DHS 107.02(3)(i)2.c. c. The provider complies with all requirements of applicable state and federal statutes, the terms and conditions of the applicable provider agreement pursuant to s. 49.45 (2) (a) 9., Stats., all applicable requirements of chs. DHS 101 to 108, including but not limited to the requirements of ss. DHS 106.02, 106.03, 107.02, and 107.03, and all applicable prior authorization procedural instructions issued by the department under s. DHS 108.02 (4);

DHS 107.02(3)(i)2.d. d. The recipient is MA eligible on the date of service; and

DHS 107.02(3)(i)2.e. e. The provider is MA certified and qualified to provide the service on the date of the service.

DHS 107.02(4) (4) Cost-sharing.

DHS 107.02(4)(a) (a) General policy. The department shall establish cost-sharing provisions for MA recipients, pursuant to s. 49.45 (18), Stats. Cost-sharing requirements for providers are described under s. DHS 106.04 (2), and services and recipients exempted from cost-sharing requirements are listed under s. DHS 104.01 (12) (a).

DHS 107.02(4)(b) (b) Notification of applicable services and rates. All services for which cost-sharing is applicable shall be identified by the department to all recipients and providers prior to enforcement of the provisions.

DHS 107.02(4)(d) (d) Limitation on copayments for prescription drugs. Providers may not collect copayments in excess of $5 a month from a recipient for prescription drugs if the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs.

DHS 107.02(5) (5) Services provided via telehealth. The department shall reimburse providers for medically necessary and appropriate health care services listed in this chapter and ss. 49.46 (2) and 49.47 (6) (a), Stats., when provided to currently eligible MA recipients via telehealth. Services provided via telehealth are subject to the same restrictions as services provided in an in-person setting unless otherwise specified in chs. DHS 101 to 109. Providers shall ensure that the locations from which they provide services via telehealth ensure privacy and confidentiality of recipient information and communications in a functionally equivalent manner to services provided in person. Benefits or services that may not be delivered via telehealth include any of the following:

DHS 107.02(5)(a) (a) Services that are not covered when provided in person.

DHS 107.02(5)(b) (b) Services that do not meet applicable laws, regulations, licensure requirements, or procedure code definitions if delivered via telehealth.

DHS 107.02(5)(c) (c) Services when a provider is required to physically touch or examine the recipient and delegation is not appropriate.

DHS 107.02(5)(d) (d) Services the provider declines to deliver via telehealth.

DHS 107.02(5)(e) (e) Services the recipient declines to receive via telehealth.

DHS 107.02(5)(f) (f) Services provided by personal care workers, home health aides, private duty nurses, or school based service care attendants.

DHS 107.02(5)(g) (g) Transportation.

DHS 107.02 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) and am. (14) (c) 12. and 13., Register, February, 1988, No. 386, eff. 3-1-88; cr. (4) (c) 14., Register, April, 1988, No. 388, eff. 7-1-88; r. and recr. (4) (c), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (4) (a), r. (4) (c), eff. 1-1-90; am. (4) (a) r. (4) (c), Register, September, 1990, No. 417, eff. 10-1-90; am. (2) (b), r. (2) (c), renum. (2) (d) and (e) to be (2) (c) and (d), cr. (2m), Register, September, 1991, No. 429, eff. 10-1-91; emerg. cr. (3) (i), eff. 7-1-92; am. (2) (c) and (d), cr. (2) (e) to (j) and (3) (i), Register, February, 1993, No. 446, eff. 3-1-93; r. (2m) (a) 17., Register, November, 1994, No. 467, eff. 12-1-94; am. (2) (a), Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520; correction in (3) (h) 3. made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538; CR 03-033: am. (2m) (a) 10. and (c) Register December 2003 No. 576, eff. 1-1-04; corrections in (2) (e) to (j), (3) (d) (intro.), (i) 1. c., 2. c., and (4) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 14-066: r. (2m) (a) 7. Register August 2015 No. 716, eff. 9-1-15; CR 21-050: am. (3) (a) Register April 2022 No. 796, eff. 5-1-22; CR 22-043: cr. (5) Register May 2023 No. 809, eff. 6-1-23; EmR2306: emerg. cr. (1) (am), eff. 5-1-23; CR 23-045: cr. (1) (am) Register January 2024 No. 817, eff. 2-1-24.

DHS 107.03 DHS 107.03 Services not covered. The following services are not covered services under MA:

DHS 107.03(1) (1) Service charges for telephone calls;

DHS 107.03(2) (2) Charges for missed appointments;

DHS 107.03(3) (3) Sales tax on items for resale;

DHS 107.03(4) (4) Services provided by a particular provider that are considered experimental in nature;

DHS 107.03(5) (5) Procedures considered by the department to be obsolete, inaccurate, unreliable, ineffectual, unnecessary, imprudent or superfluous;

DHS 107.03(6) (6) Personal comfort items, such as radios, television sets and telephones, which do not contribute meaningfully to the treatment of an illness;

DHS 107.03(7) (7) Alcoholic beverages, even if prescribed for remedial or therapeutic reasons;

DHS 107.03(8) (8) Autopsies;

DHS 107.03(9) (9) Any service requiring prior authorization for which prior authorization is denied, or for which prior authorization was not obtained prior to the provision of the service except in emergency circumstances;

DHS 107.03(10) (10) Services subject to review and approval pursuant to s. 150.21, Stats., but which have not yet received approval;

DHS 107.03(11) (11) Psychiatric examinations and evaluations ordered by a court following a person’s conviction of a crime, pursuant to s. 972.15, Stats.;

DHS 107.03(12) (12) Consultations between or among providers, except as specified in s. 49.45 (29y), Stats.;