHS 109.11.

DHS 109.14(6)(b) (b) The department shall redetermine eligibility when the request for a new benefit period is made beginning with the date a new complete application is received.

DHS 109.14(6)(c) (c) The department shall redetermine annual income for a 12-month period beginning with the date a new complete application is received.

DHS 109.14(6)(d) (d) The department shall redetermine which benefits and services under s. DHS 109.13 the applicant may receive.

DHS 109.14(6)(e) (e) The participant may withdraw the request for a new benefit period as allowed under s. DHS 109.11 (5).

DHS 109.14(6)(f) (f) Eligibility for the new benefit period shall begin on the first day of the month after the date a new complete application is received and all the eligibility requirements are met, including payment of a new enrollment fee specified in s. DHS 109.16.

DHS 109.14(6)(g) (g) Prescription drug costs that had been applied to a spend-down or deductible in a previous benefit period may not apply to the new benefit period.

DHS 109.14(6)(h) (h) Notwithstanding s. DHS 109.15, if a person eligible for SeniorCare requests a new benefit period at the same time the person’s spouse applies for SeniorCare or requests a new benefit period, eligibility shall be determined under this section.