Chapter DHS 109

DHS 109.15(4)(b)1.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, the spouse may receive spend-down services under s. DHS 109.13 (4) (a) 2.

DHS 109.15(4)(b)1.b. b. When determining whether the spouse meets the SeniorCare spend-down under s. DHS 109.13 (4) (c), the amount of the SeniorCare spend-down shall be prorated. The prorated amount shall be the annual spend-down amount under s. DHS 109.13 (4) (b) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12. Only prescription drug costs of the spouse may count towards meeting the prorated spend-down.

DHS 109.15(4)(b)1.c. c. If the spouse meets the prorated spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b). When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(4)(b)1.d. d. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(4)(b)2. 2. ‘Annual income between 160-240% of poverty line.’

DHS 109.15(4)(b)2.a. a. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b).

DHS 109.15(4)(b)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(4)(b)2.c. c. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(4)(b)3. 3. ‘Annual income less than 160% of poverty line.’

DHS 109.15(4)(b)3.a. a. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15(5) (5) If the income of the spouse was used to determine the SeniorCare benefit for the participant, the department shall determine the benefit as follows:

DHS 109.15(5)(a) (a) Annual income exceeds 240% of poverty line.

DHS 109.15(5)(a)1. 1. ‘Participant has not met spend-down.’ If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, and the participant has not met the spend-down by the date the spouse becomes eligible for SeniorCare, the spouse may receive spend-down services under s. DHS 109.13 (4).

DHS 109.15(5)(a)2. 2. ‘Participant has met spend-down.’

DHS 109.15(5)(a)2.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family and the participant met the spend-down before the spouse becomes eligible for SeniorCare, or the participant and spouse meet the spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(a)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(a)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(b) (b) Annual income between 160-240% of poverty line.

DHS 109.15(5)(b)1. 1. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(b)2. 2. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(b)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(c) (c) Annual income less than 160% of poverty line. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (4) (b) 1. c. and 2. b. and (5) (a) 2. b. and (b) 2. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.16 DHS 109.16 Fees. For each 12-month benefit period, a program participant shall pay a program enrollment fee of $30. The department shall refund the fee to applicants found to be ineligible for SeniorCare.

DHS 109.16 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.17 DHS 109.17 Applicant appeals.

DHS 109.17(1) (1) Except as provided under sub. (2), any person whose application for SeniorCare is denied or is not acted upon promptly under s. DHS 109.11 (5), or who believes that the benefits or services the person may receive under s. DHS 109.13 have not been properly determined, or that his or her eligibility has not been properly determined under s. DHS 109.11 (5), may file an appeal pursuant to the requirements under ch. HA 3 that apply to the medical assistance program.

DHS 109.17(2) (2) 

DHS 109.17(2)(a) (a) A request for a hearing concerning the SeniorCare program may only be made in writing and only to the division of hearings and appeals.

DHS 109.17(2)(b) (b) The applicant shall have 45 days from the effective date of the adverse action in which to file a request for hearing.

DHS 109.17 Note Note: A hearing request should be mailed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI, 53707-7875. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or transmitted by facsimile machine to 608-264-9885.

DHS 109.17 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

subch. III of ch. DHS 109 Subchapter III — Drug Benefits

DHS 109.31 DHS 109.31 Covered drugs and limitations on coverage.

DHS 109.31(1) (1) Covered services. Drugs and drug products covered under this chapter include prescription drugs and insulin listed in the Wisconsin medical assistance drug index that are prescribed by a physician licensed under s. 448.04, Stats., by a dentist licensed under s. 447.04, Stats., by a podiatrist licensed under s. 448.04, Stats., by an optometrist licensed under ch. 449, Stats., or by a nurse prescriber under ch. N 8, or when a physician delegates prescription of drugs to a nurse practitioner or to a physician’s assistant certified under s. 448.04, Stats., and the requirements under s. N 6.03 for nurse practitioners and under s. Med 8.07 for physician assistants are met. The limitations on coverage and services in this section apply to co-pay, spend-down and deductible.

DHS 109.31(2) (2) Prior authorization.

DHS 109.31(2)(a) (a) Drugs requiring prior authorization. The following drugs and supplies require prior authorization:

DHS 109.31(2)(a)1. 1. All schedule III and IV stimulant drugs.

