DHS 105.48 DHS 105.48 Out-of-state providers.

DHS 105.48(1) (1) When a provider in a state that borders on Wisconsin documents to the department’s satisfaction that it is common practice for recipients in a particular area of Wisconsin to go for medical services to the provider’s locality in the neighboring state, the provider may be certified as a Wisconsin border status provider, subject to the certification requirements in this chapter and the same rules and contractual agreements that apply to Wisconsin providers, except that nursing homes are not eligible for border status.

DHS 105.48(2) (2) Out-of-state independent laboratories, regardless of location, may apply for certification as Wisconsin border status providers.

DHS 105.48(2m) (2m) Out-of-state providers who meet the definition of a border-status provider as described in s. DHS 101.03 (19) and who provide services to Wisconsin members via telehealth, regardless of provider location, may apply for certification as Wisconsin border-status providers if they are licensed in Wisconsin under applicable Wisconsin statute and administrative code.

DHS 105.48(3) (3) Other out-of-state providers who do not meet the requirements of sub. (1) may be reimbursed for non-emergency services provided to a Wisconsin MA recipient upon approval by the department under s. DHS 107.04.

DHS 105.48(4) (4) The department may review border status certification of a provider annually. Border status certification may be canceled by the department if it is found to be no longer warranted by medical necessity, volume or other considerations.

DHS 105.48(5) (5) 

DHS 105.48(5)(a) (a) A provider certified in another state for services not covered in Wisconsin shall be denied border status certification for these services in the Wisconsin program.

DHS 105.48 Note Note: Examples of providers whose services are not covered in Wisconsin are music therapists and art therapists.

DHS 105.48(5)(b) (b) A provider denied certification in another state shall be denied certification in Wisconsin, except that a provider denied certification in another state because the provider’s services are not MA-covered in that state may be eligible for Wisconsin border status certification if the provider’s services are covered in Wisconsin.

DHS 105.48 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. Register, September, 1991, No. 429, eff. 10-1-91; correction in (3) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 22-043: cr. (2m) Register May 2023 No. 809, eff. 6-1-23.

DHS 105.49 DHS 105.49 Ambulatory surgical centers. For MA certification, an ambulatory surgical center shall be certified to participate in medicare as an ambulatory surgical center under 42 CFR 416.39.

DHS 105.49 Note Note: For covered ambulatory surgical center services, see s. DHS 107.30.

DHS 105.49 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.50 DHS 105.50 Hospices. For MA certification, a hospice shall be certified to participate in medicare as a hospice under 42 CFR 418.50 to 418.100.

DHS 105.50 History History: Cr. Register, February, 1988, No. 386, eff. 3-1-88.

DHS 105.51 DHS 105.51 Case management agency providers.

DHS 105.51(1) (1) Agency. For MA certification, a provider of case management services shall be an agency with state statutory authority to operate one or more community human service programs. A case management agency may be a county or Indian tribal department of community programs, a department of social services, a department of human services, or a county or tribal aging unit. Each applicant agency shall specify each population eligible for case management under s. DHS 107.32 (1) (a) 2. for which it will provide case management services. Each certified agency shall offer all 3 case management components described under s. DHS 107.32 (1) so that a recipient can receive the component or components that meet his or her needs.

DHS 105.51(2) (2) Employed personnel.

DHS 105.51(2)(a) (a) To provide case assessment or case planning services reimbursable under MA, persons employed by or under contract to the case management agency under sub. (1) shall:

DHS 105.51(2)(a)1. 1. Possess a degree in a human services-related field, possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed, and have acquired at least one year of supervised experience with the type of recipients with whom he or she will work; or

DHS 105.51(2)(a)2. 2. Possess 2 years of supervised experience or an equivalent combination of training and experience.

DHS 105.51 Note Note: The knowledge required in subd. 1. is typically gained through supervised experience working with persons in the target population.

DHS 105.51(2)(b) (b) To provide ongoing monitoring and service coordination reimbursable under MA, personnel employed by a case management agency under sub. (1) shall possess knowledge regarding the service delivery system, the needs of the recipient group or groups served, the need for integrated services and the resources available or needing to be developed.

DHS 105.51(3) (3) Sufficiency of agency certification for employed personnel. Individuals employed by or under contract to an agency certified to provide case management services under this section may provide case management services upon the department’s issuance of certification to the agency. The agency shall maintain a list of the names of individuals employed by or under contract to the agency who are performing case management services for which reimbursement may be claimed under MA. This list shall certify the credentials possessed by the named individuals which qualify them under the standards specified in sub. (2). Upon request, an agency shall promptly advise the department in writing of the employment of persons who will be providing case management services under MA and the termination of employees who have been providing case management services under MA.

DHS 105.51(4) (4) Contracted personnel. Persons under contract with a certified case management agency to provide assessments or case plans shall meet the requirements of sub. (2) (a), and to provide ongoing monitoring and service coordination, shall meet the requirements of sub. (2) (b).

DHS 105.51(5) (5) Recordkeeping. The case manager under s. DHS 107.32 (1) (d) shall maintain a file for each recipient receiving case management services which includes the following:

DHS 105.51(5)(a) (a) The assessment document;

DHS 105.51(5)(b) (b) The case plan;