Section 101.03. Definitions.

  In this chapter and chs. DHS 102 to 109 :

(1)  "Access," for purposes of BadgerCare, 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 sign up and be covered in any or all of the 18 months prior to the application or redetermination of BadgerCare eligibility.

(1m)  "Accredited" means approved by a national accrediting agency or association which has been recognized by the U.S. secretary of education.

(2)  "Active treatment" means implementation and administration of a professionally developed and supervised individual plan of care, which is developed and implemented no later than 14 days after admission to the facility and is reasonably expected to improve the recipient's condition to the extent that inpatient care is no longer necessary.

(3)  "Activities of daily living" means activities relating to the performance of self care, work and leisure or play activities, including dressing, feeding or eating, grooming, mobility and object manipulation.

(4)  "Acute mental illness" means a mental illness which is not of life-long duration, which is severe in degree and causes a substantially diminished level of functioning in the activities of daily living and an inability to cope with the ordinary demands of life, and which may lead to an inability to maintain stable adjustment and independent functioning without short-term treatment.

(5)  "Administrator" means the person who manages a health care facility.

(6)  "AFDC" means aid to families with dependent children, a public assistance program under Title IV-A of the Social Security Act of 1935, as amended, and s. 49.19 , Stats.

(7)  "AFDC-related person" means a person who meets one of the conditions under s. DHS 103.03 (1) (b) .

(8)  "Agency" means the county department of social services, or human services, or a tribal agency which administers income maintenance programs.

(9)  "Ambulatory" means able to walk without personal assistance or mechanical aids, and without difficulty.

(9m)  "Ambulatory prenatal care" means care and treatment for a pregnant woman and her fetus to protect and promote the woman's health and the healthy development of the fetus.

(10)  "Ambulatory surgical center" means a facility that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, and that meets the requirements of s. DHS 105.49 .

(11)  "Ancillary cost" means an extraordinary and unique cost incurred by a nursing home or other qualified provider of services or materials furnished to a nursing home resident, which is not included in calculating the nursing home's daily rate but which MA reimburses separately under s. DHS 107.09 (4) (a) .

(12)  "ANSI" means American national standards institute.

(12m)  "AODA day treatment" means alcohol and other drug abuse treatment services provided by a provider certified under s. DHS 105.25 to a recipient who, in the clinical judgement of a qualified treatment professional, is experiencing a problem with alcohol or other drugs and requires intensive services of a prescribed duration, which may include assessment and evaluation, treatment planning, group and individual counseling, recipient education when necessary for effective treatment, and rehabilitative services, to ameliorate or remove the disability and restore effective functioning.

(13)  "AODA treatment services" means alcohol and other drug abuse treatment services provided by a provider certified pursuant to s. DHS 105.22 or 105.23 to assist alcoholics and drug abusers and persons affected by problems related to the abuse of alcohol or drugs.

(14)  "Applicant" means a person who directly or through a representative makes application for MA.

(15)  "Application for medical assistance" means the process of completing and signing a department-approved application form by which action a person indicates to the agency authorized to accept the application a desire to receive MA.

(16)  "Approved prescription drug products list" means a list prepared by the U.S. food and drug administration that identifies drug products approved on the basis of safety and effectiveness.

(17)  "Asset limit" means that limit against which nonexempt assets under ch. DHS 103 are compared to determine financial eligibility for MA.

(17m)  "Assistive listening device" or "ALD" means a personal communication unit for sound amplification. One type of "assistive listening device" is a hearing aid.

(17r)  "BadgerCare" means the MA-related program established under s. 49.665 , Stats.

(17t)  "BadgerCare fiscal test group" means all members of the BadgerCare group and all persons who are financially responsible for all members of the BadgerCare group who live in the same household as the person for whom they are legally responsible and who are not SSI recipients.

(17w)  "BadgerCare group" means all persons listed on an application for BadgerCare who meet nonfinancial eligibility requirements.

(17x)  "Benefits counseling" means counseling that describes the effect of earned income on a person's public benefits and other support services, such as food stamps, housing assistance, supplemental security income, social security disability insurance or medical assistance.

(18)  "Board" means a community mental health board established under s. 51.42 , Stats., a developmental disabilities board established under s. 51.437 , Stats., or a community human services board established under s. 46.23 , Stats.

(19)  "Border-status provider" means a provider located outside of Wisconsin who regularly gives service to Wisconsin recipients and who is certified to participate in MA.

(20)  "Budgetable income" means earned and unearned income that is considered available for determining financial eligibility for MA under s. 49.46 (1) or 49.47 (4) , Stats., and ch. DHS 103 .

(22)  "Capitation fee" means a fee the department pays periodically to a provider for each recipient enrolled under a contract with the provider for the provision of medical services, whether or not the recipient receives services during the period covered by the fee.

(22g)  "Caretaker relative" means a person listed in s. 49.19 (1) (a) 2. a. , Stats.

(22m)  "Case management" means activities which help MA recipients and, when appropriate, their families, identify their needs and manage and gain access to necessary medical, social, rehabilitation, vocational, educational and other services. Case management includes assessment, case plan development, and ongoing monitoring and service coordination under s. DHS 107.32 .

(23)  "Categorically needy" means the group of persons who meet the nonfinancial and financial eligibility conditions to be eligible for AFDC or SSI.

(24)  "Certified occupational therapist assistant" or "COTA"means a person who meets the requirements of s. DHS 105.28 (2) .

(24m)  "CESA" means a cooperative educational service agency under ch. 116 , Stats.

(25)  "Chronic mental illness" means a mental illness which may be of lifelong duration, which is severe in degree and persistent in duration, which causes a substantially diminished level of functioning in the primary activities of daily living and an inability to cope with the ordinary demands of life, and which may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support.

(26)  "Claim" means a request from a provider on an approved claim form for payment for services to a recipient.

(27)  "Clinical note" means a dated written notation of contact with a patient by a member of a health care team, which contains a description of signs and symptoms, treatment or drugs given, the patient's reaction and any changes in physical or emotional condition.

(27g)  "COBRA continuation coverage" has the meaning under 29 CFR 2590.701 - 2 (2).

(27m)  "Community support program" or "CSP" means a community-based coordinated care and treatment program operated by a provider certified under s. DHS 105.255 to provide mental health and psychosocial rehabilitative services, including case management services, to MA-eligible, chronically mentally ill recipients residing in the community.

(28)  "Compensation received" means the dollar value that can be attached to what is received in return for property and, without limitation by enumeration, that is in one or more of the following forms:

(a) Cash;

(b) Other assets such as accounts receivable and promissory notes, both of which must be valid and collectible to be of value, and stocks, bonds, and both land contracts and life estates;

(c) Discharge of a debt;

(d) Prepayment of a bona fide and irrevocable contract such as a mortgage, shelter lease or loan, or the prepayment of taxes; or

(e) Services, for which a valuation equal to the cost of purchase on the open market is assigned.

(29)  "Concurrent review" means the department's informal review of a complaint on the basis of which a fair hearing has been requested, including an investigation into the facts of a recipient's request for a fair hearing, whereby the department attempts to achieve an informal resolution acceptable to the recipient before the fair hearing takes place.

