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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
A covered service is any medical service that MA will pay for an eligible client, if billed. The Division of Health Care Financing ( DHCF ) certifies qualified health care providers and reimburses them for providing MA covered services to eligible MA clients. Clients may receive MA services only from certified providers, except in medical emergencies. MA reimburses emergency medical services necessary to prevent the death or serious impairment of the health of a client even when provided by a non-certified provider.
MA providers must submit a prior authorization request to the Medicaid fiscal agent before providing certain MA services.
Examples of MA covered services include:
Case management services.
Chiropractic services.
Dental services.
Family planning services and supplies.
Federally Qualified Health Center ( FQHC ) services.
HealthCheck (Early and Periodic Screening, Diagnosis and Treatment – ESPDT ) of people under 21 years of age.
Home and community-based services authorized under a waiver.
Home health services or nursing services if a home health agency is unavailable.
Hospice care.
Inpatient hospital services other than services in an institution for mental disease.
Inpatient hospital, skilled nursing facility,
and intermediate care facility services for patients in institutions for
mental disease who are:
under 21 years of age.
under 22 years of age and received services immediately before reaching age 21.
65 years of age or older.
Intermediate care facility services, other than services at an institution for mental disease.
Laboratory and X-ray services.
Legend drugs and over-the counter drugs listed in Wisconsin Medicaid’s drug index.
Medical supplies and equipment.
Mental health and medical day treatment.
Mental health and psychosocial rehabilitative services, including case management services provided by the staff of a certified community support program.
Nurse midwife services.
Nursing services, including services performed by a nurse practitioner.
Optometric or optical services, including eyeglasses.
Outpatient hospital services.
Personal care services.
Physical and occupational therapy.
Physician services.
Podiatry services.
Prenatal care coordination for women with high-risk pregnancies.
Respiratory care services for ventilator-dependent individuals.
Rural health clinic services.
Skilled nursing home services other than in an institution for mental disease.
Speech, hearing, and language disorder services.
Substance abuse (alcohol and other abuse services).
TB (tuberculosis) services.
Transportation to obtain medical care.
If you or the client have additional questions, contact Recipient Services at 1-800-362-3002.
Federal regulations require that MA programs provide transportation to clients who need to obtain MA services. Transportation by ambulance, specialized medical vehicle ( SMV ) or ESA approved common carrier is a covered MA service when provided in accordance with the appropriate sections below.
Ambulance transportation is a covered service if it is provided by a MA certified ambulance provider, and the client is suffering from an illness or injury that rules out other forms of transportation, and only if it is for:
Emergency care when immediate medical treatment
or examination is needed to deal with or guard against a worsening of
the person’s condition.
Non-emergency care when authorized in writing by a physician, physician assistant, nurse midwife or nurse practitioner.
ES is not responsible for prior authorization for ambulance services.
A Specialized Medical Vehicle ( SMV ) is a vehicle equipped with a lift or ramp for loading wheelchairs. The driver of a SMV must have first aid training and CPR certification.
SMV transportation is a covered service if the person is legally blind, or indefinitely or temporarily disabled as documented in writing by a physician, physician assistant, nurse midwife, or nurse practitioner. The documentation from the provider must indicate why the person’s condition prevents him/her from using a common carrier or private vehicle. In the case of a temporary disability , the documentation must indicate the expected length of time SMV services will be necessary, as well as why the person cannot use common carrier transportation.
SMV services are available only for transportation to a MA covered service (including community waiver services if transportation is included in the per diem). A client’s age, place of residence, lack of parental supervision, or lack of a driver’s license are not qualifying criteria for SMV services.
ES is not responsible for prior authorization for SMV services, but may refer a client who is unable to use common carrier to a MA certified SMV provider.
Managed Care
MA HMOs and special managed care programs authorize and reimburse transportation providers for ambulance and specialized medical vehicle services. Care Management Organizations ( CMOs ) do not cover common carrier or ambulance service, but do contract for SMV services. If a client is not in a HMO, s/he can call 1-800-362-3002 with questions on ambulance or SMV providers.
