Section 104.02. Recipient duties.

 

(1)   Not to seek duplication of services. A recipient may not seek the same or similar services from more than one provider, except as provided in s. DHS 104.04 .

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

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

(4)   Informational cooperation with providers. Recipients shall give providers full, correct and truthful information requested by providers and necessary for the submission of correct and complete claims for MA reimbursement. This information shall include but is not limited to:

(a) Information concerning the recipient's eligibility status, accurate name, address and MA identification number;

(b) Information concerning the recipient's use of the MA card;

(c) Information concerning the recipient's use of MA benefits; and

(d) Information concerning the recipient's coverage under other insurance programs.

(5)   Not to abuse or misuse the MA card or benefits. If a recipient abuses or misuses the MA card or benefits in any manner, the department or agency, as appropriate, may limit or terminate benefits. For purposes of this subsection,"abuses or misuses" includes, but is not limited to, any of the following actions:

(a) Altering or duplicating the MA card in any manner;

(b) Permitting the use of the MA card by any unauthorized individual for the purpose of obtaining health care through MA;

(c) Using an MA card that belongs to another recipient;

(d) Using the MA card to obtain any covered service for another individual;

(e) Duplicating or altering prescriptions;

(f) Knowingly misrepresenting material facts as to medical symptoms for the purpose of obtaining any covered service;

(g) Knowingly furnishing incorrect eligibility status or other information to a provider;

(h) Knowingly furnishing false information to a provider in connection with health care previously rendered which the recipient has obtained and for which MA has been billed;

(i) Knowingly obtaining health care in excess of established program limitations, or knowingly obtaining health care which is clearly not medically necessary;

(j) Knowingly obtaining duplicate services from more than one provider for the same health care condition, excluding confirmation of diagnosis or a second opinion on surgery; or

(k) Otherwise obtaining health care by false pretenses.

(6)   Notification of personal or financial status changes. Recipients shall inform the agency within 10 days of any change in address, income, assets, need, or living arrangements which may affect eligibility. In addition, the department may require as a condition for continuation of MA coverage that certain recipients report each month whether there has been any change of circumstances that may affect eligibility.

(7)   Financial responsibility of spouse or responsible relative. Within the limitations provided by s. 49.90 , Stats., and this chapter, the spouse of an applicant of any age or the parent of an applicant under 18 years of age shall be charged with the cost of medical services before MA payments shall be made. However, eligibility may not be withheld, delayed or denied because a responsible relative fails or refuses to accept financial responsibility. When the agency determines that a responsible relative is able to contribute without undue hardship to self or immediate family but refuses to contribute, the agency shall exhaust all available administrative procedures to obtain that relative's contribution. If the responsible relative fails to contribute support after the agency notifies the relative of the obligation to do so, the agency shall notify the district attorney in order to commence legal action against that relative.

History: Cr. Register, December, 1979, No. 288 , eff. 2-1-80; am. Register, February, 1986, No. 362 , eff. 3-1-86; corrections in (6) and (7) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554 .