(30)  "Conditional eligibility" means eligibility for MA which is conditional upon the applicant or recipient meeting the financial eligibility standards specified in 20 CFR 416.1240 and 416.1242 within a predetermined period of time.

(31)  "Confined to a place of residence" means a recipient's physical medical condition or functional limitation in one or more of the areas listed in s. DHS 134.13 (9) (c) , including self-care, understanding and use of language, learning, mobility, self-direction and capacity for independent learning, which:

(a) Restricts the recipient's ability to leave his or her place of residence except with the aid of a supportive device such as crutches, a cane, a wheelchair or a walker, the assistance of another person or the use of special transportation;

(b) Is such that leaving the residence is medically contraindicated; or

(c) Requires a considerable and taxing effort to leave the home for medical services.

(32)  "Consultation" means communication between 2 or more providers concerning the diagnosis or treatment in a given case, which may include, but is not limited to, history-taking examination of the patient, rendering an opinion concerning diagnosis or treatment, or offering service, assistance or advice.

(33)  "Controlling interest or ownership" means that a person:

(a) Possesses a direct or indirect interest in 5% or more of the issued shares of stock in a corporate entity;

(b) Is the owner of an interest of 5% or more in any mortgage, deed of trust, note, or other secured obligation;

(c) Is an officer or director of the corporation; or

(d) Is a partner in the partnership.

(33m)  "Convalescent leave" means a resident's temporary release from an institution for mental diseases (IMD) to residency in a community setting, not more frequently than once a year and beginning on the fourth day after release, with the trial period of residence in the community lasting at least 4 days but not longer than 30 days or until the person is permanently discharged from the IMD, whichever occurs first.

(34)  "Corrective shoes" means:

(a) Surgical straight case shoes for metatarsus adductus;

(b) Any shoe attached to a brace, not including arch supports, for prosthesis;

(c) Mismated shoes involving a difference of a full size or more; or

(d) Shoe modifications for a discrepancy in limb length or a rigid foot deformation.

(34m)  "Cost-effectiveness" means the cost of paying premiums or purchasing health insurance for a medicaid purchase plan recipient through an employer and the associated administrative cost is likely to be less than or equal to the cost of providing medical assistance.

(35)  "Covered service" means a service, procedure, item or supplies for which MA reimbursement is available, provided to a recipient of MA by an MA-certified provider qualified to provide the particular service, procedure, item or supplies or under the supervision of a certified and qualified provider.

(36)  "Daily nursing home rate" means the amount that a nursing home is reimbursed for providing each day of routine health care services to a recipient who is a patient in the home, determined in accordance with s. 49.45 (6m) (a) , Stats.

(36m)  "Date of account creation" means the date the recipient establishes an independence account with a financial institution.

(37)  "Day treatment" or "day hospital" means a non-residential program in a medically supervised setting that provides case management, medical care, psychotherapy and other therapies, including recreational, physical, occupational and speech therapies, and follow-up services, to alleviate problems related to mental illness or emotional disturbances.

(38)  "Deeming" means a process by which income and assets are considered available to applicants or recipients for the purpose of determining financial eligibility for MA under s. 49.46 (1) or 49.47 (4) , Stats., and ch. DHS 103 .

(39)  "Department" means the department of health services.

(40)  "Department-approved occupancy rate" means a rate of nursing home occupancy established by the department and communicated to providers which is used for purposes of determining whether a bed-hold payment may be made to a nursing home.

(41)  "Developmental disability" means mental retardation or a related condition such as cerebral palsy, epilepsy, or autism, but excluding mental illness and infirmities of aging, which is:

(a) Manifested before the individual reaches age 22;

(b) Likely to continue indefinitely; and

(c) Results in substantial functional limitations in 3 or more of the following areas of major life activity:

1. Self-care;

2. Understanding and use of language;

3. Learning;

4. Mobility;

5. Self-direction;

6. Capacity for independent living; and

7. Economic self-sufficiency.

(42)  "Differential diagnostic examination" means an examination and assessment of a recipient's emotional and social functioning which includes one or more of the following: neurologic studies, psychological tests and psycho-social assessments.

(42m)  "Direct deposit" means an electronic transfer of funds from the recipient's financial institution to the medicaid purchase plan or the department's fiscal agent, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.

(43)  "Direct, immediate, on-premises supervision" means supervision with face-to-face contact between the supervisor and the person being supervised, as necessary, with the supervisor being physically present in the same building when the service is being performed by the person being supervised.

(44)  "Direct services" mean nursing home services that benefit patient recipients on an individual basis rather than a group basis, including physician visits to patients, therapy modalities, drug dispensing, radiology or laboratory services provided by a certified radiology or laboratory unit, oral exams, and physical examinations."Direct services" are often referred to as billable services, medical services or professional services.

(45)  "Dispensary providers" means providers who dispense drugs, medical supplies or equipment upon a prescription or order from a prescriber authorized under ch. 447 or 448 , Stats., to prescribe the items.

(46)  "Divestment" means the disposal of any nonexempt resource for a value received which is less than the net market value.

(47)  "Division" means the department's division of health care financing.

(48)  "Drug dispensing" means the interpretation of an order for a drug or biological and the proper selection, measuring, labeling, packaging and issuance of the drug or biological for a patient or for a service unit of a hospital or other health care facility.

(49)  "Drug index" means the list of covered legend and nonlegend drugs maintained and updated by the department.

(50)  "Durable medical equipment" means equipment which can withstand repeated use, is primarily used for medical purposes, is generally not useful to a person in the absence of illness or injury and is appropriate for use in the home.

(51)  "Earned income" means income received in the form of wages, salary, commissions or profits from activities in which the applicant or recipient is engaged as an employee or as a self-employed person.

(51m)  "Electronic funds transfer" means any electronic transfer of a recipient's financial holdings or a portion of these holdings as determined by the recipient to another account, initiated by the completion of all registration forms deemed necessary by the department, the recipient's financial institution, or the department's fiscal agent and prepared with evidence of authorized consent from all parties involved in the transaction.

(52)  "Emergency services" means those services which are necessary to prevent the death or serious impairment of the health of the individual.

(52g)  "Employed" means the person receives income for ongoing services and as a result of this income has incurred a potential tax liability. Any of the following may be used to verify employment:

(a) Pay stubs.

(b) Wage tax receipts.

(c) State or federal income tax returns.

(d) Self-employment bookkeeping records.

(e) Employer's wage records.

(f) Statements from employers. Employer statements may include those from personnel officers, supervisors or other employees of the company who have direct knowledge of the applicant's or recipient's wages. The person making the statement must provide evidence (such as employment records, business correspondence, etc.) that the applicant or recipient is or was an employee of the company during the calendar month for which the applicant or recipient requests eligibility.

(g) Other agencies who receive reports of the applicant's or recipient's income directly from the employer.

(52m)  "Employer-subsidized health care coverage" means family coverage under a group health insurance plan offered by an employer for which the employer pays at least 80% of the cost, excluding any deductibles or copayments that may be required under the plan.

