Chapter DHS 152

Chapter DHS 152

REIMBURSEMENT FOR TREATMENT OF CHRONIC RENAL DISEASE

DHS 152.01   Authority and purpose.

DHS 152.02   Definitions.

DHS 152.03   Eligibility and certification.

DHS 152.035   Events which affect eligibility.

DHS 152.04   Patient rights and responsibilities.

DHS 152.05   Certification of renal transplantation centers, dialysis centers and dialysis facilities.

DHS 152.06   Provider reimbursement.

DHS 152.065   Patient liability.

DHS 152.07   Standards for renal transplantation centers.

DHS 152.08   Standards for renal dialysis centers and facilities.

DHS 152.09   CRD program advisory committee.

Ch. DHS 152 Note Note: Chapter H 52 as it existed on June 30, 1988, was repealed and a new chapter HSS 152 was created effective July 1, 1988. Chapter HSS 152 as it existed on September 30, 1999, was renumbered to chapter HFS 152, Register, September, 1999, No. 525, eff. 10-1-99 and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, September, 1999, No. 525. Chapter HFS 152 was renumbered chapter DHS 152 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637.

DHS 152.01 DHS 152.01 Authority and purpose. This chapter is promulgated under the authority of ss. 49.68 (2), 49.687 (1) and 227.11 (2) (a), Stats., to implement a treatment cost reimbursement program for residents of Wisconsin who have chronic renal disease.

DHS 152.01 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; am. Register, December, 1994, No. 468, eff. 1-1-95.

DHS 152.02 DHS 152.02 Definitions. In this chapter:

DHS 152.02(1) (1) “Agreement” means a written document executed between an ESRD unit and another unit, in which the other unit agrees to assume responsibility for furnishing specified services to patients and for obtaining reimbursement for those services.

DHS 152.02(2) (2) “Arrangement” means a written document executed between an ESRD unit and another unit, in which the other unit agrees to furnish specified services to patients but the ESRD unit retains responsibility for the services and for obtaining reimbursement.

DHS 152.02(2m) (2m) “BadgerCare” means the medical assistance-related program established under s. 49.665, Stats., and chs. DHS 101 to 108.

DHS 152.02(3) (3) “Chronic renal disease” or “CRD” means that stage of renal impairment which is virtually irreversible and requires a regular course of dialysis or kidney transplantation to maintain life.

DHS 152.02(4) (4) “CRD program advisory committee” means the committee appointed by the department under s. DHS 152.09.

DHS 152.02(4m) (4m) “Current year” means the 12-month period beginning with the month of a patient’s first application to the CRD program, or beginning with the month of a certified patient’s subsequent annual recertification for the CRD program.

DHS 152.02(5) (5) “Department” means the department of health services.

DHS 152.02(6) (6) “Dialysis” means a process by which dissolved substances are removed from a patient’s body by diffusion and osmosis from one fluid compartment to another across a semipermeable membrane.

DHS 152.02(7) (7) “Dietitian” means a person who is eligible for registration by the American dietetic association and has at least 1 year of experience in clinical nutrition, or a person who has a baccalaureate or advanced degree with major studies in food and nutrition or dietetics and at least 1 year of experience in clinical nutrition.

DHS 152.02(8) (8) “End-stage renal disease” or “ESRD” has the meaning prescribed for chronic renal disease or CRD in sub. (3).

DHS 152.02(9) (9) “ESRD unit” or “unit” means a free-standing or hospital-based renal dialysis facility, a renal dialysis center or a renal transplantation center.

DHS 152.02(9m) (9m) “Family” means a patient and that patient’s spouse, if any, and any other person who is claimed as a dependent of that patient or that patient’s spouse or who claims that patient as a dependent under the U.S. internal revenue code for the purpose of filing a federal income tax return.

DHS 152.02(9t) (9t) “Federal poverty guidelines” means the annually updated poverty income thresholds by family size published each year by the U.S. department of health and human services in the federal register.

DHS 152.02 Note Note: The federal poverty guidelines for 1999 were published in the Federal Register, March 18, 1999, 13428.

DHS 152.02(9u) (9u) “Fiscal agent” means the organization under contract to the department to process claims and determine eligibility for services provided under the CRD program.

DHS 152.02(10) (10) “Free-standing renal dialysis facility” means a non-hospital unit which is approved by the department under this chapter to furnish chronic maintenance dialysis with or without self-care dialysis training.

DHS 152.02(11) (11) “Furnishes directly” means that the ESRD unit provides the service through its own staff and employees, or through individuals who are under personal contract to furnish services for the facility.

DHS 152.02(12) (12) “Home dialysis” means dialysis performed by a trained ESRD patient or helper, or both, at home.