Common carrier means any mode of transportation approved by an Economic Support Agency ( ESA ), except an ambulance or a SMV. Common carrier transportation is a covered service if the ESA (or a designated agency) authorizes the transportation.
Transportation to Out-of-State Providers
Except for services provided by MA-certified “border-status” providers, all non-emergency out-of-state services require prior authorization from the MA program. According to s. HFS 101.03, a border-status provider is, “a provider located outside of Wisconsin who regularly gives service to Wisconsin recipients and who is certified to participate in MA.”
If the MA program approves a request for out-of-state health care services, the transportation to receive the service may be covered if authorized by the ESA. The ESA may approve a request for the transportation only if prior authorization has been granted for the health care service that the recipient will be receiving from the out-of-state provider. The ESA should not approve requests for out-of-state transportation if the MA program has not authorized the out-of-state health care service.
As with other travel, approve the least expensive means of transportation, which the client can use, and which is reasonably available when the service is required. The ESA may provide reimbursement up to the charges of the common carrier, for mileage expenses or a contracted amount the ESA or its designated agency has agreed to pay the transportation provider. Related travel expenses may be covered as described below. The ESA may request verification of expenses, or documentation that the trip occurred.
Transportation Administration
When providing common carrier transportation, the ESA should use the most cost-effective mode of transportation possible. The ESA reimburses transportation by common carrier. Clients may contact the ESA with questions on common carrier reimbursement.
Common carrier transportation requires authorization by the county/tribal agency prior to departure. The client or someone acting on his/her behalf may request the authorization. The request can be made by phone, in person, or in writing to the ESA. Denials must be in writing and must explain why the request was denied. The county/tribal agency may delegate common carrier authorization to another county/tribal, or other local agency, provided clients are assured of transportation to MA covered services.
Issue authorizations and denials with reasonable promptness. For authorizations, specify the means of transportation authorized. If recurring medical care is needed, you may authorize all of the trips needed for a specific time period.
Reimbursement
Follow these guidelines when approving or reimbursing transportation services:
Approve the least expensive means of transportation,
which the client can use, and which is reasonably available when the service
is required. If
neighbors, friends, relatives or voluntary organizations have routinely
provided transportation at no cost, the county or tribal agency does not
have to approve that transportation.
Do not restrict approval according to the type
of covered service. For
example, you may not limit reimbursement for transportation to only urgent
medical services or physician provided services.
Reimburse transportation only to and from a location where the client receives a MA covered service.
The ESA may request documentation that a
MA covered service was provided:
If provision of covered services is questionable
or
The client was unable to obtain prior approval.
The county/tribal agency may limit reimbursement
for mileage to the nearest provider if the client has reasonable access
to health care of adequate quality from that provider.
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Example: There is a pharmacy 11 miles from the client’s home that could have filled his/her prescription. But s/he went to one 32 miles from home. Reimburse him/her on the basis of the shorter distance. The county or tribal agency may require provider documentation of the need for a specialized service at the location requested. |
The ESA may reimburse clients who use their own
vehicle up to $0.24 a mile, and may bill up to $0.26 a mile and keep up
to $0.02 a mile for administration.
If the
vehicle is lift/ramp equipped, you may reimburse up to $0.50 a mile. The
ESA may bill $0.52 a mile and keep up to $0.02 a mile for administration.
A volunteer driver (someone who provides service
to another person) may be reimbursed up to $0.33 a mile. If they carry
more than one client on a single trip, volunteer drivers may be reimbursed
up to $0.35 a mile. The
county or tribal agency may bill up to $0.36 a mile ($0.38 for more than
one client on a single trip) and keep up to $0.03 a mile for administration.
You may reimburse public carriers, such as taxis
and buses for non-contracted trips, up to their usual and customary charges
to the general public. Reimburse
the provider directly, or have the client pay for the transportation and
reimburse him/her.
When no alternative transportation arrangements
are available or when it is the most cost effective alternative, the ESA
may contract with SMVs or Human Service Vehicles ( HSVs ).
Limit reimbursement to no more than $1.05 per loaded mile for each
client. Loaded
mileage is the mileage driven when the client is on board.