(52r)  "Employment barriers assessment" means an analysis that identifies a person's potential employment barriers, such as physical limitations or problems associated with the person's living situation, education or health or long term care coverage, and strategies for overcoming these potential barriers.

(52s)  "Employment plan" means a plan developed by a person describing the manner in which a person shall meet the requirements of a health and employment counseling program.

(53)  "Enrolled recipient" means a recipient who has entered into an agreement to receive services from a provider reimbursed under the terms of a prepaid capitation contract with the department.

(54)  "EPSDT" means early and periodic screening, diagnosis and treatment services provided by a provider certified pursuant to s. DHS 105.37 .

(55)  "EPSDT case management" means those activities necessary to:

(a) Inform eligible clients of the availability of EPSDT services;

(b) Make arrangements and assist clients to follow through with diagnosis and treatment; and

(c) Refer clients, upon request, to the appropriate local agencies for transportation assistance.

(56)  "EPSDT provider" means a provider certified under s. DHS 105.37 to provide EPSDT health assessment and evaluation services.

(57)  "Evaluation in physical therapy" means one or more of the tests or measures indicated in s. DHS 107.16 (1) (b) .

(58)  "Exempt assets" means assets which are not considered in the determination of financial eligibility for medical assistance.

(59)  "Exempt income" means income which is not considered when determining financial eligibility for medical assistance.

(60)  "Explanation of benefits notice" means the monthly report sent by the department to a recipient containing a summary of the department's record of MA claims paid on the recipient's behalf during that month.

(61)  "Eyeglasses" means lenses, including frames where necessary, and other aids to vision prescribed by a physician skilled in diseases of the eye or by a licensed optometrist.

(62)  "Fair hearing" has the meaning prescribed in ch. HA 3 .

(63)  "Fair market value" means the market value of the property on the date of the transaction.

(64)  "Fiscal agent" means the organization under contract to the department to process claims for services provided under MA.

(65)  "Fiscal test group" means all members of the medical assistance group and all persons who are financially responsible for members of the medical assistance group who live in the same household as the person for whom they are legally responsible and who are not SSI or AFDC recipients.

(66)  "Functional ability" means the skill to perform activities in a normal or acceptable manner with minimal dependence on devices, persons or environment.

(67)  "Functional status" means the recipient's skill in performing activities of daily living in a normal or acceptable manner.

(67m)  "Group health insurance plan" means a plan that meets the definition of a group health plan in 42 USC 300gg-91 (a)(1).

(68)  "Group occupational therapy treatment" means the delivery of occupational therapy treatment procedures in a group setting, with up to 6 patients supervised by one qualified occupational therapist and more than 6 but no more than 12 patients supervised by 2 qualified occupational therapy staff members one of whom is a registered occupational therapist.

(69)  "Group speech/language pathology treatment" means the delivery of speech/language pathology treatment procedures limited to the areas of expressive language, receptive language, and hearing/auditory training (auditory training, lip reading, and hearing-aid orientation), in a group setting for up to 4 MA recipients.

(69g)  "Health and employment counseling program" means services provided within a period of eligibility, which assist a person in pursuing and maintaining employment, that are assembled into an employment plan, reviewed by a screening agency, approved by the department and include all of the following:

(a) Benefits counseling.

(b) Employment barriers assessment.

(c) Resource networking.

(69m)  "Health insurance coverage" has the meaning provided in 42 USC 300gg-91 (b)(1) and also includes any arrangement in which a third party agrees to pay for the health care costs of the individual.

(70)  "Health maintenance organization" or "HMO" means a public or private organization organized under ch. 185 , 611 or 613 , Stats., which makes available to enrolled participants, in consideration of predetermined periodic fixed payments, comprehensive health care services provided by providers who are selected by the organization or who have entered into a referral or contractual arrangement with the organization and which is certified under s. DHS 105.47 .

(70g)  "Home care provider" means a person or organization certified to provide services to a recipient under s. DHS 105.16 , 105.17 or 105.19 .

(71)  "Home health agency" means a public agency or private organization, or a subdivision of the agency or organization, which is primarily engaged in providing skilled nursing services and other therapeutic services to a recipient at the recipient's place of residence.

(72)  "Home health aide" means an individual employed by or under contract to a certified home health agency to provide home health aide services, as defined in s. DHS 133.02 (5) , under the supervision of a registered nurse.

(73)  "Home health service" means any covered home health service enumerated in s. DHS 107.11 (2) and provided by a health worker on the staff of a home health agency or by a health worker under contract or another arrangement with the home health agency.

(75)  "Homestead" or "home" means a place of abode and lands used or operated in connection with the place of abode.

(75m)  "Hospice" means a public agency or private organization or a subdivision of either which primarily provides palliative care to persons experiencing the last stages of terminal illness and which provides supportive care for the family and other individuals caring for the terminally ill persons. This care is provided in a homelike environment, and includes short-term inpatient care as necessary to meet the individual's needs. Services provided by a hospital, long-term care facility, outpatient surgical center or home health agency do not constitute a hospice program of care unless that entity establishes a free-standing or distinct hospice unit, or has a distinct hospice program including staff, facility and services certified under s. DHS 105.50 to provide hospice care.

(76)  "Hospital" has the meaning prescribed in s. 50.33 (2) , Stats., except that it excludes those facilities exempted by s. 50.39 (3) , Stats.

(77)  "Hospital visit" means at least an overnight stay by a nursing home recipient in a certified hospital.

(78)  "Hysterectomy" means a medical procedure or surgery to remove the recipient's uterus.

(78m)  "IEP" means an individualized education program developed under s. 115.80 (4) , Stats.

(78r)  "IFSP" means an individualized family service plan developed under s. 51.44 , Stats.

(78s)  "Incapacitation". For purposes of BadgerCare, means that there has been a finding that the individual's physical or mental incapacity to provide proper parental care. The incapacitation shall be expected to last for a period of at least 30 days. The agency director shall make the incapacitation decision or a designee based on competent medical testimony. The incapacitation shall be of such a debilitating nature as to reduce substantially or eliminate the parent's ability to support care for the child.

(78u)  "Impairment-related work expense" means a cost paid for by a medicaid purchase plan applicant or recipient to work that is all the following:

(a) Related to the applicant's or recipient's disability.

(b) Not a cost that any similar worker, without a disability, would also have.

(c) Not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.

(d) Representative of the standard charge for the item or service in the applicant's or recipient's community.

(79)  "Income disregard" means an earned or unearned income which is not considered in one or more financial tests of eligibility.

(80)  "Income limit" means the limit against which budgetable income is compared to determine financial eligibility.

(80m)  "Independence account" means an account approved by the department that consists solely of savings, dividends and gains derived from savings and income earned from paid employment after the initial date that a person began receiving medical assistance under the medicaid purchase plan.

