Chapter DHS 152

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.

DHS 152.04(4) (4) The department may not discriminate against or deny benefits to anyone on the basis of race, sex, age, national origin, marital status, creed, disability, sexual orientation or ancestry.

DHS 152.04 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; am. (1), r. and recr. (2), Register, December, 1994, No. 468, eff. 1-1-95; CR 20-068: am. (4) Register December 2021 No. 792, eff. 1-1-22.

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

DHS 152.05(1) (1) Certification. For purposes of reimbursement, all ESRD units in Wisconsin that are certified under medicare shall be considered certified by the department and shall comply with the requirements of this chapter.

DHS 152.05(2) (2) Border state esrd units. A border state ESRD unit that provides medical care services to Wisconsin residents shall be considered certified by the department as a provider if it is certified under medicare. These out-of-state ESRD units shall be subject to this chapter and the same contractual agreements as Wisconsin ESRD units.

DHS 152.05 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

DHS 152.06 DHS 152.06 Provider reimbursement.

DHS 152.06(1) (1) Claim forms.

DHS 152.06(1)(a) (a) A provider shall use claim forms furnished or prescribed by the department or its fiscal agent, except that a provider may submit claims by electronic media or electronic transmission if the provider or billing service is approved by the department for electronic claims submission.

DHS 152.06(1)(b) (b) Claims shall be submitted in accordance with the claims submission requirements, claim form instruction and coding information provided by the department or its fiscal agent.

DHS 152.06(1)(c) (c) Every claim submitted shall be signed by the provider or the provider’s authorized representative, certifying to the truthfulness, accuracy and completeness of the claim.

DHS 152.06(2) (2) Timeliness.

DHS 152.06(2)(a) (a) A claim shall be submitted within 24 months after the date that dialysis or transplant services were provided, except that a claim may be submitted later if the department is notified within that 24 month period that the sole reason for late submission concerns another funding source and the claim is submitted within 180 days after obtaining a decision on reimbursement from the other funding source.

DHS 152.06(2)(b) (b) A claim may not be submitted until after the patient has received the dialysis or transplant services.

DHS 152.06(3) (3) Payment.

DHS 152.06(3)(a) (a) The department shall establish allowable charges for CRD services as a basis for reimbursing providers.

DHS 152.06(3)(b) (b) Reimbursement may not be made for any portion of the cost of medical care which is payable under any other state or federal program, grant, contract or agreement.

DHS 152.06(3)(c) (c) Before submitting a claim to the CRD program, a provider shall seek payment for services provided to a certified patient from medicare, medical assistance or another health care plan if the certified patient is eligible for services under medicare, medical assistance or the other health care plan.

DHS 152.06(3)(d) (d) When benefits from medicare, medical assistance or another health care plan or other third party payer have been paid, in whole or in part to the provider, the amount of the payment from all other payers shall be indicated on or with the bill to the CRD program. The amount of the medicare, medical assistance, other health care plan or other third party payer reimbursement shall reduce the amount of the claim for CRD program payment.

DHS 152.06(3)(e) (e) If a provider receives a payment under the program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall promptly return the amount of the erroneous or excess payment to the department.

DHS 152.06(3)(f) (f) A provider may request a hearing to review a decision to deny payment or the level of payment. A request for a hearing shall be filed with the department’s office of administrative hearings within 90 days after the date of the payment or decision to deny payment. A request for a hearing is considered filed upon its receipt by the office of administrative hearings. All appeals shall include written documentation and any information deemed necessary by the department. Hearings shall be conducted in accordance with subch. III of ch. 227, Stats.

DHS 152.06 Note Note: The mailing address of the Office of Administrative Hearings is P.O. Box 7875, Madison, Wisconsin 53707.

DHS 152.06(3)(g) (g) A provider shall accept the amount paid under this section for the service as payment in full and may not bill the patient for any amount by which the charge for the service exceeds the amount paid for the service under this section.

DHS 152.06(3)(h) (h) The department shall use common methods employed by managed care programs and the medical assistance program to contain costs, including prior authorization and other limitations regarding health care utilization and reimbursement.

DHS 152.06 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; cr. (8), r. and recr. Table, Register, May, 1992, No. 437, eff. 6-1-92; emerg. r. and recr. Table cr. (6) (d), eff. 9-1-93; r. and recr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (3) (g) and (h) Register November 2004 No. 587, eff. 12-1-04.

DHS 152.065 DHS 152.065 Patient liability.

DHS 152.065(1) (1) Calculation.

DHS 152.065(1)(a) (a) A certified patient’s liability to contribute toward the cost of treatment shall be calculated as follows:

DHS 152.065(1)(a)1. 1. If the patient’s estimated total family income for the current year exceeds 300% of the federal poverty guidelines, the patient is liable to obligate or expend a portion of that income, as specified in sub. (2), to pay the medical expenses for treatment of kidney disease before the CRD program will provide assistance in paying for treatment;

DHS 152.065(1)(a)2. 2. The patient is liable for any deductible under sub. (3);

DHS 152.065(1)(a)3. 3. The patient is liable for a coinsurance amount based on the amount reimbursable by the CRD program and family size and income in accordance with sub. (4) and Table 152.065;

DHS 152.065(1)(a)4. 4. The sum of the patient’s deductibles under sub. (3) and coinsurance obligation under sub. (4) in a year may not exceed the applicable percentage of income limit in sub. (5) unless the annual deductibles under sub. (3) are greater; and

DHS 152.065(1)(a)5. 5. In addition, the patient is liable for a copayment amount under sub. (6) when the pharmacy bills the CRD program.