Wisconsin Administrative Code

DHS 101.01 Authority and purpose. This chapter and chs. DHS 102 to 108 are promulgated pursuant to ss. 49.45 (10) and 49.665 (3), (4) and (5), Stats., for the purpose of administering the medical assistance (MA) program in Wisconsin which finances necessary health care services f…

DHS 101.02 Applicability. This chapter and chs. DHS 102 to 108 apply to all recipients of MA, all providers of MA and all persons engaged in the administration of MA.

DHS 101.03 Definitions. In this chapter and chs. DHS 102 to 109: (1) “Access,” for purposes of BadgerCare Plus, means a family member living in the household has the ability to sign up and be covered by an employer’s group health plan in the current month, or had the ability to s…

DHS 102.01 Application.

DHS 102.02 Refusal to provide information.

DHS 102.03 Verification of information.

DHS 102.035 Verification of United States citizenship.

DHS 102.036 Verification of immigration status.

DHS 102.04 Eligibility determination.

DHS 102.05 Fraud. Note: Chapter HSS 102 as it existed on February 28, 1986, was repealed and a new chapter HSS 102 was created effective March 1, 1986. Chapter HSS 102 was renumbered Chapter HFS 102 under s. 13.93, Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., S…

DHS 103.01 Introduction. (1) PERSONS ELIGIBLE. (a) Eligibility for medical assistance shall be determined pursuant to ss. 49.453, 49.454, 49.455, 49.46 (1), 49.468, 49.47 (4), 49.471, 49.472 and 49.473, Stats., and this chapter, except that medical assistance shall be provided wi…

DHS 103.03 Non-financial conditions for eligibility. In order to be eligible for MA, a person shall meet both non-financial conditions for eligibility in this section and financial conditions for eligibility under s. DHS 103.04. The non-financial conditions for eligibility are: (…

DHS 103.04 Asset and income limits. The nonexempt assets and budgetable income of the MA group or, when applicable, the fiscal test group, shall be compared to the following asset and income limits established in this section to determine the eligibility of the MA group: (1) CATE…

DHS 103.05 Determining assets and income in child-only cases. (1) MEANING OF CHILD-ONLY CASE. A child-only case exists when any of the following occur: (a) A family has been determined financially ineligible for BadgerCare Plus-related MA only and there is a child in the family w…

DHS 103.06 Assets. (1) SPECIAL SITUATIONS OF INSTITUTIONALIZED PERSONS. (a) In determining the eligibility of an institutionalized person, only the assets actually available to that person shall be considered. (b) The homestead property of an institutionalized person is not count…

DHS 103.07 Income. (1) SPECIAL SITUATIONS OF INSTI(a) Support received by institutionalized persons. 1. Any financial support or contribution received by an institutionalized person shall be considered available when determining the eligibility of that person for MA. 2. The incom…

DHS 103.075 Prevention of spousal impoverishment. (1) APPLICABILITY. For resource eligibility, this section applies to all institutionalized applicants for and recipients of MA who began a continuous period of institutionalization on or after September 30, 1989, and to their spou…

DHS 103.08 Beginning of eligibility. (1) DATE. Except as provided in subs. (2) to (5), eligibility shall begin on the date on which all eligibility requirements were met, but no earlier than the first day of the month 3 months prior to the month of application. Retroactive eligib…

DHS 103.085 Conditions for continuation of eligibility for BadgerCare Plus. (1) PREMIUMS. (a) Authority. Subject to s. 49.471 (10) (b) 2., Stats., and this section, a child under the age of 19 eligible for BadgerCare Plus may be required to pay a premium. (b) Applicability. 1. A …

DHS 103.087 Conditions for continuation of eligibility. (1) PREMIUMS. (a) Authority. Subject to this section and s. 49.472, Stats., a person eligible for the medicaid purchase plan shall pay a monthly premium. (b) Applicability. 1. An applicant or recipient eligible for the 16 me…

DHS 103.09 Termination of medical assistance. (1) FINAL MONTH COVERAGE. When eligibility ends, except in the case of death of the recipient, the MA benefits shall continue until the end of the calendar month. (2) FOUR-MONTH CONTINUATION OF ELIGIBILITY. (a) When a parent, caretake…

DHS 103.10 Redetermination of eligibility. The agency shall give the recipient timely advance notice of the date on which the recipient’s eligibility will be redetermined. This notice shall be in writing and mailed to the recipient at least 15 cal- 18 endar days but no more than …

DHS 103.11 Presumptive eligibility for pregnant women and women diagnosed with breast or cervical cancer or precancerous conditions. (1) REQUIREMENTS FOR PREGNANT WOMEN. Pregnant women may be determined presumptively eligible for MA on the basis of a statement of pregnancy, and p…

DHS 104.01 Recipient rights. (1) CIVIL RIGHTS. No applicant for or recipient of medical assistance (MA) may be excluded from participation in MA or denied benefits or otherwise be subjected to discrimination under MA for reasons which violate Title VI of the civil rights act of 1…

DHS 104.03 Primary provider. (1) REQUIRED DESIG(a) Required when program is abused. If the department discovers that a recipient is abusing the program, including abuse under s. DHS 104.02 (5), the department may require the recipient to designate, in any or all categories of hea…

DHS 104.035 Prudent buyer limitations.