(81)  "Independent provider of service" means an individual or agency which is eligible to provide health care services to nursing home recipients, to have a provider number, and to submit claims for reimbursement under MA. "Independent provider of service" includes: a physician, dentist, chiropractor, registered physical therapist, certified occupational therapist, certified speech therapist, certified audiologist, psychiatrist, pharmacist, ambulance service agency, specialized medical vehicle service agency, psychologist, x-ray clinic and laboratory.

(82)  "Indirect services" means nursing home services that benefit patient recipients on a group basis rather than an individual basis, including consulting, in-service training, medical direction, utilization review, and the services of unlicensed or uncertified assistants who are not under direct supervision. "Indirect services" are often referred to as nonbillable services, nonmedical services or nonprofessional services.

(83)  "Individual occupational therapy treatment" means delivery by one therapist to one recipient of occupational therapy treatment procedures as prescribed in the individual patient's plan of care for the purpose of restoring, improving or maintaining optimal functioning.

(84)  "Individual speech/language pathology treatment" means delivery by one therapist to one recipient of speech/language pathology treatment procedures, as prescribed in the individual recipient's plan of care, for the purpose of restoring, improving, or maintaining optimal speech and language functioning.

(85)  "Inmate of a public institution" means a person who has resided for at least a full calendar month in an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control and has received treatment or services there that are appropriate to his or her requirements.

(85m)  "Institution for mental disease" or "IMD" means an institution that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services, as determined by the department or the federal health care financing administration. An institution is an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental disease.

(86)  "Institutionalized" means being a patient in a medical institution or a resident of an intermediate care facility or skilled nursing facility.

(87)  "Institutionalized individual" means an individual who is:

(a) Involuntarily confined or detained in a rehabilitative facility, such as a psychiatric hospital or other facility for the care and treatment of mental illness, or under a civil or criminal statute in a correctional facility; or

(b) Confined, under a voluntary commitment, in a psychiatric hospital or other facility for the care and treatment of mental illness.

(88)  "Institutional provider" means a hospital, home health agency, county department operated facility, rehabilitation agency, portable x-ray provider, independent clinical laboratory, rural health clinic, skilled nursing facility, intermediate care facility, case management agency provider, personal care provider, ambulatory surgical center or hospice which is:

(a) Composed of more than one individual providing services;

(b) Eligible to receive payment only as a certified group or organization, rather than as individuals providing services within a facility or agency; and

(c) Required by the department to establish that its personnel who provide services meet the applicable certification criteria contained in ch. DHS 105 , although they need not be separately certified by the department.

(89)  "Intermediate care facility" or "ICF" means a facility that:

(a) Provides, on a regular basis, health-related services to individuals who do not require hospital or skilled nursing facility care but whose mental or physical condition requires services that are above the level of room and board and that can be made available only through institutional facilities;

(b) Is certified under s. DHS 105.11 as an intermediate care facility provider; and

(c) Is licensed pursuant to s. 50.03 , Stats., and ch. DHS 132 or 134 .

(90)  "Intermediate care services" means services provided by an intermediate care facility.

(91)  "Intermittent nursing services" means nursing services provided to a recipient who has a medically predictable recurring need for skilled nursing services. In most instances, this means that the recipient requires a skilled nursing visit at least once every 60 days.

(92)  "Laboratory" or "clinical laboratory" means a facility for the microbiological, serological, chemical, hematological, radiobiassay cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention or treatment of any disease or assessment of a medical condition.

(a) "Independent laboratory" means a laboratory performing diagnostic tests which is independent both of an attending or consulting physician's office and of a hospital.

(b) "Hospital laboratory" means a laboratory operated under the supervision of a hospital or its organized medical staff that serves hospital patients.

(c) "Physician's office laboratory" means a laboratory maintained by a physician for performing diagnostic tests for his or her own patients.

(93)  "Legally responsible" means a spouse's liability for the support of a spouse or a parent's liability for the support of a child as specified in s. 49.90 , Stats.

(94)  "Legend drug" means, for the purposes of MA, any drug requiring a prescription under 21 USC 353 (b).

(94m)  "Medicaid purchase plan" means the medical assistance program allowed under 42 USC 1396a (a) (10) (A) (ii) and s. 49.472 , Stats.

(94p)  "Medicaid review period" is the calendar month of a medical assistance recipient's application plus 11 calendar months or the medicaid eligibility review calendar month plus 11 calendar months.

(94r)  "Medical expense" means a cost paid by a medicaid purchase plan recipient for goods or services that have been prescribed or provided by a medical practitioner licensed in Wisconsin or another state. The cost is not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.

(95)  "Medical assistance" or "MA" means the assistance program operated by the department under ss. 49.43 to 49.497 and 49.665 , Stats., any services or items under ss. 49.45 to 49.497 , Stats., and this chapter and chs. DHS 102 to 108 , or any payment or reimbursement made for these services or items.

(96)  "Medical assistance group" or "MA group" means all persons listed on an application for MA who meet nonfinancial eligibility requirements, except that each AFDC recipient, SSI recipient, and each child with no legally responsible relative comprises a separate MA group.

(96m)  "Medically necessary" means a medical assistance service under ch. DHS 107 that is:

(a) Required to prevent, identify or treat a recipient's illness, injury or disability; and

(b) Meets the following standards:

1. Is consistent with the recipient's symptoms or with prevention, diagnosis or treatment of the recipient's illness, injury or disability;

2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;

3. Is appropriate with regard to generally accepted standards of medical practice;

4. Is not medically contraindicated with regard to the recipient's diagnoses, the recipient's symptoms or other medically necessary services being provided to the recipient;

5. Is of proven medical value or usefulness and, consistent with s. DHS 107.035 , is not experimental in nature;

6. Is not duplicative with respect to other services being provided to the recipient;

7. Is not solely for the convenience of the recipient, the recipient's family or a provider;

8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and

9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.

(97)  "Medically needy" means the group of persons who meet the non-financial eligibility conditions for AFDC or SSI, but whose income exceeds the financial eligibility limits for those programs.

(98)  "Medicare" means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 and 42 CFR subchapter B.

(99)  "Modality" means a treatment involving physical therapy equipment that does not require the physical therapist's personal continuous attendance during the periods of use but that does require setting up, frequent observation, and evaluation of the treated body part by the physical therapist prior to and after treatment.

(100)  "Net income" means the amount of the applicant's income that is left after deductions are made for allowable expenses and income disregards.

(101)  "Net market value" means for the purposes of divestment the fair market value of the resource on the date it was disposed of less the reasonable costs of the transaction on the open market.

(101m)  "Networking of existing resources" means the identification of and referral to an agency in the person's community for any services necessary to overcome the person's barriers to employment.

(102)  "Non-billing performing provider number" means the provider number assigned to an individual who is under professional supervision in order to be an eligible provider. A non-billing provider is not directly reimbursed for services rendered to an MA recipient.

(103)  "Non-covered service" means a service, item or supply for which MA reimbursement is not available, including a service for which prior authorization has been denied, a service listed as non-covered in ch. DHS 107 , or a service considered by consultants to the department to be medically unnecessary, unreasonable or inappropriate.

(104)  "Non-financial eligibility" means those eligibility conditions enumerated in s. DHS 103.03 .

