Wisconsin Legislature: DHS 154.07(5)(b)4.

(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.

(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 adult cystic fibrosis program will provide assistance in paying for the cost of treatment:

(a) When total family income is from 200% to 250% of the federal poverty guidelines, 0.50% of that income.

(b) When total family income is more than 250% but not more than 275% of the federal poverty guidelines, 0.75% of that income.

(c) When total family income is more than 275% but not more than 300% of the federal poverty guidelines, 1.0% of that income.

(d) When total family income is more than 300% but not more than 325% of the federal poverty guidelines, 1.25% of that income.

(e) When total family income is more than 325% but not more than 350% of the federal poverty guidelines, 2.0% of that income.

(f) When total family income is more than 350% but not more than 375% of the federal poverty guidelines, 2.75% of that income.

(g) When total family income is more than 375% but not more than 400% of the federal poverty guidelines, 3.5% of that income.

(h) When total family income is more than 400% of the federal poverty guidelines, 4.5% of that income.

(3) Participant coinsurance.

(a) A participant shall pay a coinsurance amount to cover part of the cost of treating the participant’s adult cystic fibrosis.

(b) A participant’s coinsurance amount shall be determined at the time the patient is certified for eligibility and annually thereafter.

(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 154.07.

(d) The amount that a participant pays in coinsurance annually may not exceed the following applicable percentage of the family’s income, rounded to the nearest whole dollar:

1. For an income of up to $10,000, 3%;

2. For an income of $10,001 to $20,000, 4%;

3. For an income of $20,001 to $40,000, 5%;

4. For an income of $40,001 to $60,000, 6%;

5. For an income of $60,001 to $80,000, 7%;

6. For an income of $80,001 to $100,000, 9%; and

7. For an income of $100,001 and over, 10%.

(4) Participant copayment. When a pharmacy directly bills the adult cystic fibrosis 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.

(5) Estate recovery.

(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.

(b) For purposes of applying s. DHS 108.02 (12) (b) to (e) to this subsection the following definitions apply:

1. “Beneficiary” means any person nominated in a will to receive an interest in property other than in a fiduciary capacity;

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.;

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;

4. “Recipient” means a participant who received reimbursement under s. 49.683, Stats.; and

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.

(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 154.07
Patient Coinsurance Liability for the Direct Cost of Treatment

Note: 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.

History: 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) 1., 5., (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2013 No. 696.