DHS 153.035 HistoryHistory: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04. DHS 153.037DHS 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. DHS 153.037 HistoryHistory: CR 04-051: cr. Register November 2004 No. 587, eff. 12-1-04. DHS 153.04(1)(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. DHS 153.04(2)(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. DHS 153.04(3)(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. DHS 153.04(4)(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. DHS 153.04(5)(5) Participant responsibility to provide information. DHS 153.04(5)(a)(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%. DHS 153.04(5)(b)(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. DHS 153.04(6)(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. DHS 153.04(7)(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. DHS 153.04 NoteNote: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 153.04 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95. DHS 153.05(1)(a)1.1. 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. DHS 153.05(1)(a)2.2. 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. DHS 153.05(1)(b)(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. DHS 153.05(1)(c)(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. DHS 153.05(2)(2) Other providers. To receive reimbursement, a source approved by a comprehensive hemophilia treatment center shall either: DHS 153.05(2)(a)(a) Provide a copy of a signed agreement with the treatment center to provide blood products or supplies; or DHS 153.05(2)(b)(b) Be limited to reimbursement for provision of case management services. DHS 153.05 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95. DHS 153.06(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 submission if the provider or billing service is approved by the department for electronic claims submission. DHS 153.06(1)(b)(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. DHS 153.06(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 153.06(2)(a)(a) A claim shall be submitted within 12 months after the date that services for which the claim is made are provided, except that a claim may be submitted later if the department is notified within that 12 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 153.06(2)(b)(b) A claim may not be submitted until after the patient has taken delivery of the blood products and supplies. DHS 153.06(3)(a)(a) The department shall establish allowable costs for blood products and supplies as a basis for reimbursing providers. DHS 153.06(3)(b)(b) Reimbursement may not be made for any cost of blood supplies and equipment payable under any other state or federal program or any grant or contract. DHS 153.06(3)(c)(c) Before submitting a claim to the hemophilia home care program, a provider shall seek payment for services provided to a participant from medicare, medical assistance or another health care plan if the participant is eligible for services under medicare, medical assistance or the other health care plan. DHS 153.06(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 hemophilia home care 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 hemophilia home care program payment. DHS 153.06(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 153.06(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 153.06 NoteNote: The mailing address of the Office of Administrative Hearings is P.O. Box 7875, Madison, Wisconsin 53707.
DHS 153.06(3)(g)(g) 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 153.06 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95; CR 04-051: cr. (3) (g) Register November 2004 No. 587, eff. 12-1-04. DHS 153.07(1)(1) Calculation. A participant’s liability to contribute toward the cost of treatment shall be calculated in accordance with subs. (2) to (4). If there are 2 or more participants in the same family, the family’s liability shall be limited to the liability of one member of the family. DHS 153.07(2)(2) Income deductible. A participant whose estimated total family income in the current year is at or above 200% of the federal poverty guidelines shall obligate or expend the following percentage of that income to pay the cost of medical treatment for the condition before the hemophilia home care program will provide assistance in paying for the cost of treatment: DHS 153.07(2)(a)(a) When total family income is from 200% to 250% of the federal poverty guidelines, 0.50% of that income. DHS 153.07(2)(b)(b) When total family income is more than 250% but not more than 275% of the federal poverty guidelines, 0.75% of that income. DHS 153.07(2)(c)(c) When total family income is more than 275%, but not more than 300% of the federal poverty guidelines, 1.0% of that income. DHS 153.07(2)(d)(d) When total family income is more than 300% but not more than 325% of the federal poverty guidelines, 1.25% of that income. DHS 153.07(2)(e)(e) When total family income is more than 325% but not more than 350% of the federal poverty guidelines, 2.0% of that income. DHS 153.07(2)(f)(f) When total family income is more than 350% but not more than 375% of the federal poverty guidelines, 2.75% of