(105)  "Non-institutional provider" means a provider, eligible for direct reimbursement, who is in single practice rather than group practice, or a provider who, although employed by a provider group, has private patients for whom the provider submits claims to MA.

(106)  "Non-legally responsible relative case" or "NLRR case"means a case in which there is no legally responsible caretaker relative in the home for a dependent child defined under s. 49.19 (1) (a) , Stats., but where the caretaker of the child is a qualified relative under s. 49.19 (1) (a) , Stats.

(107)  "Nonprofit agency" means an agency exempt from federal income taxation under section 501 of the internal revenue code of 1954, as amended.

(108)  "Nurse practitioner" means a registered nurse who meets the requirements of s. DHS 105.20 .

(109)  "Nursing home" has the meaning prescribed in s. 50.01 (3) , Stats.

(110)  "Nursing home payment formula" means the prospective payment system for nursing home care established annually by the department.

(111)  "Occupational therapist" or "OTR" means a person who meets the requirements of s. DHS 105.28 (1) , is the primary performing provider of occupational therapy services, is responsible for and signs all billings for occupational therapy services, and is not required to be supervised.

(112)  "Occupational therapy procedure" means treatment, with or without equipment, which requires the continuous personal attendance of a registered occupational therapist or a certified occupational therapist assistant.

(113)  "Outpatient facility" has the meaning prescribed for outpatient treatment facility in s. 632.89 (1) (a) , Stats.

(114)  "Outpatient physical therapy services" means physical therapy services furnished by a provider of these services, a rehabilitation agency or by others under an arrangement with and supervised by the provider or rehabilitation agency, to an individual on an outpatient basis, which may include services to correct a pathological condition of speech.

(114m)  "Palliative care" means treatment provided to persons experiencing the last stages of terminal illness for the reduction and management of pain and other physical and psychosocial symptoms of terminal illness, rather than treatment aimed at investigation and intervention for the purpose of cure. "Palliative care" will normally include physician services, skilled nursing care, medical social services and counseling.

(114p)  "Parent" means any of the following:

(a) A biological parent.

(b) A person who has consented to the artificial insemination of his wife under s. 891.40 , Stats.

(c) A parent by adoption.

(d) A man adjudged in a judicial proceeding to be the biological father of a child if the child is a nonmarital child who is not adopted or whose parents do not subsequently marry each other under s. 767.803 , Stats.

(e) A man who has signed and filed with the state registrar under s. 69.15 (3) (b) 3. , Stats., a statement acknowledging paternity.

(114q)  "Participant" means a person who is participating in a health and employment counseling program.

(114r)  "Part-time, intermittent" means skilled nursing and therapy services provided in the home for less than 8 hours in a calendar day.

(115)  "Person" means an individual, corporation, partnership, association, trustee, governmental unit or other entity.

(115m)  "Period of eligibility" means nine calendar months from the initial calendar month of participation in a health and employment counseling program.

(116)  "Personal care service" means a service enumerated in s. DHS 107.112 (1) when provided by a provider meeting the certification requirements for a personal care provider under s. DHS 105.17 .

(117)  "Personal care worker" means an individual employed by a personal care provider certified under s. DHS 105.17 or under contract to the personal care provider to provide personal care services under the supervision of a registered nurse.

(118)  "Personal needs allowance" means that amount of monthly unearned income identified in s. 49.45 (7) (a) , Stats., which may be retained for the personal needs of an institutionalized person.

(119)  "Persons with related conditions" means individuals who have epilepsy, cerebral palsy or another developmental disability.

(120)  "Physical therapist" means a person who meets the requirements of s. DHS 105.27 (1) .

(121)  "Physical therapy aide" means a person who provides services under s. DHS 107.16 (1) (e) .

(122)  "Physical therapist assistant" means a person who meets the requirements of s. DHS 105.27 (2) .

(122m)  "Physically or sensory disabled" means a condition which affects a person's physical or sensory functioning by limiting his or her mobility or ability to see or hear, is the result of injury, disease or congenital deficiency, and significantly interferes with or limits one or more major life activities and the performance of major personal or social roles.

(123)  "Physician" means a person licensed under ch. 448 , Stats. , to practice medicine and surgery, including a graduate of an osteopathic college who holds an unlimited license to practice medicine and surgery.

(124)  "Physician assistant" means a person certified by the department to participate in MA who holds the minimum qualifications specified in s. DHS 105.05 (2) .

(124m)  "Plan of care," for purposes of ss. DHS 105.16 , 105.19 , 107.11 , 107.113 and 107.12 , means a written plan of care for a recipient prescribed and periodically reviewed by a physician and developed in consultation with the agency staff which covers all pertinent diagnoses, including mental status, type of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency and duration. Orders for therapy services may be developed in accord with the therapist or other agency personnel. Agency personnel shall participate in developing the plan of care.

(125)  "Portable x-ray service" means a service provided by a provider certified pursuant to s. DHS 105.44 .

(125m)  "Poverty line" means the federal poverty guidelines by family size updated annually under 42 USC 9902 (2).

(126)  "Practical nurse" or "LPN" means a person who is licensed as a practical nurse under ch. 441 , Stats. , or, if practicing in another state, is licensed as a practical nurse by that state.

(127)  "Prepaid health plan" or "PHP" means a plan made available by a provider, other than a health maintenance organization, that provides medical services to enrolled recipients under contract with the department on a capitation fee basis.

(128)  "Prescription" means an order for a service for a particular patient, written in accordance with s. DHS 107.02 (2m) (b) .

(129)  "Presumptive disability" means a non-financial eligibility condition determined under s. DHS 103.03 (1) (e) .

(129m)  "Presumptive eligibility" means eligibility of a pregnant woman for MA coverage of ambulatory prenatal care and other services, as determined under s. 49.465 (2) , Stats., prior to application and determination of MA eligibility under ss. 49.46 (1) , and 49.47 (4) , Stats., and ch. DHS 103 .

(130)  "Preventive or maintenance occupational therapy" means occupational therapy procedures which are provided to forestall deterioration of the patient's condition or to preserve the patient's current status. Preventive or maintenance occupational therapy makes use of the procedures and techniques of minimizing further deterioration in areas including, but not limited to, the treatment of arthritic conditions, multiple sclerosis, upper extremity contractures, chronic or recurring mental illness and mental retardation.

(131)  "Preventive or maintenance physical therapy" means physical therapy modalities and procedures which are provided to forestall the patient's condition from deteriorating or to preserve the patient's current physical status. Preventive or maintenance physical therapy makes use of the procedures and techniques of minimizing further deterioration in areas including, but not limited to, daily living skills, mobility, positioning, edema control and other physiological processes.

(132)  "Primary person" means the person applying for MA.

(133)  "Primary provider" means a provider who provides health care service in the area in which the recipient resides and is designated by the recipient, with the concurrence of the designated provider, to be the recipient's primary provider.

(134)  "Prior authorization" means the written authorization issued by the department to a provider prior to the provision of a service.

