Chapter DHS 109

DHS 109.61 DHS 109.61 Participant duties.

DHS 109.61(1) (1) Not to seek duplication of services. A participant may not seek the same or similar covered drugs from more than one SeniorCare provider.

DHS 109.61(2) (2) Prior identification of eligibility. Except in emergencies that preclude prior identification, the participant shall, before receiving prescription drugs, inform the SeniorCare provider that the participant is receiving benefits under SeniorCare and shall present to the SeniorCare provider a current valid SeniorCare identification card.

DHS 109.61(3) (3) Review of benefits notice. Participants shall review the explanation of benefits (EOB) notice sent to them by the department and shall report to the department any payments made for drugs not actually provided.

DHS 109.61(4) (4) Informational cooperation with SeniorCare providers. Participants shall give SeniorCare providers full, correct and truthful information requested by SeniorCare providers and necessary for the submission of correct and complete claims for SeniorCare reimbursement, including information about all of the following:

DHS 109.61(4)(a) (a) The participant’s eligibility status, accurate name, address and SeniorCare identification number.

DHS 109.61(4)(b) (b) The participant’s use of the SeniorCare card.

DHS 109.61(4)(c) (c) The participant’s use of SeniorCare benefits.

DHS 109.61(4)(d) (d) The participant’s coverage under other insurance programs.

DHS 109.61(5) (5) Not to abuse or misuse the SeniorCare card or benefits. If a participant abuses or misuses the SeniorCare card or SeniorCare benefits in any manner, the department may terminate benefits or limit access to benefits under s. DHS 109.31 (4). For purposes of this subsection, “abuses or misuses” includes any of the following actions:

DHS 109.61(5)(a) (a) Altering or duplicating the SeniorCare card in any manner.

DHS 109.61(5)(b) (b) Permitting the use of the SeniorCare card by any unauthorized individual for the purpose of obtaining health care through SeniorCare.

DHS 109.61(5)(c) (c) Using a SeniorCare card that belongs to a person not authorized under that card.

DHS 109.61(5)(d) (d) Using the SeniorCare card to obtain any covered service for another individual.

DHS 109.61(5)(e) (e) Duplicating or altering prescriptions.

DHS 109.61(5)(f) (f) Knowingly misrepresenting material facts as to medical symptoms for the purpose of obtaining any covered service.

DHS 109.61(5)(g) (g) Knowingly furnishing incorrect eligibility status or other information to a SeniorCare provider.

DHS 109.61(5)(h) (h) Knowingly furnishing false information to a SeniorCare provider in connection with health care previously rendered to the participant and for which SeniorCare has been billed.

DHS 109.61(5)(i) (i) Knowingly obtaining health care in excess of established program limitations, or knowingly obtaining health care that is clearly not medically necessary.

DHS 109.61(5)(j) (j) Otherwise obtaining health care by false pretenses.

DHS 109.61 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 22-046: am. (2) Register June 2023 No. 810, eff. 7-1-23.

DHS 109.62 DHS 109.62 Recovery of incorrect payments from participants.

DHS 109.62(1) (1) The department shall begin recovery action against any SeniorCare participant to whom or on whose behalf an incorrect payment was made resulting from any of the following:

DHS 109.62(1)(a) (a) A misstatement or omission of fact by the person supplying information on an application, a request for a new benefit period, or a review of eligibility for SeniorCare benefits.

DHS 109.62(1)(b) (b) A check submitted for the program enrollment fee is returned for non-sufficient funds under s. DHS 109.11 (6) (d).

DHS 109.62(1)(c) (c) A recipient fails to inform the department, within 10 calendar days of the change, of changes in circumstances that affect eligibility.

DHS 109.62(1)(d) (d) A recipient received benefits while an appeal requested under s. DHS 109.63 was pending and the contested decision is upheld.

DHS 109.62(2) (2) The amount of recovery may not exceed the amount of the SeniorCare benefits incorrectly provided.

DHS 109.62(3) (3) Department records of payment for the period of ineligibility shall be evidence of the amounts paid on behalf of the participant.

