Chapter DHS 109

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

DHS 109.41 DHS 109.41 Annual report to legislature. The department shall monitor compliance with s. 49.688, Stats., and the provisions of this chapter by SeniorCare providers.

DHS 109.41 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.42 DHS 109.42 Prohibition on fraud.

DHS 109.42(1) (1) No person may do any of the following:

DHS 109.42(1)(a) (a) Knowingly and willfully make or cause to be made any false statement or representation of a material fact in any application for any SeniorCare benefit or payment.

DHS 109.42(1)(b) (b) Knowingly and willfully make or cause to be made any false statement or representation of a material fact for use in determining rights to any SeniorCare benefit or payment.

DHS 109.42(1)(c) (c) Have knowledge of the occurrence of any event affecting the initial or continued right to any SeniorCare benefit or payment, or the initial or continued right to any such benefit, or payment of any other individual in whose behalf he or she has applied for or is receiving such benefit or payment, or conceal or fail to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized.

DHS 109.42(1)(d) (d) Having made application to receive any SeniorCare benefit or payment for the use and benefit of another and having received it, knowingly and willfully convert such benefit or payment or any part thereof to a use other than for the use and benefit of such other person.

DHS 109.42(2) (2) Violators of this section shall be subject to penalties under s. 49.688 (9), Stats.

DHS 109.42 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

subch. V of ch. DHS 109 Subchapter V — Provider Rights and Responsibilities

DHS 109.51 DHS 109.51 Provider responsibility.

DHS 109.51(1) (1) Audit and program monitoring.

DHS 109.51(1)(a) (a) Providers shall comply with the audit and program monitoring conditions under s. DHS 105.01 (3) (f) 1. to 3.

DHS 109.51(1)(b) (b) Nothing in this subsection shall be construed to limit the right of a provider to appeal a department recovery action brought under s. DHS 109.53 (4).

DHS 109.51(2) (2) Confidentiality of medical information. Information about participants shall be confidential in accordance with ss. 146.81 to 146.83, Stats. No privilege exists under the SeniorCare program regarding communications or disclosures of information requested by appropriate federal or state agencies or an authorized agent of such agencies concerning the extent or kind of services provided participants under the program. The disclosure by a SeniorCare provider of these communications or medical records, made in good faith under the requirements of this program, shall not create any civil liability or provide any basis for criminal actions for unprofessional conduct.

DHS 109.51(3) (3) Provider responsibility. At the request of a person authorized by the department and on presentation of that person’s credentials, a SeniorCare provider shall permit access to any requested records, whether in written, electronic, or micrographic form. Access for purposes of this subsection shall include the opportunity to inspect, review, audit and reproduce the records.

DHS 109.51(4) (4) Record retention. Termination of a SeniorCare provider’s program participation does not end the SeniorCare provider’s responsibility to retain and provide access to records unless an alternative arrangement for retention, maintenance and access has been established by the SeniorCare provider and approved in writing by the department.

DHS 109.51(5) (5) Submission of claims. A SeniorCare provider shall submit all claims for prescription drugs purchased by a participant during spend-down and deductible periods.

DHS 109.51(6) (6) Third party liability. A SeniorCare provider shall seek reimbursement from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs prior to billing the SeniorCare program.

DHS 109.51(7) (7) Refunds to participants. A SeniorCare provider shall fully refund participant payments for drugs subsequently covered by SeniorCare. If either the deductible or copayment retroactively applies, the provider shall fully refund the participant the excess amount that the participant paid. The excess is the difference between the actual amount the participant paid and the amount the participant is responsible for under SeniorCare.

DHS 109.51(8) (8) Limitations on copayments and deductibles.

DHS 109.51(8)(a) (a) As a condition of participation by a SeniorCare provider in the program under s. 49.45, 49.46, or 49.47, Stats., the SeniorCare provider may not charge an eligible participant who presents a valid prescription order and a SeniorCare identification an amount for a prescription drug under the order that exceeds the following:

DHS 109.51(8)(a)1. 1. For a deductible benefit, as specified in s. DHS 109.13 (3), the program payment rate.

DHS 109.51(8)(a)2. 2. For a prescription benefit, the copayment amount, as applicable, that is specified in s. DHS 109.13 (2) (b). No dispensing fee may be charged to a person under this paragraph.

DHS 109.51(8)(a)3. 3. For persons receiving spend-down services, as specified in s. DHS 109.13 (4), the retail price.

DHS 109.51(8)(b) (b) The department shall calculate and transmit amounts that may be used in calculating charges under par. (a) to SeniorCare providers.

DHS 109.51 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; correction in (1) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-046: am. (5) Register June 2023 No. 810, eff. 7-1-23.

DHS 109.52 DHS 109.52 Provider certification.

DHS 109.52(1) (1) General. This section identifies the terms and conditions under which SeniorCare providers of drugs are certified for participation in the program.

DHS 109.52(2) (2) Pharmacies.

DHS 109.52(2)(a) (a) For SeniorCare certification, pharmacies located in Wisconsin shall meet the requirements for registration and practice under ch. 450, Stats., and chs. Phar 1 to 17. Pharmacies certified to serve patients under the medical assistance program under ch. DHS 105 are required to serve SeniorCare participants.

DHS 109.52(2)(b) (b) Pharmacies located outside of Wisconsin are exempt from the requirement under par. (a), but shall be registered or licensed by the appropriate agency in the state in which they are located.

