DHS 107.21 Note Note: For more information on prior authorization, see DHS 107.02 (3).

DHS 107.21(3) (3) Non-covered services. The following services are not covered services:

DHS 107.21(3)(a) (a) The sterilization of a recipient under the age of 21 or of a recipient declared legally incapable of consenting to such a procedure;

DHS 107.21(3)(b) (b) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to:

DHS 107.21(3)(b)1. 1. Artificial insemination, including but not limited to intra-cervical or intra-uterine insemination;

DHS 107.21(3)(b)2. 2. Infertility counseling;

DHS 107.21(3)(b)3. 3. Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;

DHS 107.21(3)(b)4. 4. Reversal of female sterilizations, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;

DHS 107.21(3)(b)5. 5. Fertility-enhancing drugs provided for the treatment of infertility;

DHS 107.21(3)(b)6. 6. Reversal of vasectomies;

DHS 107.21(3)(b)7. 7. Office visits, consultations and other encounters to enhance fertility; and

DHS 107.21(3)(b)8. 8. Other fertility-enhancing services and items;

DHS 107.21(3)(c) (c) Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services;

DHS 107.21(3)(d) (d) Testicular prosthesis; and

DHS 107.21(3)(e) (e) Services that are not covered under ss. DHS 107.03 and 107.06 (5).

DHS 107.21 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.21 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) (c) 3., (3), r. (1) (d) 4., renum. (1) (d) 5. to 8. to be (1) (d) 4. to 7; Register, January, 1997, No. 493, eff. 2-1-97.

DHS 107.22 DHS 107.22 Early and periodic screening, diagnosis and treatment (EPSDT) services.

DHS 107.22(1) (1) Covered services. Early and periodic screening and diagnosis to ascertain physical and mental defects, and the provision of treatment as provided in sub. (4) to correct or ameliorate the defects shall be covered services for all recipients under 21 years of age when provided by an EPSDT clinic, a physician, a private clinic, an HMO or a hospital certified under s. DHS 105.37.

DHS 107.22(2) (2) EPSDT health assessment and evaluation package. The EPSDT health assessment and evaluation package shall include at least those procedures and tests required by 42 CFR 441.56. The package shall include the following:

DHS 107.22(2)(a) (a) A comprehensive health and developmental history;

DHS 107.22(2)(b) (b) A comprehensive unclothed physical examination;

DHS 107.22(2)(c) (c) A vision test appropriate for the person being assessed;

DHS 107.22(2)(d) (d) A hearing test appropriate for the person being assessed;

DHS 107.22(2)(e) (e) Dental assessment and evaluation services furnished by direct referral to a dentist for children beginning at 3 years of age;

DHS 107.22(2)(f) (f) Appropriate immunizations; and

DHS 107.22(2)(g) (g) Appropriate laboratory tests.

DHS 107.22(3) (3) Supplemental tests. Selection of additional tests to supplement the health assessment and evaluation package shall be based on the health needs of the target population. Consideration shall be given to the prevalence of specific diseases and conditions, the specific racial and ethnic characteristics of the population, and the existence of treatment programs for each condition for which assessment and evaluation is provided.

DHS 107.22(4) (4) Other needed services. In addition to diagnostic and treatment services covered by Wisconsin MA under applicable provisions of this chapter, any services described in the definition of “medical assistance” under federal law, 42 USC 1396d(a), when provided to EPSDT patients, are covered if the EPSDT health assessment and evaluation indicates that they are needed. Prior authorization under s. DHS 107.02 (3) is required for coverage of services under this subsection.