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 NoteNote: 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 HistoryHistory: 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 152.065DHS 152.065Patient 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.
DHS 152.065(1)(b)(b) If there are 2 or more certified patients in the same family, the family’s liability shall be limited to the liability of one member of the family.
DHS 152.065(2)(2)Income deductible. A certified patient 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 chronic renal disease before the CRD program will provide assistance in paying for the cost of treatment:
DHS 152.065(2)(a)(a) When total family income is from 200% to 250% of the federal poverty guidelines, 0.50% of that income.
DHS 152.065(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 152.065(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 152.065(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 152.065(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 152.065(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 152.065(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 152.065(2)(h)(h) When total family income is more than 400% of the federal poverty guidelines, 4.5% of that income.
DHS 152.065(3)(3)Medicare-equivalent deductibles.
DHS 152.065(3)(a)(a) An amount equal to the medicare part A deductible, as defined under 42 USC 1395e and 42 CFR 409.82, shall be assessed all certified patients for the first inpatient hospital stay in a 12-month period.
DHS 152.065(3)(b)(b) An amount equal to the medicare part B deductible, as defined under 42 USC 1395L (b), shall be assessed all certified patients for the first outpatient visit in a 12-month period.
DHS 152.065(4)(4)Patient coinsurance.