DHS 109.15(5) (5) If the income of the spouse was used to determine the SeniorCare benefit for the participant, the department shall determine the benefit as follows:

DHS 109.15(5)(a) (a) Annual income exceeds 240% of poverty line.

DHS 109.15(5)(a)1. 1. ‘Participant has not met spend-down.’ If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, and the participant has not met the spend-down by the date the spouse becomes eligible for SeniorCare, the spouse may receive spend-down services under s. DHS 109.13 (4).

DHS 109.15(5)(a)2. 2. ‘Participant has met spend-down.’

DHS 109.15(5)(a)2.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family and the participant met the spend-down before the spouse becomes eligible for SeniorCare, or the participant and spouse meet the spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(a)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(a)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(b) (b) Annual income between 160-240% of poverty line.

DHS 109.15(5)(b)1. 1. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(b)2. 2. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(b)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(c) (c) Annual income less than 160% of poverty line. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (4) (b) 1. c. and 2. b. and (5) (a) 2. b. and (b) 2. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.16 DHS 109.16 Fees. For each 12-month benefit period, a program participant shall pay a program enrollment fee of $30. The department shall refund the fee to applicants found to be ineligible for SeniorCare.

DHS 109.16 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.17 DHS 109.17 Applicant appeals.

DHS 109.17(1) (1) Except as provided under sub. (2), any person whose application for SeniorCare is denied or is not acted upon promptly under s. DHS 109.11 (5), or who believes that the benefits or services the person may receive under s. DHS 109.13 have not been properly determined, or that his or her eligibility has not been properly determined under s. DHS 109.11 (5), may file an appeal pursuant to the requirements under ch. HA 3 that apply to the medical assistance program.

DHS 109.17(2) (2) 

DHS 109.17(2)(a) (a) A request for a hearing concerning the SeniorCare program may only be made in writing and only to the division of hearings and appeals.

DHS 109.17(2)(b) (b) The applicant shall have 45 days from the effective date of the adverse action in which to file a request for hearing.

DHS 109.17 Note Note: A hearing request should be mailed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI, 53707-7875. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or transmitted by facsimile machine to 608-264-9885.

DHS 109.17 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.

subch. III of ch. DHS 109 Subchapter III — Drug Benefits

DHS 109.31 DHS 109.31 Covered drugs and limitations on coverage.

DHS 109.31(1) (1) Covered services. Drugs and drug products covered under this chapter include prescription drugs and insulin listed in the Wisconsin medical assistance drug index that are prescribed by a physician licensed under s. 448.04, Stats., by a dentist licensed under s. 447.04, Stats., by a podiatrist licensed under s. 448.04, Stats., by an optometrist licensed under ch. 449, Stats., or by a nurse prescriber under ch. N 8, or when a physician delegates prescription of drugs to a nurse practitioner or to a physician’s assistant certified under s. 448.04, Stats., and the requirements under s. N 6.03 for nurse practitioners and under s. Med 8.07 for physician assistants are met. The limitations on coverage and services in this section apply to co-pay, spend-down and deductible.

DHS 109.31(2) (2) Prior authorization.

DHS 109.31(2)(a) (a) Drugs requiring prior authorization. The following drugs and supplies require prior authorization:

DHS 109.31(2)(a)1. 1. All schedule III and IV stimulant drugs.

DHS 109.31(2)(a)2. 2. Drugs that have been demonstrated to entail significant expense or overuse for the medical assistance program. These drugs shall be noted in the Wisconsin medical assistance drug index.