DHS 153.03(3)(3) Enter into a written agreement with a comprehensive hemophilia treatment center for compliance with a maintenance program. The agreement shall specify:

DHS 153.03(3)(b)(b) Responsibilities of the patient and the center relating to development of the plan of treatment and conformance of the patient to applicable center policies;

DHS 153.03(3)(d)(d) Procedures for semi-annual evaluation of the maintenance program and for verification that the patient is complying with the established treatment regimen; and

DHS 153.03(4)(4) Provide to the department or its designated agent full, truthful and correct information necessary for the department to determine eligibility and liability on forms specified by the department. A patient shall be ineligible for financial assistance if he or she refuses to provide information, withholds information, refuses to assist the department in verifying the information or provides inaccurate information. The department may verify or audit an applicant’s total family income.

DHS 153.03(5)(5) Complete one of the following actions:

DHS 153.03(5)(a)(a) First apply for benefits under all other health care coverage programs for which the person may reasonably be eligible, including medicare, BadgerCare, medical assistance and SeniorCare.

DHS 153.03(5)(b)(b) Apply for and receive from the department a waiver from par. (a) for religious reasons. If the department does not approve the request for a waiver, the applicant shall meet the requirements of par. (a).

DHS 153.03 NoteNote: Persons desiring a waiver from the requirements under par. (a) should submit their request to the Division of Public Health, Bureau of Community Health Promotion, Wisconsin Chronic Disease Program, P.O. Box 2659, Madison, WI 53701-2659, or call 1-800-947-9627. Requests must describe the basis of the religious belief that precludes application for benefits under one or more of the programs listed under par. (a).

DHS 153.035DHS 153.035 Termination of eligibility. Eligibility under the hemophilia home care program is terminated if any of the following events occur:

DHS 153.035(1)(1) The patient dies.

DHS 153.035(2)(2) The patient moves out of the state of Wisconsin.

DHS 153.037DHS 153.037 Retroactive eligibility. Retroactive eligibility is not available under the hemophilia home care program. Patients who are found to be eligible under s. DHS 153.03 become eligible for benefits on the date the application was received.

DHS 153.04(1)(1) Application. To apply for assistance in paying for the costs of blood products and supplies used in the home care of hemophilia, a patient shall complete a form available from a comprehensive hemophilia treatment center, and shall submit the completed form either to the center or directly to the department. The completed form shall include a signed certification by the physician director of the center that the patient has successfully participated in a home care program, and that the physician director will review the patient’s maintenance program every 6 months and, on request of the department, will verify that the patient is complying with the program.

DHS 153.04(2)(2) Notification of applicant. The department shall certify a patient as eligible for reimbursement for part of the costs of blood products and supplies used in the home treatment of hemophilia if all requirements under s. DHS 153.03 are met. The department shall notify the patient, in writing, of its decision within 60 days after the department receives an application for assistance. If the application is denied, the notice shall include the reason for denial with information that the patient may request a hearing under sub. (7) on that decision.

DHS 153.04(3)(3) Recertification. Certification is for one year. To be recertified, a participant shall complete, sign and submit to the department a financial statement form received from the department. The participant shall provide to the department full, truthful and correct information necessary for the department to determine eligibility and liability.

DHS 153.04(4)(4) Revocation or nonrenewal of certification. The department may revoke or not renew a participant’s certification if the department finds that the participant is no longer eligible for the program. The department shall send written notice of revocation or nonrenewal to the participant, stating the reason for it and with information that the participant may request a hearing under sub. (7) on that decision.

DHS 153.04(5)(5) Participant responsibility to provide information.

DHS 153.04(5)(a)(a) A participant shall inform the department within 30 days of any change in address, other source of health care coverage or family size, or any change in income of more than 10%.

DHS 153.04(5)(b)(b) The department may verify or audit a participant’s total family income. The department may redetermine a participant’s estimated total family income for the current year based on a change in the family’s financial circumstances.

DHS 153.04(6)(6) Confidentiality of patient information. All personally identifiable information provided by or on behalf of a patient to the department shall remain confidential and may not be used for any purpose other than to determine program eligibility, patient liability and the payment of claims. Statistical analyses of program data may not reveal patient identity.

DHS 153.04(7)(7) Appeal. A patient denied assistance under sub. (2) or a participant whose certification is revoked or not renewed under sub. (4) may request a hearing on that decision under ss. 227.44 to 227.50, Stats., by the department of administration’s division of hearings and appeals. The request for a hearing shall be in writing and shall be sent to the division of hearings and appeals so that it is received there within 30 days after the date of the notice of denial, revocation or nonrenewal of certification.