DHS 109.62(4) (4) The department shall notify the participant or the participant’s representative of the period of ineligibility and the amounts incorrectly paid, and shall request arrangement of repayment within a specified period of time.

DHS 109.62(5) (5) If the department does not recover incorrect payments under sub. (4), the department shall refer cases of possible recovery to the district attorney or corporation counsel for investigation and the district attorney or corporation counsel may bring whatever action may be appropriate for prosecution for fraud or collection under civil liability statutes. If not satisfied at the time the judgment or order for restitution is rendered, judgments obtained in these actions shall be filed as liens against property in any county in which the participant is known to possess assets. Execution may be taken on the judgments as otherwise provided in statute.

DHS 109.62(6) (6) The department may seek recovery through an order for restitution by the court of jurisdiction in which the participant or former participant is being prosecuted for fraud.

DHS 109.62 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.63 DHS 109.63 Participant appeals.

DHS 109.63(1) (1) Except as provided under sub. (2), any participant who is aggrieved by the department’s action or inaction may file an appeal pursuant to the requirements under ch. HA 3 that apply to the medical assistance program.

DHS 109.63(2) (2) 

DHS 109.63(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 109.63(2)(b) (b) The participant shall have 45 days from the effective date of the adverse action in which to file a request for hearing.

DHS 109.63(3) (3) If a recipient requests a hearing before the effective date of the action, SeniorCare benefits and services may not be suspended, reduced or discontinued until a decision is rendered after the hearing. However, SeniorCare benefit payments made pending the hearing decision may be recovered by the department if the contested decision or failure to act is upheld.

DHS 109.63 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, Wisconsin or transmitted by facsimile machine to 608-264-9885.

DHS 109.63 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

subch. VII of ch. DHS 109 Subchapter VII — Program Administration

DHS 109.71 DHS 109.71 Rebate agreement. The department shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department. The manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons under s. DHS 109.13 (2) (b) and (3) (b), to the state treasurer to be credited to the appropriation account under s. 20.435 (4) (j), Stats., each calendar quarter or according to a schedule established by the department.

DHS 109.71 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.72 DHS 109.72 Payment for drugs. The department shall provide to SeniorCare providers payments for prescription drugs sold by the SeniorCare providers to eligible persons under s. DHS 109.13 (2) (b). The payment for each prescription drug under this subsection shall be no more than the program payment rate, minus any copayment paid by the person under s. DHS 109.13 (2) (b).

DHS 109.72 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

DHS 109.73 DHS 109.73 Program suspension. During any period in which funding under s. 20.435 (4) (bv), Stats., is completely expended for the payments to SeniorCare providers, the requirements of ss. DHS 109.71 and 109.72 do not apply to prescription drugs purchased during that period. However, the department shall continue to accept applications and determine eligibility under subchapter II and shall indicate to applicants that the eligibility of program participants to purchase prescription drugs as specified in this chapter, under the requirements of s. DHS 109.72, is conditioned on the availability of funding under s. 20.435 (4) (bv), Stats.

DHS 109.73 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 22-046: am. Register June 2023 No. 810, eff. 7-1-23.

DHS 109.74 DHS 109.74 Safeguarded information.

DHS 109.74(1) (1) Except for purposes directly related to direct program administration, the department may not use or disclose any information concerning past or present applicants and participants in SeniorCare.

DHS 109.74(2) (2) For purposes of direct program administration, the department may permit disclosure to, or use of safeguarded information by, legally qualified persons or agency representatives outside the department. Governmental authorities, the courts, and law enforcement officers are persons outside the department who shall comply with sub. (3).

DHS 109.74(3) (3) Persons or agency representatives outside the department to whom the department may disclose or permit use of safeguarded information shall meet all of the following qualifications:

DHS 109.74(3)(a) (a) The persons’ or agency representatives’ purpose for use or disclosure shall involve direct program administration.

DHS 109.74(3)(b) (b) The person or agency shall be bound by law or other legally enforceable obligation to observe confidentiality standards comparable to those observed by the department.

DHS 109.74 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.