DHS 107.08 NoteNote: For more information on non-covered services, see s. DHS 107.03. DHS 107.08 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (4) (e) and (f), cr. (4) (g), Register, February, 1988, No. 388, eff. 3-1-88; correction in (3) (g) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1990, No. 414; emerg. renum. (4) to be (4) (a) and am. (4) (a) (intro.) 1., 2., 4., 6. and 7., cr. (4) (b) to (f) eff. 1-1-91; r. and recr. Register, September, 1991, No. 429, eff. 10-1-91; correction in (2) (d) made under s. 13.93 (2m) (b) 7., Register August 2006 No. 608; corrections in (1) and (3) (c) 1., made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 107.09(1)(1) Definition. In this section, “active treatment” means an ongoing, organized effort to help each resident attain his or her developmental capacity through the resident’s regular participation, in accordance with an individualized plan, in a program of activities designed to enable the resident to attain the optimal physical, intellectual, social and vocational levels of functioning of which he or she is capable. DHS 107.09(2)(2) Covered services. Covered nursing home services are medically necessary services provided by a certified nursing home to an inpatient and prescribed by a physician in a written plan of care. The costs of all routine, day-to-day health care services and materials provided to recipients by a nursing home shall be reimbursed within the daily rate determined for MA in accordance with s. 49.45 (6m), Stats. These services are the following: DHS 107.09(2)(a)2.2. Special care services, including activity therapy, recreation, social services and religious services; DHS 107.09(2)(a)3.3. Supportive services, including dietary, housekeeping, maintenance, institutional laundry and personal laundry services, but excluding personal dry cleaning services; DHS 107.09(2)(a)5.5. Physical plant, including depreciation, insurance and interest on plant; DHS 107.09(2)(b)(b) Personal comfort items, medical supplies and special care supplies. These are items reasonably associated with normal and routine nursing home services which are listed in the nursing home payment formula. If a recipient specifically requests a brand name which the nursing home does not routinely supply and for which there is no equivalent or close substitute included in the daily rate, the recipient, after having been informed in advance that the equivalent or close substitute is not available without charge, will be expected to pay for that brand item at cost out of personal funds; and DHS 107.09(2)(c)(c) Indirect services provided by independent providers of service. DHS 107.09 NoteNote: Copies of the Nursing Home Payment Formula may be obtained from Division of Medicaid Services, Bureau of Rate Setting, P.O. Box 7851, Madison, WI 53703-7851.
DHS 107.09 NoteNote: Examples of indirect services provided by independent providers of services are services performed by a pharmacist reviewing prescription services for a facility and services performed by an occupational therapist developing an activity program for a facility.
DHS 107.09(3)(3) Services requiring prior authorization. The rental or purchase of a specialized wheelchair for a recipient in a nursing home, regardless of the purchase or rental cost, requires prior authorization from the department. DHS 107.09 NoteNote: For more information on prior authorization, see s. DHS 107.02 (3). DHS 107.09(4)(a)1.1. Treatment costs which are both extraordinary and unique to individual recipients in nursing homes shall be reimbursed separately as ancillary costs, subject to any modifications made under sub. (2) (b). The following items are not included in calculating the daily nursing home rate but may be reimbursed separately: DHS 107.09(4)(a)1.a.a. Oxygen in liters, tanks, or hours, including tank rentals and monthly rental fees for concentrators; DHS 107.09(4)(a)1.b.b. Tracheostomy and ventilatory supplies and related equipment, subject to guidelines and limitations published by the department in the provider handbook; DHS 107.09(4)(a)1.c.c. Transportation of a recipient to obtain health treatment or care if the treatment or care is prescribed by a physician as medically necessary and is performed at a physician’s office, clinic, or other recognized medical treatment center, if the transportation service is provided by the nursing home, in its controlled equipment and by its staff, or by common carrier such as bus or taxi, and if the transportation service was provided prior to July 1, 1986. Transportation shall not be reimbursed as an ancillary service on or after July 1, 1986; and DHS 107.09(4)(a)1.d.d. Direct services provided by independent providers of service only if the nursing home can demonstrate to the department that to pay for the service in question as an add-on adjustment to the nursing home’s daily rate is equal in cost or less costly than to reimburse the independent service provider through a separate billing. The nursing home may receive an ancillary add-on adjustment to its daily rate in accordance with s. 49.45 (6m) (b), Stats. The independent service provider may not claim direct reimbursement if the nursing home receives an ancillary add-on adjustment to its daily rate for the service. DHS 107.09(4)(a)2.2. The costs of services and materials identified in subd. 1. which are provided to recipients shall be reimbursed in the following manner: DHS 107.09(4)(a)2.a.a. Claims shall be submitted under the nursing home’s provider number, and shall appear on the same claim form used for claiming reimbursement at the daily nursing home rate;