Wisconsin Legislature: DHS 153.02(11g)

REIMBURSEMENT FOR BLOOD PRODUCTS AND SUPPLIES USED
IN THE HOME CARE OF HEMOPHILIA

DHS 153.01 Authority and purpose.

DHS 153.02 Definitions.

DHS 153.03 Eligibility.

DHS 153.035 Termination of eligibility.

DHS 153.037 Retroactive eligibility.

DHS 153.04 Patient certification.

DHS 153.05 Provider approval.

DHS 153.06 Provider reimbursement.

DHS 153.07 Participant liability.

DHS 153.08 Standards for comprehensive treatment centers.

Note: Chapter HSS 153 as it existed on December 31, 1994 was repealed and a new chapter HSS 153 was created effective January 1, 1995. Chapter HSS 153 was renumbered to chapter HFS 153 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, September, 1999, No. 525. Chapter HFS 153 was renumbered chapter DHS 153 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 153.01 Authority and purpose. This chapter is promulgated under the authority of ss. 49.685 (8) (c), 49.687 (1) and 227.11 (2), Stats., to implement a program of reimbursement for the cost of blood products and supplies for use in the home care of residents of Wisconsin who have hemophilia.

History: Cr. Register, December, 1994, No. 468, eff. 1-1-95.

DHS 153.02 Definitions. In this chapter:

(1) “Approved source” means a provider who has an agreement with a comprehensive hemophilia treatment center for distribution of blood products and supplies to program participants.

(1m) “BadgerCare” means the medical assistance-related program established under s. 49.665, Stats., and chs. DHS 101 to 108.

(2) “Case management services” means services essential for effective use of blood products and supplies, namely, home care initial training, nurse monitoring for participant compliance and annual comprehensive evaluation of a participant.

(3) “Comprehensive hemophilia treatment center” means a center, including its satellite facilities, certified by the department under this chapter to provide services, including development of maintenance programs, to persons with hemophilia and other related congenital bleeding disorders.

(4) “Current year” means the 12-month period beginning with the month of a patient’s first application to the hemophilia home care program, or beginning with the month of a participant’s subsequent annual recertification for the program.

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

(6) “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.

(7) “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.

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

(8) “Hemophilia” means a bleeding disorder resulting from a genetically determined clotting factor, protein or platelet function abnormality or deficiency.

(9) “Home care” means a patient’s self-infusion of blood products on an outpatient basis, or the infusion of blood products to a patient on an outpatient basis by a person trained in that procedure.

(10) “Income” 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.

(11) “Maintenance program” means a patient’s therapeutic and treatment regimen, including medical, dental, social and vocational rehabilitation services and home health care.

(11g) “Medical assistance” has the meaning specified in s. 49.43 (8), Stats., and chs. DHS 101 to 108.

(11r) “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.

(12) “Participant” means a patient who has been found eligible by the department under s. 49.685, Stats., and this chapter for reimbursement for the costs of blood products and supplies used in the home care of hemophilia.

(13) “Patient” means a person diagnosed as having hemophilia.

(14) “Physician director” means the medical director of the comprehensive hemophilia treatment center which is directly responsible for a patient’s maintenance program.

(15) “Program” means the hemophilia home care program under s. 49.685, Stats., and this chapter.

(16) “Provider” means a comprehensive hemophilia treatment center, an approved source of blood products and supplies or a provider of case management services for program participants.

(17) “Resident” means any person who is living in Wisconsin with the intention of remaining permanently in the state.

Note: DWD 11.15 was repealed eff. 4-1-02.

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

History: Cr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (1m), (11g), (11r) and (18) Register November 2004 No. 587, eff. 12-1-04; corrections in (1m), (5), (11g) and (18) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637; CR 23-046: am. (17) Register April 2024 No. 820, eff. 5-1-24.

DHS 153.03 Eligibility. To be eligible for the hemophilia home care program, a patient shall:

(1) Be a resident of Wisconsin;

(2) Be diagnosed by a comprehensive hemophilia treatment center as having hemophilia;

(3) Enter into a written agreement with a comprehensive hemophilia treatment center for compliance with a maintenance program. The agreement shall specify:

(a) The services to be provided;

(b) Responsibilities of the patient and the center relating to development of the plan of treatment and conformance of the patient to applicable center policies;

(d) Procedures for semi-annual evaluation of the maintenance program and for verification that the patient is complying with the established treatment regimen; and

(4) Provide to the department or its designated agent full, truthful and correct information necessary for the department to determine eligibility and liability on forms specified by the department. A patient shall be ineligible for financial assistance if he or she refuses to provide information, withholds information, refuses to assist the department in verifying the information or provides inaccurate information. The department may verify or audit an applicant’s total family income.

(5) Complete one of the following actions:

(a) 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.

(b) Apply for and receive from the department a waiver from par. (a) for religious reasons. If the department does not approve the request for a waiver, the applicant shall meet the requirements of par. (a).

Note: Persons desiring a waiver from the requirements under par. (a) should submit their request to the Division of Public Health, Bureau of Community Health Promotion, Wisconsin Chronic Disease Program, P.O. Box 2659, Madison, WI 53701-2659, or call 1-800-947-9627. Requests must describe the basis of the religious belief that precludes application for benefits under one or more of the programs listed under par. (a).

History: Cr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (5) Register November 2004 No. 587, eff. 12-1-04.

DHS 153.035 Termination of eligibility. Eligibility under the hemophilia home care program is terminated if any of the following events occur:

(1) The patient dies.

(2) The patient moves out of the state of Wisconsin.

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

DHS 153.037 Retroactive eligibility. Retroactive eligibility is not available under the hemophilia home care program. Patients who are found to be eligible under s. DHS 153.03 become eligible for benefits on the date the application was received.

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

DHS 153.04 Patient certification.

(1) Application. To apply for assistance in paying for the costs of blood products and supplies used in the home care of hemophilia, a patient shall complete a form available from a comprehensive hemophilia treatment center, and shall submit the completed form either to the center or directly to the department. The completed form shall include a signed certification by the physician director of the center that the patient has successfully participated in a home care program, and that the physician director will review the patient’s maintenance program every 6 months and, on request of the department, will verify that the patient is complying with the program.

(2) Notification of applicant. The department shall certify a patient as eligible for reimbursement for part of the costs of blood products and supplies used in the home treatment of hemophilia if all requirements under s. DHS 153.03 are met. The department shall notify the patient, in writing, of its decision within 60 days after the department receives an application for assistance. If the application is denied, the notice shall include the reason for denial with information that the patient may request a hearing under sub. (7) on that decision.

(3) Recertification. Certification is for one year. To be recertified, a participant shall complete, sign and submit to the department a financial statement form received from the department. The participant shall provide to the department full, truthful and correct information necessary for the department to determine eligibility and liability.

(4) Revocation or nonrenewal of certification. The department may revoke or not renew a participant’s certification if the department finds that the participant is no longer eligible for the program. The department shall send written notice of revocation or nonrenewal to the participant, stating the reason for it and with information that the participant may request a hearing under sub. (7) on that decision.

(5) Participant responsibility to provide information.

(a) A participant shall inform the department within 30 days of any change in address, other source of health care coverage or family size, or any change in income of more than 10%.

(b) The department may verify or audit a participant’s total family income. The department may redetermine a participant’s estimated total family income for the current year based on a change in the family’s financial circumstances.

(6) Confidentiality of patient information. All personally identifiable information provided by or on behalf of a patient to the department shall remain confidential and may not be used for any purpose other than to determine program eligibility, patient liability and the payment of claims. Statistical analyses of program data may not reveal patient identity.

(7) Appeal. A patient denied assistance under sub. (2) or a participant whose certification is revoked or not renewed under sub. (4) may request a hearing on that decision under ss. 227.44 to 227.50, Stats., by the department of administration’s division of hearings and appeals. The request for a hearing shall be in writing and shall be sent to the division of hearings and appeals so that it is received there within 30 days after the date of the notice of denial, revocation or nonrenewal of certification.

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

History: Cr. Register, December, 1994, No. 468, eff. 1-1-95.

DHS 153.05 Provider approval.

(1) Comprehensive hemophilia treatment centers.

(a) Condition.

1. To be reimbursed by the program for blood products and supplies, including case management services, provided to program participants, a center treating hemophilia patients shall submit an application to the department and shall comply with the standards in s. DHS 153.08. Within 60 days after receiving a complete application for certification, the department shall either approve or deny the application. If the application is denied, the department shall give the applicant reasons, in writing, for the denial.

2. As part of its application for certification under par. (a), a hemophilia treatment center shall execute a written agreement with the department to be a comprehensive hemophilia treatment center and to receive state reimbursement. This agreement shall, unless terminated by either party, remain in full force and effect from the date of execution.

(b) Border state treatment centers. The department may approve a hemophilia treatment center in a state bordering on Wisconsin as a comprehensive hemophilia treatment center if the center is within 100 miles of the Wisconsin border, has a practice which includes providing blood products and supplies to Wisconsin residents and meets the requirements for certification specified in s. DHS 153.08. A border state treatment center is subject to the same rules and contractual agreements as comprehensive hemophilia treatment centers located in Wisconsin.

(c) List of approved sources. A comprehensive hemophilia treatment center shall, upon request of the department, furnish in writing the names and addresses of all vendors of blood products and supplies provided to participants in the hemophilia home care program.

(2) Other providers. To receive reimbursement, a source approved by a comprehensive hemophilia treatment center shall either:

(a) Provide a copy of a signed agreement with the treatment center to provide blood products or supplies; or

(b) Be limited to reimbursement for provision of case management services.

History: Cr. Register, December, 1994, No. 468, eff. 1-1-95.

DHS 153.06 Provider reimbursement.

(1) Claim forms.

(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 submission if the provider or billing service is approved by the department for electronic claims submission.

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

(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.

(2) Timeliness.