DHS 107.09(4)(s)(s) Recovery of costs of services. All medicare-certified SNF facilities shall recover all medicare-allowable costs of services provided to recipients entitled to medicare benefits prior to billing MA. Refusal to recover these costs may result in a fine of not less than $10 nor more than $100 a day, as determined by the department.

DHS 107.09(4)(u)(u) Active treatment. All developmentally disabled residents of SNF or ICF certified facilities who require active treatment shall receive active treatment subject to the requirements of s. DHS 132.695.

DHS 107.09(5)(d)(d) ICF-level services provided to a developmentally disabled person admitted after September 15, 1986, to an ICF facility other than to a facility certified under s. DHS 105.12 as an intermediate care facility for individuals with intellectual disabilities unless the provisions of s. DHS 132.51 (2) (d) 1. have been waived for that person; and

DHS 107.09(5)(e)(e) Inpatient services for residents between the ages of 21 and 64 when provided by an institution for mental disease, except that services may be provided to a 21 year old resident of an IMD if the person was a resident of the IMD immediately prior to turning 21 and continues to be a resident after turning 21.

DHS 107.09 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; renum. (1) to (4) to be (2) to (5) and am. (4) (g) 2. and (5) (6) and (c), cr. (1) (4) (u), (5) (d) and (e), Register, February, 1988, No. 386, eff. 3-1-88; emerg. cr. (4) (v), eff. 8-1-88; cr. (4) (v), Register, December, 1988, No. 396, eff. 1-1-89; correction in (4) (a) 1. intro. made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520; corrections in (4) (v) (intro.) made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538; corrections in (4) (g) 1., 2., (j) 1. g., (k), (n) 2., (u) and (5) (d) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; 2019 Wis. Act 1: am. (4) (o) 2., (5) (d) Register May 2019 No. 761, eff. 6-1-19; CR 20-039: r. (4) (v) Register October 2021 No. 790, eff. 11-1-21; CR 23-046: r. (4) (L) Register April 2024 No. 820, eff. 5-1-24.

DHS 107.10(1)(1) Covered services. Drugs and drug products covered by MA include legend and non-legend drugs and supplies listed in the Wisconsin medicaid drug index which are prescribed by a physician licensed under s. 448.04, Stats., by a dentist licensed under s. 447.05, Stats., by a podiatrist licensed under s. 448.04, Stats., by an optometrist licensed under ch. 449, Stats., by an advanced practice nurse prescriber licensed under s. 441.16, Stats., or when a physician delegates the prescribing 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.

DHS 107.10(2)(c)(c) Medically necessary, specially formulated nutritional supplements and replacement products, including enteral and parenteral products used for the treatment of severe health conditions such as pathologies of the gastrointestinal tract or metabolic disorders, as described in the MA provider handbooks and bulletins, but not including enteral nutrition products administered through a tube.

DHS 107.10(2)(d)(d) Drugs the department has determined entail substantial cost or utilization problems for the MA program. These drugs shall be noted in the Wisconsin medicaid drug index;

DHS 107.10(2)(e)(e) Any drug produced by a manufacturer who has not entered into a rebate agreement with the federal secretary of health and human services, as required by 42 USC 1396r-8, if the prescribing provider under sub. (1) demonstrates to the department’s satisfaction that no other drug sold by a manufacturer who complies with 42 USC 1396r-8 is medically appropriate and cost-effective in treating the recipient’s condition;

DHS 107.10(2)(f)(f) Drugs identified by the department that are sometimes used to enhance the prospects of fertility in males or females, when proposed to be used for treatment of a condition not related to fertility; and

DHS 107.10(2)(g)(g) Drugs identified by the department that are sometimes used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.

DHS 107.10(3)(a)(a) Dispensing of schedule III, IV and V drugs shall be limited to the original dispensing plus 5 refills, or 6 months from the date of the original prescription, whichever comes first.

DHS 107.10(3)(b)(b) Dispensing of non-scheduled drugs shall be limited to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.

DHS 107.10(3)(c)(c) Generically-written prescriptions for drugs listed in the federal food and drug administration approved drug products publication shall be filled with a generic drug included in that list. Prescription orders written for brand name drugs which have a lower cost commonly available generic drug equivalent shall be filled with the lower cost drug product equivalent, unless the prescribing provider under sub. (1) writes “brand medically necessary” on the face of the prescription.