When an
agency contracts with a SMV, HSV, taxi company or similar entity, the
agency may charge administrative costs of up to five percent of the amount
paid. The
amount paid must not exceed $1.05 per loaded mile for each client.
County or tribal agencies may operate their own program to transport
clients. They
may claim reimbursement as follows:
For the most current state rates, refer to http://www.dhfs.state.wi.us/bfs/pdf/APP/Travel/trav10.pdf.
The information
in this page should be updated annually.
The county or tribal agency may not use common
carrier transportation funds to pay drivers while they are not
actively providing direct transportation services. Do
not claim reimbursement for the cost of purchasing the vehicle.
The county or tribal agency may cover travel-related expenses if the travel is “other than routine.” Travel that is other than routine may be defined as trips that are significantly beyond the distances typically traveled to obtain health care services in a particular locality.
Related travel expenses may also include
the cost of meals and commercial lodging en route to and from, and while
receiving, a MA-covered service. Related
travel expenses may also include the cost of an attendant to accompany
the client if, the client’s age and/or physical condition warrants an
attendant. If
the client is age 16 years or older, the need for an attendant must be
determined and documented in writing by a physician, physician assistant,
nurse midwife, or nurse practitioner.
Only reimburse the cost of one attendant, unless the physician, physician
assistant, nurse midwife, or nurse practitioner documents in writing,
that the recipient’s condition requires the physical presence of more
than one attendant. The
ESA or its designated agency must maintain the statement of need.
An attendant is a person,
in addition to the driver, that is specifically trained in procedures
that are necessary for care and transportation of the client. An
attendant’s costs may include transportation, lodging, meals, and a salary.
When the attendant is a member of the client’s family, limit reimbursable
costs to transportation, commercial lodging and meals. A
client’s family consists of the client, his/her spouse, parent, stepparent,
foster parent, half-siblings, the client’s natural, adoptive, and stepchildren,
grandparent, and grandchildren.
County/tribal agencies may approve up to four weeks of expenses without
DHFS approval. A
request for attendant care over four weeks requires prior authorization
by DHFS. Send
prior authorization requests to:
Transportation Policy Analyst
Division of Health Care Financing
P.O. Box 309
Madison, WI 53701-0309
Reimbursement for the client’s and/or attendant’s meals and lodging
must be no greater than the amounts paid by the state to its employees
for those expenses. Reimburse
multiple night stays at state rates for employees. The
minimum salary for an attendant must be the minimum federal hourly wage.
For the most current state rates, refer to http://www.dhfs.state.wi.us/bfs/pdf/APP/Travel/trav10.pdf.
The information in this page should be updated annually.
The county/tribal agency may establish their own
procedures for cash advances to clients.
Apply these reimbursement guidelines for clients
who are retroactively certified for MA. They
are entitled to request reimbursement of medical transportation costs
that occurred during the retroactive period.
Medicare beneficiaries who are ineligible for
MA are not eligible for MA transportation reimbursement.
For common carrier transportation, MA will reimburse
ESA’s for transportation costs that have prior authorization. The
ESA may also work with an HMO to coordinate the common carrier transportation.
MA encourages ESA’s that choose not to contract with an HMO for transportation
to work with the HMO so that the enrollee’s transportation needs can be
met.
Transportation Waiver
When you deny a request for transportation expenses, tell the client that s/he can ask for a waiver. If s/he asks for a waiver, write up the waiver request.
In your waiver request
Refer to the Administrative
Rule permitting waivers ( HFS 106.13 ).
If the denial is
for a family member’s attendant services,
note the waiver request is to waive Administrative Rule HFS 107.23 (3).
Describe the specific
case situation.
Give your reason(s)
for requesting the waiver. An
example of a reason would be that enforcement of the requirement would
result in unreasonable hardship for the person.
Sign the request
and send it to:
Transportation Policy Analyst
Division of Health Care Financing
P.O. Box 309
Madison, WI 53701-0309
This page last updated in Release Number : 03-02
Release Date: 04/01/03
Effective Date: 04/01/03
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