DHS 109.31(2)(a)2. 2. Drugs that have been demonstrated to entail significant expense or overuse for the medical assistance program. These drugs shall be noted in the Wisconsin medical assistance drug index.

DHS 109.31(2)(a)3. 3. Drugs identified by the department that may be used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.

DHS 109.31(2)(b) (b) Request for prior authorization.

DHS 109.31(2)(b)1. 1. In considering a prior authorization request under this chapter made by a provider under sub. (1), the department shall require the information required in s. DHS 107.02 (3) (d) and apply the review criteria in s. DHS 107.02 (3) (e).

DHS 109.31(2)(b)2. 2.

DHS 109.31(2)(b)2.a. a. If a SeniorCare provider under sub. (1) does not request and obtain prior authorization before providing a prescription drug requiring prior authorization, the department may not provide reimbursement except in an emergency.

DHS 109.31(2)(b)2.b. b. Except in an emergency case as specified under subd. 2. a., the department may not cover a prescription drug or apply a participant’s purchase to the deductible or spend-down if the department has not prior authorized a drug requiring prior authorization. A certified provider may not hold a recipient liable for payment for a covered service requiring prior authorization by the department unless the department denies the prior authorization request and the provider informs the recipient of the recipient’s personal liability before provision of the service. If the department denies the recipient’s prior authorization request, the recipient may request a fair hearing under s. DHS 109.63. SeniorCare providers are required to request prior authorization for all SeniorCare participants.

DHS 109.31(3) (3) Other limitations.

DHS 109.31(3)(a) (a) SeniorCare providers shall limit dispensing of schedule III, IV and V drugs to the original dispensing plus 5 refills, or 6 months from the date of the original prescription, whichever comes first.

DHS 109.31(3)(b) (b) SeniorCare providers shall limit dispensing of non-scheduled legend drugs and insulin to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.

DHS 109.31(3)(c) (c) SeniorCare providers shall fill:

DHS 109.31(3)(c)1. 1. Generically-written prescriptions for drugs listed in the federal food and drug administration approved drug products publication with a generic drug included in that list.

DHS 109.31(3)(c)2. 2. Prescription orders written for brand name drugs that have a lower cost generically available drug with the lower cost drug product, unless the prescribing provider under sub. (1) writes “brand medically necessary” on the face of the prescription. The prescribing provider shall document in the patient’s record the reason why the drug is medically necessary.

DHS 109.31(3)(d) (d) Except as provided in par. (e), SeniorCare providers shall dispense prescription drugs in amounts not to exceed a 34-day supply.

DHS 109.31(3)(e) (e) SeniorCare providers may dispense certain maintenance drugs specified under s. DHS 107.10 (3) (e), in amounts up to but not to exceed a 100-day supply, as prescribed by a physician.

DHS 109.31 Note Note: The maintenance drugs listed in section DHS 107.10 (3) (e) are: digoxin, digitoxin, digitalis; hydrochlorothiazide and chlorothiazide; prenatal vitamins; fluoride; levothyroxine, liothyronine and thyroid extract; phenobarbital; phenytoin; and oral contraceptives.

DHS 109.31 Note Note: Par. (e) is amended by 2023 Wis. Act 71 as shown below, effective upon approval by the federal secretary of health and human services of a waiver or amendment to a waiver requested under Section (3) of 2023 Wis. Act 71. If the waiver or amendment to a waiver requested under Section 3 is denied, the amendment by 2023 Wis. Act 71, as shown below, is void.

DHS 109.31 Note (e) SeniorCare providers may dispense certain maintenance drugs specified under s. DHS 107.10 (3) (e) or any other drug, as determined by the department on the basis of clinical considerations, safety, costs, and other factors, in amounts up to but not to exceed a 100-day supply, as prescribed by a physician.

DHS 109.31(3)(f) (f) The only general category of over-the-counter drugs that shall be covered are the insulins.

DHS 109.31(3)(g) (g) The innovator of a multiple-source drug shall be a covered service only when the prescribing provider under sub. (1) certifies by writing the phrase “brand medically necessary” on the prescription.

DHS 109.31(3)(h) (h) SeniorCare shall only cover vaccines that are recommended for immunization to adults by the federal centers for disease control and prevention’s advisory committee on immunization practices and administered by a SeniorCare provider in an allowed place of service.

DHS 109.31(4) (4) Lock-in program.