(134m)  "Private duty nursing" means RN or LPN services provided to a recipient who requires 8 or more hours of skilled nursing care in a calendar day, as specified in s. DHS 107.12 .

(135)  "PRO" or "peer review organization" means the organization under contract to the department which makes determinations of medical necessity and reviews quality of services received by recipients of MA, medicare and maternal and child health programs when these recipients are hospitalized.

(136)  "Procedure" means a treatment that requires the therapist's personal attendance on a continuous basis.

(136m)  "Professional services" means the covered services listed in s. DHS 107.08 (4) (d) that are provided by health care professionals to MA recipients who are inpatients of a hospital.

(137)  "Provider" means a person who has been certified by the department to provide health care services to recipients and to be reimbursed by MA for those services.

(138)  "Provider agreement" means the contract between a provider and the department which sets forth conditions of participation and reimbursement.

(139)  "Provider assistant" means a provider whose services must be performed under the supervision of a certified or licensed professional provider. A provider assistant, while required to be certified, is not eligible for direct reimbursement from MA.

(140)  "Provider certification" means the process of approving a provider for participation in the MA program, as specified in s. DHS 105.01 .

(141)  "Provider handbook" means a publication developed by the department for the use of providers which outlines program policies and includes instructions on claim filing and other aspects of participation in MA.

(142)  "Provider's eligibility date" means the first date on which a provider may begin participation in MA which is no earlier than and may be later than the initial date of a signed written application. The applicant has 30 calendar days within which to complete and return the signed application form to the fiscal agent.

(143)  "Provider's initial date of application" means the earliest of the following:

(a) The date on which the department receives a letter from a person requesting an application to be a provider;

(b) The date on which the department receives an unsolicited application form from a person wishing to become a provider; or

(c) The date on which the department receives a person's rejected claim which was rejected due to an invalid provider number.

(144)  "Psychiatric hospital" or "psychiatric facility" means an institution which is primarily engaged in providing, by or under the supervision of a physician, inpatient psychiatric services for the diagnosis and treatment of mental illness which may include services for the diagnosis and treatment of the abuse of alcohol or other drugs.

(145)  "Psychotherapy" means the treatment of an individual who is mentally ill or has medically significant emotional or social dysfunctions by a psychotherapy provider. The treatment is a planned and structured program based on information from a differential diagnostic examination and directed at the accomplishment of specified goals. The treatment goals may include removing, modifying, or retarding existing symptoms, mediating disturbed patterns of behavior, and promoting positive personal growth and development by enhancing the ability to adapt and cope with internal and external stresses.

(146)  "Psychotherapy provider" means a person certified by the department to participate in MA who holds the minimum qualifications specified in s. DHS 105.22 .

(147)  "Public agency" means an agency operated by the state or a local government.

(148)  "Public health agency" means an administrative organization established by the state or a local government, the primary function of which is to maintain the health of the population served by providing environmental health services, preventive medical service and, when necessary, therapeutic medical services.

(149)  "Public health nurse" means a registered nurse who has completed a baccalaureate degree program approved by the national league for nursing for public health nursing preparation or post-registered nurse study which includes content approved by the national league for nursing for public health nursing preparation.

(149m)  "Qualified provider" means a provider who is qualified to determine presumptive eligibility of pregnant women, as ascertained by the department in accordance with 42 USC 1396a (a) (10).

(150)  "Recipient" means a natural person who is entitled to receive benefits under MA.

(151)  "Registered nurse" or "RN" means a person who holds a current certificate of registration as a registered nurse under ch. 441 , Stats. , or, if practicing in another state, is registered with the appropriate licensing agency in that state.

(152)  "Rehabilitation agency" means an agency providing an integrated multi-disciplinary program of services designed to upgrade the physical functioning of handicapped, disabled individuals by bringing together as a team specialized rehabilitation personnel to provide these services, the services at a minimum consisting of physical therapy or speech pathology services and a rehabilitation program which, in addition to physical therapy or speech pathology services, includes social or vocational adjustment services.

(152m)  "Remedial expense" means a cost paid by a medicaid purchase plan recipient that may be considered to be related to that person's health, employment or disability. The cost is not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.

(153)  "Resident" means an individual who resides as an inpatient in a skilled nursing facility (SNF), intermediate care facility (ICF) or other medical institution.

(154)  "Resident recipient" or "patient recipient" means a person who resides in a nursing home and is eligible to receive or is receiving benefits under MA.

(155)  "Resource" means a recipient's homestead and all other personal and real property in which the recipient has a legal interest.

(155m)  "Respiratory care" means the treatment of a person who receives mechanically assisted respiration.

(155r)  "Respiratory therapist" or "RT" means a person who is certified under ch. Med 20 .

(156)  "Restorative occupational therapy" means the application of procedures and techniques to achieve maximum reduction of a physical disability or the establishment of a patient at the best possible functional level, including but not limited to techniques which improve motor skills, sensory integrative functioning, cognitive skills, the ability to engage in activities of daily living, social interpersonal skills and psychological intrapersonal skills, and those procedures provided to relieve pain, improve cardio-pulmonary function, and adapt orthotic, prosthetic, assistive and adaptive appliances or devices and train the patient in their use.

(157)  "Restorative physical therapy" means physical therapy modalities and procedures which are provided for the purpose of achieving maximum reduction of a physical disability or the establishment of the recipient at the best possible functional level. Restorative physical therapy includes but is not limited to exercises to increase range-of-motion, strength, tolerance, coordination and the ability to engage in activities of daily living. Restorative physical therapy also includes those physical therapy modalities and procedures provided to relieve pain, promote wound healing, improve cardio-pulmonary function and adapt orthotic, prosthetic, assistive and adaptive appliances or devices and train the patient in their use.

(158)  "Rural health clinic" means an outpatient health clinic located in a rural area designated by the federal department of health and human services as a rural shortage area, which is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases but which complies with all other appropriate federal, state and local laws.

(159)  "Rural shortage area" means a defined geographic area that is not delineated as an urbanized area by the U.S. bureau of the census and that is designated by the federal department of health and human services as having either:

(a) A shortage of personal health services under section 1302 (7) of the public health service act; or

(b) A shortage of primary medical care personnel under 42 USC 254e and 42 CFR Part 5 , Appendix A.

(160)  "Schedule" means, in reference to drugs, those drugs listed in schedules II, III, IV and V of subch. II of the controlled substances act, ss. 961.16 , 961.18 , 961.20 and 961.22 , Stats., and additions made to these schedules by ch. CSB 2 .

(160m)  "Screener" means a person certified by the department and employed at a screening agency to review employment plans.

(160r)  "Screening agency" means an agency certified by the department to review employment plans.

(161)  "Semi-private room" means the lowest cost, multiple-bed accommodation in the section of the hospital appropriate for treatment of the recipient's condition, which is available at the time of admission.

(162)  "Skilled nursing facility" or "SNF" means a facility that meets the requirements of s. DHS 105.08 .

(163)  "Skilled nursing services" means those professional nursing services furnished pursuant to a physician's orders which require the skills of a registered nurse or licensed practical nurse and which are provided either directly by or under the supervision of the registered nurse or licensed practical nurse.

