Section 1.01. Purpose, definitions, exempted services.

 

(1)   Authority and purpose. Sections DHS 1.01 to 1.065 are promulgated under the authority of ss. 46.03 (18) , 46.10 (1) to (14) (a) and 227.11 (2) , Stats., to implement ss. 46.03 (18) , 46.011 (1g) , 46.10 (1) to (14) (a) , 46.27 (11) , 46.275 , 46.277 , 46.278 , 46.985 (2) (a) 8. , 48.837 (7) , 48.839 (1) and 51.30 (4) (b) 2. , Stats. Sections DHS 1.01 to 1.065 standardize on a statewide basis the determination of liability and ability to pay and otherwise regulate billing and collection activities for care and services provided or purchased by the department, a county department of social services or a county department established under s. 46.23 , 51.42 or 51.437 , Stats.

(2)   Definitions.

(a) "Administratively unfeasible" means that the total payments realized would approximate or be less than the cost of collections for a specified type of service.

(b) "Department" means the state department of health services.

(c) "Division" means one of the major subunits of the department.

(d) "Facility" means any agency, office, institution, clinic, etc., that delivers client services.

(e) "Family" means an adult and that person's spouse, if any, and any other person who meets internal revenue service standards as their dependent, except that:

1. When a foster parent seeks child day care for a foster child so that the foster parent may attend school or work, the foster child shall be counted as a member of the foster parent's family; and

2. Any of the following persons shall not be included as a family member in determining the ability to pay of any responsible party under this chapter:

a. A family member who is receiving services in an out-of-home placement;

b. A legal dependent living outside the household of the responsible party for whom there is a court-ordered support or maintenance obligation; or

c. An adult client residing in the home of his or her parent or parents. This person is considered a separate family in determining ability to pay under this chapter for any fee chargeable service that he or she may receive.

(f) "Fee" means a single, cost-related, per unit charge or rate assigned to a purchased or provided service furnished by a provider of service calculated and/or approved according to the provisions of this rule for the purpose of establishing the liability of responsible parties and billing third-party payers.

(g) "Full financial information" means information about a family's income, expenses, assets, and insurance coverage that is necessarily and reasonably requested for the purpose of determining ability-to-pay and for billing all applicable insurance.

(h) "Income" means gross earnings, including money, wages or salary, net income from non-farm self-employment, net income from farm self-employment, as well as unearned income, including social security, dividends, interest on savings or on money loaned, income from estates or trusts, net rental income or royalties, public assistance, pensions or annuities, unemployment compensation, workers' compensation, maintenance (alimony), child support, family support, veterans' pensions, educational grants given for living expenses and, for foster parents receiving day care services or funds under s. 49.155 , Stats., foster care payments.

(i) "Parent" means a child's adoptive or biological mother or father who has legal responsibility for the child.

(j) "Parental payment limit" means the amount established or approved by the department under s. DHS 1.03 (21) or under s. DHS 1.065 as the maximum daily or monthly amount that parents may be billed for care or services provided to their minor children.

(k) "Payment approval authority" means an administrator of a division, the director of a county department of social services, or the program director of a board established under s. 51.42 , 51.437 , or 46.23 , Stats., or a designee.

(L) "Secretary" means the secretary of the department of health services.

(m) "Student" means an individual who is attending a school, college, university, or a course of vocational or technical training.

(3)   Where rules apply. These rules apply to all client-specific care and services purchased or provided by the department, county departments of social services, and boards created under s. 51.42 , 51.437 or 46.23 , Stats., except as provided in sub. (4) .

(4)   Exceptions. The following services are not subject to direct billing to responsible parties under these rules:

(a) Federal exemptions: any service for which the imposition of a charge is prohibited by federal law, regulation, or valid federal grant requirement, including educational services to handicapped pre-school age children with exceptional education needs under Title I of P.L. 89-313 .

(b) Statutory or judicial exemptions: services exempted in ss. 46.03 (18) (a) and 46.10 (2m) , Stats., services for handicapped children with exceptional education needs which local school districts must ensure be available under s. 115.77 , Stats., and any other care or service for which the imposition of a charge is prohibited by state law.

(c) Exemptions established by the department, pursuant to s. 46.03 (18) (a) , Stats.:

1. Services offered, defined and funded under the state plan for Title XX of the Social Security Act which are specifically exempted from fee charging in the plan.

2. Probation and parole services, court ordered supervision and other supervision service provided to adults.

3. Purchases of education services by the department of corrections.

4. Sheltered employment, work activity, and adult non-medical day services programs for the handicapped except, transportation related to these services.

5. Non-medical initial diagnosis and evaluation services.

6. Family planning services.

7. Advocacy.

(d) Further exemptions:

1. Any provider of a service may request that the service be exempted from these rules under the following procedures unless prohibited by law, if the secretary or designee finds that the benefit of the service in question will be significantly impaired if the imposition of a charge continues or that the imposition of a charge is administratively unfeasible.

2. Agencies seeking an exemption of a service not listed in par. (c) shall submit a request containing documentation. At a minimum data must include a full review for 3 continuous months of the maximum monthly payment rates computed according to s. DHS 1.03 for all clients receiving the service.

3. Each request shall also include the following summary information:

a. Full description of the type of service (e.g. how it is provided, its intended purpose, etc.).

b. Per unit cost of service.

c. Units of service provided each month under review.

d. Total number of clients during the full period of review.

e. Number of clients in each of the Maximum Monthly Payment Rate levels.

( Note: For example 15 clients - 0
  3 clients - $4 - $10/mo.
  4 clients - $11 - $20/mo., Etc.)

f. A statement indicating the potential recovery from third party payers and whether the services are eligible for federal financial participation under the state Title XX plan.

g. Documentation of extra administrative cost to operate the uniform fee system for this service.

h. Reason and evidence to sustain any contra-therapeutic claim for exemption.

4. Agencies providing services under contract with a county agency shall submit the supporting materials to the appropriate purchasing agency. If the county agency concurs with the request for exemption, the request and any additional supporting information and rationale shall be forwarded by the county agency to the Secretary, Department of Health Services - Subject: Uniform Fee Exemption.

5. Fee exemption, when approved, relates to all clients receiving the specified service from the service provider. The secretary may expand the fee exemption to include like services from all similar providers of service. Fee exemptions shall be communicated by letter to the appropriate county agency(ies).