DHS 109.31(4)(a) (a) Required when program is abused. If the department discovers that a participant is abusing the program, including the type of abuse under s. DHS 109.61 (1) and (5), the department may require the participant to designate one pharmacy as the SeniorCare lock-in provider of the participant’s choice.

DHS 109.31(4)(b) (b) Selection of lock-in provider. The department shall allow a participant to choose a lock-in provider from the department’s current list of certified SeniorCare providers. The participant’s choice shall become effective only with the concurrence of the designated lock-in provider.

DHS 109.31(4)(c) (c) Failure to cooperate. If the participant fails to designate a lock-in provider within 15 days after receiving a formal request from the department, the department shall designate a lock-in provider for the participant.

DHS 109.31(5) (5) Non–covered services. In addition to possible non-coverage without prior authorization of some drugs under sub. (2) (b) 2., the following drugs are not covered under this chapter:

DHS 109.31(5)(a) (a) A drug not covered under the medical assistance program under s. DHS 107.10 (4).

DHS 109.31(5)(b) (b) A drug produced by a manufacturer who has not entered into a rebate agreement with the department, as required by s. 49.688, Stats.

DHS 109.31(6) (6) Drug review, counseling and recordkeeping.

DHS 109.31(6)(a) (a) In addition to complying with ch. Phar 7, a SeniorCare provider shall do all of the following:

DHS 109.31(6)(a)1. 1. Provide for a review of drug therapy before each prescription is filled or delivered to a SeniorCare participant. The review shall include screening for potential drug therapy problems including therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions and clinical abuse or misuse.

DHS 109.31(6)(a)2. 2. Offer to discuss with each SeniorCare participant, the participant’s legal representative or the participant’s caregiver who presents the prescription, matters which, in the exercise of the SeniorCare provider’s professional judgment and consistent with state statutes and rules governing provisions of this information, the SeniorCare provider deems significant, including the following:

DHS 109.31(6)(a)2.a. a. The name and description of the medication.

DHS 109.31(6)(a)2.b. b. The route, dosage form, dosage, route of administration, and duration of drug therapy.

DHS 109.31(6)(a)2.c. c. Specific directions and precautions for preparation, administration and use by the patient.

DHS 109.31(6)(a)2.d. d. Common severe side effects or adverse effects or interactions and therapeutic contraindications that may be encountered, including how to avoid them, and the action required if they occur.

DHS 109.31(6)(a)2.e. e. Techniques for self-monitoring drug therapy.

DHS 109.31(6)(a)2.f. f. Proper storage.

DHS 109.31(6)(a)2.g. g. Prescription refill information.

DHS 109.31(6)(a)2.h. h. Action to be taken in the event of a missed dose.

DHS 109.31(6)(a)3. 3. Make a reasonable effort to obtain, record and maintain at least the following information regarding each SeniorCare participant for whom the SeniorCare provider dispenses drugs under the SeniorCare program:

DHS 109.31(6)(a)3.a. a. The participant’s name, address, telephone number, date of birth or age and gender.

DHS 109.31(6)(a)3.b. b. The participant’s medical history where significant, including any disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices.

DHS 109.31(6)(a)3.c. c. The SeniorCare provider’s comments related to the participant’s drug therapy.

DHS 109.31(6)(b) (b) Nothing in this subsection shall be construed as requiring a SeniorCare provider to provide consultation when a SeniorCare participant, the participant’s legal representative or the participant’s caregiver refuses the consultation.

DHS 109.31 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; corrections in (2) (b), (3) (e) and (5) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register February 2014 No. 698; CR 22-046: cr. (3) (h) Register June 2023 No. 810, eff. 7-1-23.

DHS 109.32 DHS 109.32 Coverage while out-of-state. Drugs shall be covered for a SeniorCare participant only if the participant is within the United States, Canada or Mexico. Drugs provided by a person in another state who is not certified as a border status provider shall be covered only under either of the following circumstances:

DHS 109.32(1) (1) As a result of an accident or sudden illness, the individual needs the drug to prevent the individual’s death or the serious impairment of the individual’s health.

DHS 109.32(2) (2) When the department has granted prior authorization for provision of a non-emergency service, except that prior authorization is not required for non-emergency services provided to Wisconsin participants by border status providers certified by the Wisconsin medical assistance program.

DHS 109.32 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

subch. IV of ch. DHS 109 Subchapter IV — Program Integrity