DHS 152.02(13) (13) “Hospital-based renal dialysis facility” means a hospital unit approved by the department to furnish one or more of the following dialysis services to ESRD patients:

DHS 152.02(13)(a) (a) Outpatient dialysis;

DHS 152.02(13)(b) (b) Inpatient dialysis;

DHS 152.02(13)(c) (c) Home dialysis;

DHS 152.02(13)(d) (d) Self-dialysis training.

DHS 152.02(14) (14) 

DHS 152.02(14)(a) (a) “Income,” for the period January 1, 1994 to June 30, 1994, has the meaning prescribed in s. 49.485 (1) (dm), 1991 Stats., except that a certified patient may for that period elect to use the definition under par. (b).

DHS 152.02(14)(b) (b) “Income,” beginning July 1, 1994, means a family’s total earnings, including wages and salary and net income from self-employment, as well as unearned income including social security and supplemental security income, dividends and interest income, income from estates or trusts, net rental income, public assistance, pensions or annuities, unemployment compensation, maintenance or alimony, child support or family support, nontaxable deferred compensation, and nontaxable interest such as interest on federal, state or municipal bonds, but not capital gains income.

DHS 152.02(15) (15) “Inpatient dialysis” means dialysis which, because of medical necessity, is furnished to an ESRD patient on a temporary basis in a hospital.

DHS 152.02(15m) (15m) “Medical assistance” has the meaning specified in s. 49.43 (8), Stats.

DHS 152.02(16) (16) “Medicare” means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395zz and 42 CFR Pts. 405 to 421.

DHS 152.02(17) (17) “Nephrologist” means a physician licensed in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, who is board-eligible or board-certified by the American board of internal medicine, or by an equivalent certifying body as determined by the department on recommendation of the CRD program advisory committee, and who has a minimum of 12 months of fellowship training in nephrology or 2 years of experience in delivering care to ESRD patients. Pediatric training may be substituted for internal medicine board eligibility or board certification if the ESRD unit’s services are associated with pediatric ESRD care.

DHS 152.02(18) (18) “Nurse” means a full-time supervisory nurse registered in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, with at least 12 months of experience in clinical nursing and an additional 6 months of experience in nursing care of an outpatient dialysis or kidney transplantation patient, including training in and experience with the dialysis process, or 18 months of experience in nursing care of an outpatient dialysis or kidney transplantation patient, including training in and experience with the dialysis process. If the nurse is in charge of home dialysis or self-dialysis training, at least 3 months of the total required ESRD experience shall be in home dialysis or self-dialysis patient training.

DHS 152.02(19) (19) “Outpatient dialysis” means dialysis which is regularly furnished on an outpatient basis to an ESRD patient in a renal dialysis center, hospital-based renal dialysis facility or a free-standing renal dialysis facility.

DHS 152.02(20) (20) “Patient” means a person who has been diagnosed as having ESRD and who receives treatment for ESRD. “Patient” does not include a kidney donor.

DHS 152.02(21) (21) “Patient registry program” means a computerized list of all certified patients on dialysis which includes verification that each case has been reviewed by a transplant surgeon and that cases meeting criteria for a transplant are placed on the transplant list.

DHS 152.02(22) (22) “Provider” means a renal dialysis facility or center, a renal transplantation center, or another source of dialysis or transplantation services approved by the department.

DHS 152.02(23) (23) “Renal dialysis center” means a hospital unit approved by the department to furnish the full spectrum of diagnostic services, therapeutic services including inpatient dialysis furnished directly or under arrangement, and rehabilitative services, except renal transplantation, required for the care of ESRD patients.

DHS 152.02(24) (24) “Renal transplantation center” means a hospital unit approved by the department to furnish transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement or agreement.

DHS 152.02(26) (26) “Self-dialysis” means dialysis which is regularly furnished on an outpatient basis to an ESRD patient in a renal dialysis center, hospital-based renal dialysis facility or a free-standing renal dialysis facility, in which the ESRD patient is responsible for the dialysis treatment but is supervised by a dialysis nurse.

DHS 152.02(26m) (26m) “SeniorCare” means the program of prescription drug assistance for eligible elderly persons under s. 49.688, Stats., and ch. DHS 109.

DHS 152.02(27) (27) “Social worker” means a person who provides counseling to an ESRD patient and his or her family, and has either completed a course of study with specialization in clinical practice at a graduate school of social work accredited by the council on social work education and holds a masters degree from that school, or has worked for at least 2 years as a social worker, 1 year of which was in a dialysis or transplantation setting, and receives consultation from a social worker who holds a masters degree from an accredited school of social work.

DHS 152.02(28) (28) “Transplant surgeon” means a physician licensed in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, who is board-eligible or board-certified by the American board of surgery or by an equivalent certifying body as determined by the department on recommendation of the CRD program advisory committee, and who has a minimum of 12 months of training or experience in the performance of renal transplantation and the care of renal transplant patients in an accredited teaching institution.