that income. DHS 153.07(2)(g)(g) When total family income is more than 375% but not more than 400% of the federal poverty guidelines, 3.5% of that income. DHS 153.07(2)(h)(h) When total family income is more than 400% of the federal poverty guidelines, 4.5% of that income. DHS 153.07(3)(a)(a) A participant shall pay a coinsurance amount to cover part of the cost of blood products and home care supplies. DHS 153.07(3)(b)(b) A participant’s coinsurance amount shall be determined at the time the patient is certified for eligibility and annually thereafter. DHS 153.07(3)(c)(c) The amount of a participant’s coinsurance shall be related to family size and to family income rounded to the nearest whole dollar, in accordance with the schedule in Table 153.07. DHS 153.07(3)(d)(d) The amount that a patient pays in coinsurance annually may not exceed the following applicable percentage of the family’s income, rounded to the nearest whole dollar: DHS 153.07(4)(4) Participant copayment. When a pharmacy directly bills the hemophilia home care program for a prescription received by a program participant, the participant is responsible for a $7.50 copayment amount for each generic drug and a $15.00 copayment amount for each brand name drug. DHS 153.07(5)(a)(a) An heir or beneficiary of the estate of a participant or a participant’s surviving spouse may apply to the department for a waiver of an estate claim filed by the department pursuant to s. 49.682 or 49.849, Stats. The criteria for granting waivers in s. DHS 108.02 (12) (b) shall apply to applications under this subsection. All of the procedures and rights in s. DHS 108.02 (12) (b) to (e) shall apply to this subsection. DHS 153.07(5)(b)1.1. “Beneficiary” means any person nominated in a will to receive an interest in property other than in a fiduciary capacity; DHS 153.07(5)(b)2.2. “Decedent” means a deceased participant or the deceased surviving spouse of a participant who received benefits that are subject to recovery under s. 49.682 or 49.849, Stats.; DHS 153.07(5)(b)3.3. “Heir” means any person who is entitled under the statutes of intestate succession, ch. 852, Stats., to an interest in property of a decedent; DHS 153.07(5)(b)5.5. “Waiver applicant” means a beneficiary or heir of a decedent who requests the department to waive an estate claim filed by the department pursuant to s. 49.682 or 49.849, Stats. DHS 153.07(5)(c)(c) The department may make adjustments to and settle estate claims filed under s. 49.682 or 49.849, Stats., to obtain the fullest amount practicable. Table 153.07
Patient Coinsurance Liability for the Direct Cost of Treatment
DHS 153.07 NoteNote: To illustrate how a patient’s coinsurance liability is calculated, assume that the family has 2 members and an annual income of $38,000, and that a bill has been received for treatment in the amount of $600. The patient would be liable for 16% of that bill, or $96.
DHS 153.07 HistoryHistory: Cr. Register, December, 1994, No. 468, eff. 1-1-95; emerg. cr. (5), eff. 11-1-95; cr. (5), Register, April, 1996, No. 484, eff. 5-1-96; CR 02-070: am. (4) Register October 2002 No. 562, eff. 11-1-02; CR 04-051: am. (2) and (4), cr. (2) (f) to (h) Register November 2004 No. 587, eff. 12-1-04; corrections in (5) (a) and (b) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637; corrections in (5) (a), (b) 2., 5., (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2014 No. 696. DHS 153.08DHS 153.08 Standards for comprehensive treatment centers. DHS 153.08(1)(1) Compliance. A comprehensive hemophilia treatment center shall comply with the standards in this section. DHS 153.08(2)(2) Staffing. A comprehensive hemophilia treatment center shall have the following staff: DHS 153.08(2)(a)1.1. The physician director shall be a physician licensed in Wisconsin and certified by the American board of internal medicine or American board of pediatrics or equivalent certifying body, with specialized training in hematology. DHS 153.08(2)(a)2.2. The responsibilities of the physician director shall include organizing and coordinating the administrative functions of the comprehensive hemophilia treatment center; delegating duties and establishing a formal means of accountability for those involved in patient care; participating in the development, negotiation and implementation of agreements into which the center may enter; maintaining records and submitting any required reports to the department; providing medical supervision; and developing written home care training policies and procedures and supervising their implementation. DHS 153.08(2)(b)1.1. The center shall have a multidisciplinary staff which shall include a hematologist, internist, pediatrician, orthopedic surgeon, oral surgeon or dentist, radiologist, physical therapist, registered nurse, social worker and financial counselor. DHS 153.08(2)(b)2.2. The multidisciplinary staff and the physician director shall develop patient maintenance programs and shall provide services, including the training of patients in home care, access to the necessary psychosocial evaluations and referrals and assistance in securing reimbursement.
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