DHS 104.05 Preferred enrollment. requests a determination of presumptive eligibility to receive MA services shall file an application only with a qualified provider designated by the department and certified under s. DHS 103.11. (5) APPEALS. (a) Fair hearing. 1. Applicants and re…

DHS 105.01 Introduction. (1) PURPOSE. This chapter identifies the terms and conditions under which providers of health care services are certified for participation in the medical assistance program (MA). (2) DEFINITIONS. In this chapter: (a) “Group billing provider” means an ent…

DHS 105.02 Requirements for maintaining certification. Providers shall comply with the requirements in this section in order to maintain MA certification. (1) CHANGE IN PROVIDER STATUS. Providers shall report to the department in writing any change in licensure, certification, gr…

DHS 105.03 Participation by non-certified persons. (1) REIMBURSEMENT FOR EMERGENCY SERVICES. If a resident DHS 105.055 of Wisconsin or of another state who is not certified by MA in this state provides emergency services to a Wisconsin recipient, that person shall not be reimburs…

DHS 105.04 Supervision of provider assistants. Provider assistants shall be supervised. Unless otherwise specified under ss. DHS 105.05 to 105.49, supervision shall consist of at least intermittent face-to-face contact between the supervisor and the assistant and a regular review…

DHS 105.05 Physicians and assistants. (1) PHYSIFor MA certification, physicians shall be licensed to practice medicine and surgery pursuant to ss. 448.05 and 448.07, Stats., and chs. Med 1, 2, 3, 4, 5 and 14. (2) PHYSICIAN ASSISTANTS. For MA certification, physician assistants sh…

DHS 105.055 Nurse anesthetists and anesthesiologist assistants. (1) CERTIFIED REGISTERED NURSE ANESTHETIST. For MA certification, a nurse anesthetist shall be licensed as a registered nurse pursuant to s. 441.06, Stats., and shall meet one of the following additional requirements…

DHS 105.06 Dentists and dental hygienists. (1) DENTISTS. For MA certification, dentists shall be licensed pursuant to ss. 447.03 and 447.04, Stats. (2) DENTAL HYGIENISTS. For MA certification, dental hygienists shall be licensed pursuant to s. 447.04 (2), Stats.; have 2 years or …

DHS 105.07 General hospitals. For MA certification a hospital shall be approved as a general hospital under s. 50.35, Stats., and ch. DHS 124, shall meet conditions of participation for medicare and shall have a utilization review plan that meets the requirements of 42 CFR 456.10…

DHS 105.075 Rehabilitation hospitals. For MA certification, a rehabilitation hospital shall be approved as a general hospital under s. 50.35, Stats., and ch. DHS 124, and shall meet the conditions of participation for medicare and shall have a utilization review plan that meets t…

DHS 105.08 Skilled nursing facilities. For MA certification, skilled nursing facilities shall be licensed pursuant to s. 50.03, Stats., and ch. DHS 132. Note: For covered nursing home services, see s. DHS 107.09. 4

DHS 105.09 Medicare bed requirement. (1) DEFINIIn this section, “sufficient number of medicare-certified beds” means a supply of beds that accommodates the demand for medicare beds from both the home county and contiguous counties so that no dual eligible recipient is denied acce…

DHS 105.10 SNFs and ICFs with deficiencies. If the department finds a facility deficient in meeting the standards specified in s. DHS 105.08, 105.09, 105.11 or 105.12, the depart- the chapter was last published. 5 DEPARTMENT OF HEALTH SERVICES ment may nonetheless certify the fac…

DHS 105.11 Intermediate care facilities. For MA certification, intermediate care facilities shall be licensed pursuant to s. 50.03, Stats., and ch. DHS 132. Note: For covered nursing home services, see s. DHS 107.09.

DHS 105.12 ICFs for individuals with intellectual disabilities or individuals with related conditions. For MA certification, institutions for individuals with intellectual disabilities or individuals with related conditions shall be licensed pursuant to s. 50.03, Stats., and ch. …

DHS 105.14 Adult day care centers. (1) GENERAL (a) Introduction. In accordance with s. 49.45 (2) (a) 11. and (47) (a) and (b), Stats., this section is promulgated to establish regulations and standards for the care, treatment or services, and health, safety, rights, well-being an…

DHS 105.15 Pharmacies. For MA certification, pharmacies shall meet the requirements for registration and practice under ch. 450, Stats., and chs. Phar 1 to 17. History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. Register, December, 1991, No. 432, eff. 1-1-92; correct…

DHS 105.155 Pharmacists. (1) For MA certification, a pharmacist must be licensed under ss. 450.03 and 450.05, Stats. (2) When a pharmacist performs services under a delegation agreement in accordance with s. 450.033, they shall document and maintain the agreement in accordance wi…

DHS 105.16 Home health agencies. For MA certification, a home health agency shall be certified to participate in medicare as a home health agency, be licensed pursuant to ch. DHS 133 and meet the requirements of this section as follows: (1) HOME HEALTH AGENCY SERVICES. For MA cer…

DHS 105.19 Nurses in independent practice. (1) QUALIFICATIONS. (a) For MA certification to perform skilled nursing services as a nurse in independent practice providing home health services under s. DHS 107.11 (6) or private duty nursing services under s. DHS 107.12, the nurse sh…

DHS 105.20 Nurse practitioners. (1) QUALIFICAFor MA certification, a nurse practitioner shall be licensed as a registered nurse pursuant to s. 441.06, Stats., and fulfill one of the following requirements: (a) If practicing as a pediatric nurse practitioner, be currently certifie…