(a) Intravenous, intramuscular, or subcutaneous injections and hypodermoclysis or intravenous feeding;

(b) Levin tube and gastrostomy feedings;

(c) Nasopharyngeal and tracheotomy aspiration;

(d) Insertion and sterile irrigation and replacement of catheters;

(e) Application of dressings involving prescription medications and aseptic techniques;

(f) Treatment of extensive decubitus ulcers or other widespread skin disorder;

(g) Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress;

(h) Initial phases of a regimen involving administration of medical gases; and

(i) Rehabilitation nursing procedures, including the related teachings and adaptive aspects of nursing that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs.

(164)  "Skilled nursing services for individuals age 21 or older"means skilled nursing services that are:

(a) Needed on a daily basis and required to be provided on an inpatient basis;

(b) Provided by a facility or distinct part of a facility that is certified under s. DHS 105.08 ; and

(c) Ordered by and to be administered under the direction of a physician.

(164m)  "Skilled nursing services provided primarily in the home" means nursing services requiring the skills of a licensed professional nurse or a licensed practical nurse supervised by a registered nurse according to the requirements of ch. N 6 and directly provided as specified by a written plan of care.

(165)  "Skilled rehabilitation services" means those services furnished pursuant to a physician's orders which require the skills of a physical therapist, occupational therapist, speech pathologist or audiologist and which are provided either directly by or under the supervision of the professional personnel.

(166)  "Specialized medical vehicle" or "SMV" means a non-emergency vehicle used to transport a recipient who is confined to a wheelchair or whose condition contraindicates transportation by common carrier, and whose physician has prescribed specialized medical vehicle transportation to a facility at which the recipient primarily receives medical services.

(167)  "Spell of illness" means, in relationship to physical therapy, occupational therapy, and speech pathology services, a condition characterized by a demonstrated loss of functional ability to perform daily living skills, caused by a new disease, injury or medical condition or by an increase in the severity of a pre-existing medical condition. For a condition to be classified as a new spell of illness, the recipient must display the potential to reachieve the skill level that he or she had previously.

(168)  "Spend-down period" means the period during which excess income may be expended or obligations to expend excess income may be incurred for the purpose of obtaining MA eligibility, as described under s. DHS 103.08 (2) (a) .

(169)  "SSI" means supplemental security income, the assistance program under Title XVI of the Social Security Act of 1935, as amended, and s. 49.77 , Stats.

(170)  "SSI-related person" means a person who meets the requirements of s. DHS 103.03 (1) (c) .

(170m)  "State employees health plan" means family or individual coverage under a group health insurance plan offered by a unit of state government to its employees.

(170s)  "Standard maintenance allowance" means a deduction established by the department and adjusted annually in accordance with increases in the cost of living as described in 20 CFR 404.272 . The standard maintenance allowance may not be less than the sum of $20, plus the federal supplemental security income payment level described under 42 USC 1382 (b) plus the state supplemental security income payment described under s. 49.77 (2m) , Stats.

(171)  "Stepparent case" means an MA case consisting of a family in which a legal parent, a stepparent and a child under age 18 reside in the home.

(172)  "Sterilization" means any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.

(172m)  "Subscriber" means the person through whom health insurance benefits are made available, who either owns a health insurance policy or is the policyholder of a health insurance policy provided by his or her employer.

(172s)  "Substantial gainful activity level" means the income standards as described in 20 CFR 404.1572 and the federal social security administration's program operations manual.

(173)  "Supervision," unless otherwise indicated in chs. DHS 101 to 108 , means at least intermittent face-to-face contact between supervisor and assistant and a regular review of the assistant's work by the supervisor.

(174)  "Tape billing service" means a provider or an entity under contract to a provider which provides magnetic tape billing for one or more providers.

(175)  "Therapeutic/rehabilitative program" means a formal or structured medical or health care activity which is designed to contribute to the mental, physical or social development of its participants, and is certified or approved, or its sponsoring group is certified or approved, by a national standard-setting or certifying organization when such an organization exists.

(176)  "Therapeutic visit" means a visit by a resident recipient to the home of relatives or friends for at least an overnight stay.

(177)  "Three-generation case" means an MA case in which there are 3 generations living in the home and the second generation is a never-married minor parent.

(178)  "Time out" means time away from positive reinforcement. It is a behavior modification technique in which, in response to undesired behavior, the resident is removed from the situation in which positive reinforcement is available.

(179)  "Treatment unit" means, for purposes of reimbursement for therapy services, the time spent in direct treatment services to the individual patient. Time spent in activities not associated with the treatment of the individual patient such as preparation of the patient for treatment, preparation of the treatment area and preparation of the patient for return from the treatment area, otherwise known as "preparation time", shall also be reimbursable for up to 15 minutes per patient per treatment day. Time spent in other activities which are not associated with the treatment of the individual patient, including end of the day clean-up of the treatment area, paperwork, consultations, transportation time and training, is not reimbursable.

(180)  "Unearned income" means income which is not the direct result of labor or services performed by the individual as an employee or as a self-employed person.

(180m)  "Income disregard" means earned or unearned income that is not considered when calculating an applicant's or recipient's monthly premium amount.

(181)  "Usual and customary charge" means the provider's charge for providing the same service to persons not entitled to MA benefits.

(182)  "Ventilator-dependent person" means a person who requires mechanically assisted respiration.

(183)  "Wrap-around coverage" means the supplemental health care coverage necessary to provide any services which would be covered under medical assistance but which are not covered under the group health plan offered by the employer.