DHS 152.02(29) (29) “Vascular surgeon” means a physician licensed in Wisconsin or, if employed by an ESRD unit approved under this chapter in a border state, in that state, who is board-eligible or board-certified by the American board of surgery or by an equivalent certifying body as determined by the department on recommendation of the CRD program advisory committee under s. DHS 152.09, and who has a minimum of 12 months of training or experience in the performance of vascular access procedures.

DHS 152.02 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; cr. (15m), Register, May, 1992, No. 437, eff. 6-1-92; emerg. cr. (9 g), am. (14), eff. 9-1-93; cr. (4m), (9m), (9t) and (9u), r. and recr. (14) and (25), Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (2m) and (26m) Register November 2004 No. 587, eff. 12-1-04; corrections in (2m), (5) and (26m) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637; CR 20-039: r. (25) Register October 2021 No. 790, eff. 11-1-21.

DHS 152.03 DHS 152.03 Eligibility and certification.

DHS 152.03(1) (1) Conditions. To be eligible for the CRD program, a patient shall:

DHS 152.03(1)(a) (a) Be a resident of Wisconsin;

DHS 152.03(1)(b) (b) Be diagnosed as having ESRD;

DHS 152.03(1)(c) (c) If eligible for medicare, register and pay the premium for coverage by medicare; and

DHS 152.03(1)(d) (d) Provide to the department or its designated agent full, truthful and correct information necessary for the department to determine patient eligibility and liability, including information about any change in income of more than 10%. A patient shall be denied reimbursement if he or she refuses to provide information, withholds information or provides inaccurate information. The department may verify or audit a certified patient’s total family income. The department may redetermine a certified patient’s estimated total family income for the current year based on change in the family’s financial circumstances.

DHS 152.03(1)(e) (e) First apply for benefits under all other health care coverage programs for which the person may reasonably be eligible, including medicare, BadgerCare, medical assistance and SeniorCare.

DHS 152.03(2) (2) Patient certification.

DHS 152.03(2)(a) (a) Certification for coverage of dialysis shall be determined by the department upon the recommendation of a nephrologist from an approved dialysis unit. Certification for coverage of renal transplantation shall be determined by the department upon the recommendation of a transplant surgeon from an approved renal transplantation center.

DHS 152.03(2)(b) (b) A statewide list of certified ESRD patients shall be maintained either by the department or by another agency upon arrangement with the department. This list shall include names of all certified outpatient dialysis and kidney transplant patients in the state. Additional information deemed necessary and appropriate by the department shall be provided by the dialysis and transplant centers to determine eligibility and facilitate reimbursement.

DHS 152.03(2)(c) (c) The department or its fiscal agent shall certify an eligible patient for reimbursement upon receipt from any dialysis unit approved under ss. DHS 152.05 and 152.08 or renal transplantation center approved under ss. DHS 152.05 and 152.07 of a satisfactorily completed application for certification submitted on behalf of the patient.

DHS 152.03 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; emerg. am. (1) (c), eff. 9-1-93; r. and recr. (1), am. (2) (c), Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (1) (e) Register November 2004 No. 587, eff. 12-1-04.

DHS 152.035 DHS 152.035 Events which affect eligibility.

DHS 152.035(1) (1) Eligibility under the CRD program is terminated if any of the following events occur:

DHS 152.035(1)(a) (a) The patient dies.

DHS 152.035(1)(b) (b) The patient stops making medicare premium payments.

DHS 152.035(1)(c) (c) The patient moves out of the state of Wisconsin.

DHS 152.035(1)(d) (d) The patient no longer requires a regular course of chronic dialysis because the patient’s kidneys resume function and the patient has not had a kidney transplant.

DHS 152.035(2) (2) An applicant who has died may be retroactively eligible for benefits only if the applicant had signed and completed an application prior to the date of the applicant’s death.

DHS 152.035 History History: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04.

DHS 152.04 DHS 152.04 Patient rights and responsibilities.

DHS 152.04(1) (1) A certified patient or, if the patient is a minor or has a guardian, the patient’s parent or guardian shall inform the department within 30 days after there is any change in the patient’s address, other sources of health care coverage, income of more than 10% or family size.

DHS 152.04(2) (2) 

DHS 152.04(2)(a) (a) A patient applying for benefits or a certified patient may request an administrative hearing under subch. III of ch. 227, Stats., in the event that reimbursement is denied or certification is terminated.

DHS 152.04(2)(b) (b) A request for a hearing shall be in writing and shall be filed with the department of administration’s division of hearings and appeals within 45 days after the date of notice of denial of reimbursement or termination of certification. A request for a hearing is considered filed upon its receipt by the division of hearings and appeals.

DHS 152.04 Note Note: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.

DHS 152.04(3) (3) All information provided by a certified patient to the department or to a provider shall remain confidential and may not be used for any purpose other than to determine eligibility for benefits, patient liability and the types of medical services required for proper care. Statistical analyses of program data may not reveal patient identity.