DHS 109.52(3) (3) General conditions for participation. In order to be certified by the department to dispense drugs under this program, a SeniorCare provider shall do all of the following:

DHS 109.52(3)(a) (a) Affirm in writing that the SeniorCare provider and each person employed by the SeniorCare provider for the purpose of providing the service holds all licenses or similar entitlements as specified in this chapter and as required by federal or state statute, regulation or rule for the provision of the service.

DHS 109.52(3)(b) (b) Affirm in writing that neither the SeniorCare provider, nor any person in whom the SeniorCare provider has a controlling interest, nor any person having a controlling interest in the SeniorCare provider, has been convicted of a crime related to, or been terminated from, a federally-assisted or state-assisted medical program.

DHS 109.52(3)(c) (c) Disclose in writing to the department all instances in which the SeniorCare provider, any person in whom the SeniorCare provider has a controlling interest, or any person having a controlling interest in the SeniorCare provider has been sanctioned by a federally-assisted or state-assisted medical program.

DHS 109.52(3)(d) (d) Furnish the following information to the department in writing:

DHS 109.52(3)(d)1. 1. The names and addresses of all vendors of drugs, medical supplies or transportation, or other providers in which the SeniorCare provider has a controlling interest or ownership.

DHS 109.52(3)(d)2. 2. The names and addresses of all persons who have a controlling interest in the SeniorCare provider.

DHS 109.52(3)(d)3. 3. Whether any of the persons named in compliance with subd. 1. or 2., is related to another named in subd. 1. or 2.

DHS 109.52(3)(e) (e) Execute a SeniorCare provider agreement with the department.

DHS 109.52(4) (4) Notification of certification decision. Within 60 days after the department receives a complete application for certification, including evidence of licensure or Medicare certification, or both, if required, the department shall either approve the application and issue the certification, or deny the application. If the application for certification is denied, the department shall give the applicant reasons, in writing, for the denial.

DHS 109.52(5) (5) Requirements for maintaining certification.

DHS 109.52(5)(a) (a) Compliance with requirements. A SeniorCare provider shall maintain compliance with the requirements in this subsection in order to maintain SeniorCare certification.

DHS 109.52(5)(b) (b) Change in provider status. A SeniorCare provider shall report to the department in writing any change in licensure, certification, group affiliation, corporate name or ownership by the time of the effective date of the change. The department may require the SeniorCare provider to complete a new provider application and a new provider agreement when a change in status occurs. A SeniorCare provider shall immediately notify the department of any change of address but the department shall not require the completion of a new provider application or a new provider agreement for a change of address.

DHS 109.52(5)(c) (c) Change in ownership. If the ownership of a certified SeniorCare provider changes, the provider agreement shall automatically terminate.

DHS 109.52(5)(d) (d) Program compliance. A SeniorCare provider may lose SeniorCare certification for any of the reasons listed in sub. (12) or in s. DHS 106.06.

DHS 109.52(6) (6) Response to inquiries. A SeniorCare provider shall respond as directed to inquiries by the department regarding the validity of provider information maintained by the department.

DHS 109.52(7) (7) Maintenance of records. A SeniorCare provider shall prepare and maintain whatever records are necessary to fully disclose the nature and extent of services provided by the SeniorCare provider under the program, including those enumerated in sub. (8). Each SeniorCare provider shall maintain all required records for at least a period of 5 years from the date the department pays for the services rendered, unless otherwise stated in this chapter. If a SeniorCare provider’s participation in the program terminates for any reason, all related records shall remain subject to the conditions enumerated in this subsection and sub. (8).

DHS 109.52(8) (8) Records to be maintained. SeniorCare providers shall retain all of the following records:

DHS 109.52(8)(a) (a) Contracts or agreements with persons or organizations for the furnishing of SeniorCare items or services, payment for which may be made in whole or in part, directly or indirectly, by the department.

DHS 109.52(8)(b) (b) Billings and records of services or supplies which are the subject of the billings that are necessary to fully disclose the nature and extent of the SeniorCare services or supplies.

DHS 109.52(8)(c) (c) All policies and regulations adopted by the SeniorCare provider’s governing body.

DHS 109.52(8)(d) (d) Prescriptions that support SeniorCare billings, including records of SeniorCare covered vaccines and vaccine administration.

DHS 109.52(8)(e) (e) SeniorCare patient profiles.

DHS 109.52(8)(f) (f) SeniorCare purchase invoices and receipts.

DHS 109.52(8)(g) (g) Receipts for costs associated with SeniorCare services billed.

DHS 109.52(9) (9) Provider agreement duration. The provider agreement shall, unless terminated, remain in full force and effect for a maximum of one year from the date the department accepts a SeniorCare provider into the program. In the absence of a notice of termination by the SeniorCare provider or department, the agreement shall automatically renew and extend for a period of one year.

DHS 109.52(10) (10) Participation by non–certified persons.

DHS 109.52(10)(a) (a) Reimbursement for emergency services. If a person in Wisconsin or in another state who is not certified as a SeniorCare provider by the department in this state provides emergency services to a Wisconsin participant, that person may not be reimbursed for those services unless the drugs are covered under this chapter and all of the following conditions are met:

DHS 109.52(10)(a)1. 1. The person submits to the department a provider data form and a claim for reimbursement of emergency services on forms prescribed by the department.