History: Cr. Register, February, 1986, No. 362 , eff. 3-1-86; cr. (9m), (22m), (75m), (85m), (114m), (122m), (129m) and (149m), am. (88), Register, February, 1988, No. 386 , eff. 3-1-88; am. (73), (116) and (117), r. (74), Register April, 1988, No. 388 , eff. 7-1-88; emerg. cr. (30m) and (33m) eff. 8-1-88; cr. (30m) and (33m), Register, December, 1988, No. 396 , eff. 1-1-89; emerg. cr. (12m), eff. 3-9-89; emerg. am. (30m), eff. 6-1-89; cr. (12m), Register, December, 1989, No. 408 , eff. 1-1-90; r. (33m), renum. (30m) to be (33m) and am. Register, February, 1990, No. 410 , eff. 3-1-90; cr. (17m), Register, May, 1990, No. 413 , eff. 6-1-90; cr. (27m), Register, September, 1990, No. 417 , eff. 10-1-90; am. (108), Register, January, 1991, No. 421 , eff. 2-1-91; cr. (136m), Register, September, 1991, No. 429 , eff. 10-1-91; emerg. am. (31) (intro.) and (35), cr. (96m), (114r), (134m) and (164m), eff. 7-1-92; am. (8), (23), (31) (intro.), 93, 97 and (126), r. and recr. (35), cr. (70g), (96m), (114r), (124m), (155m), (155r), (164m) and (182), Register, February, 1993, No. 446 , eff. 3-1-93; correction in (89) (c) made under s. 13.93 (2m) (b) 7., Stats., Register, February, 1993, No. 446 ; correction in (62) made under s. 13.93 (2m) (b) 7., Stats., Register, May, 1995, No. 473 ; cr. (24m), (78m), (78r), Register, January, 1997, No. 493 , eff. 2-1-97; emerg. cr. (24m), (78m) and (78r), eff. 6-15-96; correction in (21), (47) and (140) made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, April, 1999, No. 520 ; emerg. renum. (1) to be (1m), cr. (1), (17r), (17t), (17w), (22g), (52m), (67m), (69m), (114p), (125m), (170m) and (172m) and am. (95) and (132), eff. 7-1-99; renum. (1) to be (1m), cr. (1), (17r), (17t), (17w), (22g), (27g), (52m), (67m), (69m), (78s), (114p), (125m), (170m) and (172m) and am. (95) and (132), Register, March, 2000, No. 531 , eff. 4-1-00; correction in (72) made under s. 13.93 (2m) (b) 7., Stats., Register, March, 2000, No. 531 ; cr. (17x), (34m), (36m), (42m), (51m), (52g), (52r), (52s), (69g), (78u), (80m), (94m), (94p), (94r), (101m), (114q), (115m), (152m), (160m), (160r), (170s), (172s), (180m) and (183), Register, November, 2000, No. 539 , eff. 12-1-00; corrections in (6), (11), (128) and (169) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554 ; CR 02-154 : am. (intro.) Register April 2003 No. 568 , eff. 5-1-03; CR 02-154 : am. (intro.) Register April 2003 No. 568 , eff. 5-1-03; correction in (62) made under s. 13.93 (2m) (b) 7., Stats., Register April 2003 No. 568 ; CR 03-033 : am. (49) Register December 2003 No. 576 , eff. 1-1-04; corrections in (intro.), (7), (10), (11), (12m), (13), (16), (20), (22m), (24), (27m), (31), (38), (39), (54), (56), (57), (70) to (73), (75m), (88) (c), (89) (b), (c), (95), (96m) (intro.), 5., (103), (104), (108), (111), (114p) (d), (116), (117), (120) to (122), (124), (124m), (125), (128) to (129m), (134m), (136m), (140), (146), (162), (164) (c), (168) and (170) made under s. 13.92 (4) (b) 6. and 7., Stats., Register December 2008 No. 636 .

Note

The plan of care is designed to achieve the recipient's discharge from inpatient status at the earliest possible time. Microsoft Windows NT 6.1.7601 Service Pack 1 The administrator should have a bachelor's degree and either experience or specialized training in the administration of health institutions or agencies; or qualifications and experience in one of the professional health disciplines. Microsoft Windows NT 6.1.7601 Service Pack 1 Examples of AODA treatment services are client evaluation, orientation and motivation, treatment planning, consultation and referral, client education, individual counseling, group counseling and crisis intervention. Microsoft Windows NT 6.1.7601 Service Pack 1 The presumption that services and accommodations rendered to each other by the members of a family or other relatives were gratuitous can be rebutted only by direct and positive evidence of a prior express contract for payment. Microsoft Windows NT 6.1.7601 Service Pack 1 This review does not preclude the recipient's right to a fair hearing. Microsoft Windows NT 6.1.7601 Service Pack 1 Day treatment services are provided by an interdisciplinary team on a routine, continuous basis for a scheduled portion of a 24-hour day and may include structural rehabilitative activities including training in basic living skills, interpersonal skills and problem-solving skills. Microsoft Windows NT 6.1.7601 Service Pack 1 Examples of dispensary providers are pharmacies, durable medical equipment suppliers and providers of vision care supplies. Microsoft Windows NT 6.1.7601 Service Pack 1 Examples of "durable medical equipment" are wheelchairs, hospital beds and side rails. Microsoft Windows NT 6.1.7601 Service Pack 1 In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead. Microsoft Windows NT 6.1.7601 Service Pack 1 Impairment-related work expenses are as described in 20 CFR 404.1576 . Microsoft Windows NT 6.1.7601 Service Pack 1 A physician's office laboratory which accepts at least 100 specimens in any category during any calendar year on referral from other physicians is considered an independent laboratory. Microsoft Windows NT 6.1.7601 Service Pack 1 The federal poverty guidelines for 1999 were published in the Federal Register , March 18, 1999 , pp. 13428-13430. Microsoft Windows NT 6.1.7601 Service Pack 1 Some services are covered only if they are authorized by the department before they are provided. Some otherwise covered services must be prior authorized after certain thresholds have been reached. Microsoft Windows NT 6.1.7601 Service Pack 1 Examples of services which would qualify as skilled nursing services are: Microsoft Windows NT 6.1.7601 Service Pack 1 Skilled rehabilitation services include: Microsoft Windows NT 6.1.7601 Service Pack 1 (a) Ongoing assessment of rehabilitation needs and potential, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficits, speech and language or hearing disorders and sensory integrative abilities; Microsoft Windows NT 6.1.7601 Service Pack 1 (b) Therapeutic exercises or activities which, because of the type of exercises employed or the condition of the patient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the patient and the effectiveness of the treatment; Microsoft Windows NT 6.1.7601 Service Pack 1 (c) Gait evaluation and training furnished to restore function in a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality; Microsoft Windows NT 6.1.7601 Service Pack 1 (d) Range of motion exercises which are part of the active treatment of a specific disease state which has resulted in loss or restriction of mobility as evidenced by a therapist's notes showing the degree of motion lost and the degree to be restored; Microsoft Windows NT 6.1.7601 Service Pack 1 (e) Sensory integrative evaluation and training which, because of the type of training or the condition of the patient, must be performed by or under the supervision of a qualified occupational therapist or physical therapist or other appropriate licensed health care provider to ensure the safety of the patient and the effectiveness of the treatment; Microsoft Windows NT 6.1.7601 Service Pack 1 (f) Preventive therapy utilizing the principles or techniques of minimizing further debilitation in the areas of energy preservation, joint protection, edema control, positioning, etc., which requires the specialized knowledge and judgment of a qualified occupational or physical therapist; Microsoft Windows NT 6.1.7601 Service Pack 1 (g) Maintenance therapy, when the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient's needs, and consistent with the patient's capacity and tolerance; Microsoft Windows NT 6.1.7601 Service Pack 1 (h) Ultrasound, shortwave, and microwave therapy treatments by a qualified physical therapist; Microsoft Windows NT 6.1.7601 Service Pack 1 (i) Hot pack, hydrocollator, infra-red treatments, paraffin baths, and whirlpool in particular cases where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications, and where the skills, knowledge, and judgment of a qualified physical therapist are required; Microsoft Windows NT 6.1.7601 Service Pack 1 (j) Therapeutic adaptations, including orthotics, splinting, prosthetics and assistive or adaptive equipment prescribed by a physician and provided by a qualified occupational or physical therapist are required; and Microsoft Windows NT 6.1.7601 Service Pack 1 (k) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing. Microsoft Windows NT 6.1.7601 Service Pack 1