DHS 104.01(12)(a)1. 1. Recipients of MA are liable for payment of any copayment or deductible amount established by the department pursuant to s. 49.45 (18), Stats., for the cost of a service, except as provided in this subsection. The recipient shall pay the copayment or deductible to the provider of service. Copayments or deductibles are not required in each of the following circumstances:

DHS 104.01(12)(a)1.a. a. A recipient is a resident in a nursing home.

DHS 104.01(12)(a)1.b. b. Former foster care youth also known as individuals under the age of 26 who were in foster care under the responsibility of any state when they turned 18 years old.

DHS 104.01(12)(a)1.c. c. A recipient is under age 19.

DHS 104.01(12)(a)1.d. d. A recipient is a pregnant women and the services relate to the pregnancy, or to any medical condition which may complicate the pregnancy when it can be determined from the claim submitted that the recipient was pregnant.

DHS 104.01(12)(a)1.e. e. Services provided are emergency hospital and ambulance services and emergency services related to the relief of dental pain.

DHS 104.01(12)(a)1.f. f. Services provided are family planning services and related supplies.

DHS 104.01(12)(a)1.g. g. Services provided are transportation services by a specialized medical vehicle.

DHS 104.01(12)(a)1.h. h. Services provided are transportation services provided through or paid for by a county social services department.

DHS 104.01(12)(a)1.i. i. Services provided are home health services or for home nursing services if a home health agency is not available.

DHS 104.01(12)(a)1.j. j. Services provided are outpatient psychotherapy services received over 15 hours or $500, whichever comes first, during one calendar year.

DHS 104.01(12)(a)1.k. k. Services provided are occupational, physical or speech therapy services received exceeding 30 hours or $1,500 for any one therapy, whichever occurs first, during one calendar year.

DHS 104.01(12)(a)1.L. L. Services provided are case management services provided under s. DHS 107.32.

DHS 104.01(12)(a)1.m. m. Services provided are personal care services provided under s. DHS 107.112.

DHS 104.01(12)(a)1.n. n. Services provided are hospice care services.

DHS 104.01(12)(a)1.o. o. Services provided are alcohol and other drug abuse (AODA) day treatment services.

DHS 104.01(12)(a)1.p. p. Services provided are respiratory care for ventilator-assisted recipients provided under s. DHS 107.113.

DHS 104.01(12)(a)1.q. q. Services provided are community support program (CSP) services provided under s. DHS 107.13 (6).

DHS 104.01(12)(a)2. 2. If the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs, the monthly amount of copayment a recipient is required to pay may not exceed $5.

DHS 104.01(12)(b) (b) Freedom from having to pay for services covered by MA. Recipients may not be held liable by certified providers for covered services and items furnished under the MA program, except for copayments or deductibles under par. (a), if the patient identifies himself or herself as an MA recipient and shows the provider the MA identification card.

DHS 104.01 Note Note: Recipients seeking nonemergency services from noncertified providers are liable for all charges, unless the services were authorized by the department prior to service delivery.

DHS 104.01(12)(c) (c) Prior authorization of services. When a service must be authorized by the department in order to be covered, the recipient may not be held liable by the certified provider unless the prior authorization was denied by the department and the recipient was informed of the recipient’s personal liability before provision of the service. In that case the recipient may request a fair hearing. Negligence on the part of the certified provider in the prior authorization process shall not result in recipient liability.

DHS 104.01 Note Note: For example, if a provider does not inform a recipient that a procedure or service requires prior authorization, and performs the service before submitting a prior authorization request or receiving an approval and then submits a claim for services rendered which is rejected, the recipient may not be held liable.

DHS 104.01(12)(d) (d) Freedom from having to pay the difference between charges and MA payment. Providers may not charge recipients for the amount of the difference between charge for service and MA reimbursement, except in the case of recipients wishing to be in a private room in a nursing home or hospital, in which case the provisions of s. DHS 107.09 (4) (k) shall be met.

DHS 104.01 History History: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; am. (4) (b), cr. (4) (f) and (g), r. (12) (a) 1. j. and k., Register, February, 1988, No. 386, eff. 3-1-88; renum. (12) (a) 1. l. and m. under s. 13.93 (2m) (b) 1., Stats., Register, February, 1988, No. 386; emerg. am. (1) (k), cr. (1) (l) to (q), eff. 1-1-90; am. (1) (k), cr. (1) (l) to (q), Register, September, 1990, No. 417, eff. 10-1-90; correction in (4) (c) and (5) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, May, 1995, No. 473; correction in (5) (d) and (12) (d) made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, April, 1999, No. 520; corrections in (4) (c) and (5) (d) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; corrections in (4) (f), (g), (5) (a) 1., (9) (b) 2. j., (12) (a) 1. L., m., p., q. and (d) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-039: am. (3), r. (9) (b) 2. g. Register October 2021 No. 790, eff. 11-1-21; CR 20-068: am. (2) Register December 2021 No. 792, eff. 1-1-22; CR 22-026: am. (5) (a) 1. Register May 2023 No. 809, eff. 6-1-23; CR 23-046: am. (12) (a) 1. (intro.), r. and recr. (12) (a) 1. a., b., am. (12) (a) 1. c. to q. Register April 2024 No. 820, eff. 5-1-24.

DHS 104.02 DHS 104.02 Recipient duties.

DHS 104.02(1) (1) Not to seek duplication of services. A recipient may not seek the same or similar services from more than one provider.

DHS 104.02(2) (2) Prior identification of eligibility. Except in emergencies that preclude prior identification, the recipient shall, before receiving services, inform the provider that the recipient is receiving benefits under MA and shall present to the provider a current valid MA identification card.

DHS 104.02(3) (3) Review of benefits notice. Recipients shall review the monthly explanation of benefits (EOB) notice sent to them by the department and shall report to the department any payments made for services not actually provided. The explanation of benefits notice may not specify confidential services, such as family planning, and may not be sent if the only service furnished is confidential.