DHS 107.28(3)(h)(h) Provide that HMO-enrolled recipients may be excluded from specific MA requirements, including but not limited to copayments, prior authorization requirements, and the second surgical opinion program; and

DHS 107.28(3)(i)(i) Provide that if a recipient who is a member of an HMO or other prepaid plan seeks medical services from a certified provider who is not participating in that plan without a referral from a provider in that plan, or in circumstances other than emergency circumstances as defined in 42 CFR 434.30, the recipient shall be liable for the entire amount charged for the service.

DHS 107.28 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; cr. (1) (c), Register, October, 2000, No. 538, eff. 11-1-00; correction in (1) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.29(1)(1) Services furnished by a physician within the scope of practice of the profession under state law, if the physician performs the services in the clinic or the services are furnished away from the clinic and the physician has an agreement with the clinic providing that the physician will be paid by it for these services;

DHS 107.29(2)(2) Services furnished by a physician assistant or nurse practitioner if the services are furnished in accordance with the requirements specified in s. DHS 105.35;

DHS 107.29(3)(3) Services and supplies that are furnished incidental to professional services furnished by a physician, physician assistant or nurse practitioner;

DHS 107.29(4)(4) Part-time or intermittent visiting nurse care and related medical supplies, other than drugs and biologicals, if:

DHS 107.29(4)(b)(b) The services are furnished by a registered nurse or licensed practical nurse employed by or otherwise compensated for the services by the clinic;

DHS 107.29(4)(c)(c) The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic, or that is established by a physician, physician assistant or nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

DHS 107.29(4)(d)(d) The services are furnished to a homebound recipient. In this paragraph, “homebound recipient” means, for purposes of visiting nurse care, a recipient who is permanently or temporarily confined to a place of residence, other than a hospital or skilled nursing facility, because of a medical or health condition. The person may be considered homebound if the person leaves the place of residence infrequently; and

DHS 107.29(5)(5) Other ambulatory services furnished by a rural health clinic. In this subsection, “other ambulatory services” means ambulatory services other than the services in subs. (1), (2), and (3) that are otherwise included in the written plan of treatment and meet specific state plan requirements for furnishing those services. Other ambulatory services furnished by a rural health clinic are not subject to the physician supervision requirements under s. DHS 105.35.

DHS 107.29 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; corrections in (2) and (5) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.30(1)(1) Covered services. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulatory surgical center. The physician shall demonstrate that the recipient requires general or local anesthesia, and a postanesthesia observation time, and that the services could not be performed safely in an office setting. These services shall be performed in conformance with generally-accepted medical practice. Covered ambulatory surgical center services shall be limited to the following procedures: