Service

Covered hospital outpatient services are those medically necessary preventive, diagnostic, rehabilitative or palliative items or services provided by a hospital certified by DHFS and performed by or under the direction of a physician, psychologist or dentist.

Hospitals (in-state) are reimbursed for outpatient services at an interim rate per visit with a subsequent retrospective final settlement.  The settlement takes into account the costs incurred by the hospital during its cost-reporting period.  Reimbursed costs under the retrospective settlement are limited to a prospectively established ceiling amount.  The ceiling amount is a prospective, hospital-specific rate per outpatient visit that is based on a hospital’s historical cost and adjusted to stay within the State’s available funding for outpatient hospital services.

Covered RHC services are the following:

·         Services furnished by a physician within scope of practice;

·         Services furnished by a physician assistance or nurse practitioner (meeting certain requirements);

·         Services and supplies that are furnished incidental to professional services of physicians, PAs or NPs;

·         Part-time or intermittent visiting nurse care and related medical supplies, if certain requirements are met; and

·         Other ambulatory services.

If a physician performs services in the clinic or the services are furnished away from the clinic and the physician must have an agreement with the clinic providing that the physician will be paid by the RHC for these services.

RHCs are reimbursed encounter-specific rates. 

Wisconsin Medicaid may provide additional quarterly reimbursement based on the provider’s encounter rate as established via the RHC cost report.

Wisconsin Medicaid will provide the RHC a final reconciliation payment reimbursing the RHC for 100% of reasonable costs.

The following services are covered:

·         Professional services;

·         Supplies and pharmaceuticals incidental to professional services;

·         Pharmaceuticals provided by an FQHC in compliance with pharmacy guidelines;

·         Obstetrical and perinatal care;

·         Clinic visits;

·         FQHC professional services provided to FQHC patients if covering inpatient hospital visits;

·         FQHC professional services provided to FQHC patients if surgical services are directly provided by the center or clinic; and Mental health visits provided in compliance with mental health guidelines.

DHFS establishes an encounter-specific reimbursement rate for all “FQHC covered services”.  The encounter rate reimburses 100% of reasonable costs.

Initial FFS reimbursement to FQHCs is made per the terms of reimbursement for the certified performing provider.  DHFS may provide additional quarterly reimbursement based on the provider’s encounter rate as established through the FQHC cost report.

Medicaid covered services that are not considered FQHC services may be eligible for Medicaid FFS or HMO reimbursement.

Professional and technical diagnostic services covered by Wisconsin Medicaid are laboratory services provided by a physician or under a physician’s supervision, or prescribed by a physician and provided by an independent certified laboratory, and x-ray services prescribed by a physician and provided by or under the general supervision of a physician.

All diagnostic services must be prescribed or ordered by a physician or dentist.

Portable x-ray services are covered only for recipients in who reside in nursing homes and only when provided in a nursing home.

DHFS establishes maximum allowable fees for certified lab and x-ray providers.  DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

Covered nursing home services include but are not limited to:

·         Nursing services;

·         Special care services, including activity therapy, recreation, social services and religious services;

·         Supportive services, including dietary, housekeeping, maintenance, institutional laundry and personal laundry services;

·         Transportation services; and

·         Personal comfort items, medical supplies and special care supplies.

Nursing homes are paid per diem rates.

Physician services covered by Wisconsin Medicaid are any medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a physician’s office, hospital, nursing home, recipient’s residence or elsewhere, within scope of practice.

Certain limitations, including prior authorization, apply.

Medically necessary ancillary services provided under the direct on-site supervision of a certified physician may be reimbursed under the physician’s Medicaid provider number.

DHFS establishes maximum allowable fees for certified physicians.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

Covered dental services include:

·         Diagnostic procedures, including oral exams and x-rays;

·         Preventive procedures including prophylaxis;

·         Restorative procedures, including amalgam fillings and crowns;

·         Endodontic procedures including root canals;

·         Removable prosthodontic procedures, including dentures;

·         Fixed prosthodontic procedures, including bridges and inlays;

·         Periodontic procedures, including gingivectomy or gingivoplasty; and

·         Oral surgery procedures.

Many dental procedures require prior authorization.

DHFS establishes maximum allowable fees for certified dental providers.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

The EPSDT program in Wisconsin is called HealthCheck.

HealthCheck consists of a comprehensive health screening of Medicaid recipients under the age of 21.  The screening includes, but is not limited to the following:

·         A review of the recipient’s health history;

·         An assessment of growth and development;

·         Identification of potential physical or developmental problems;

·         Preventive health education;

·         Referral assistance to providers.

Under HealthCheck, Wisconsin Medicaid covers necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects, physical and mental illnesses, and conditions discovered during the screening services.

Services may be provided by physicians, outpatient hospital facilities, HMOs, visiting nurse associations, clinics operated under a physician’s supervision, local public health agencies, RHCs, Indian health agencies and neighborhood health centers.

Services are free for Medicaid recipients under age 18.  Recipients age 18 to 20 who are not enrolled in a Medicaid HMO pay a copayment of $1.00.

DHFS establishes maximum allowable fees for certified EPSDT providers.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

Covered family planning services include:

·         Physical examination;

·         Laboratory and other diagnostic services;

·         Counseling services related to family planning;

·         Contraceptive procedures such as furnishing and fitting an IUD;

·         Office visits; and

·         Contraceptive supplies such as birth control pills and condoms.

The following services are not covered:

·         Sterilization of individuals under age 21;

·         Services and items relating to enhancement of fertility; and

·         Reversal of sterilization.

DHFS establishes maximum allowable fees for certified family planning providers.  DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

Medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services are covered in a clinic setting.

DHFS establishes maximum allowable fees for certified clinics.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

Wisconsin Medicaid covers most legend drugs and a limited number of over-the-counter (OTC) drugs.

A legend drug is any drug that requires a prescription under federal code 21 USC 353(b). Legend drugs are covered by Wisconsin Medicaid when:

• The drug is approved by the Food and Drug Administration (FDA) and is not on the Negative Formulary List.
• The manufacturer has signed the federal rebate agreement for the drug.
• The manufacturer has reported the drug information to First DataBank.

Some drugs covered by Wisconsin Medicaid may require prior authorization (PA), and others require an appropriate diagnosis code for reimbursement.

Some covered legend drugs are reimbursed at either the drug’s Average Wholesale Price (AWP) minus 11.25% (reflects the current rate, but may change when Governor Doyle signs the biennial budget) plus a dispensing fee, or the provider’s usual and customary charge, whichever is less.

Other legend drugs are reimbursed at either the drug’s price on the Medicaid Maximum Allowed Cost (MAC) List plus a dispensing fee or the provider’s usual and customary charge, whichever is less.

TCM is available to the following populations:

·         Persons age 65 or over;

·         Persons with a diagnosis of Alzheimer’s disease or related dementia;

·         Persons with a developmental disability

·         Persons who are age 21 or older with a chronic mental illness;

·         Persons with a physical or sensory disability;

·         Persons having an alcohol or drug dependency;

·         Persons diagnosed as having HIV infection;

·         Persons who are severely emotionally disturbed and under age 21;

·         Persons diagnosed with asthma and under age 21

·         Persons infected with tuberculosis

·         Women 45 to 64 years old

·         Children enrolled in a Birth to 3 Program; and

·         Families with a child(ren) under age 21 who is at risk of a physical, mental or emotional dysfunction.

These services may only be provided by certified case management agencies.

Wisconsin Medicaid covers case management services on a FFS basis for recipients enrolled in Medicaid-contracted HMOs.

The following special managed care program include case management as a covered service; therefore, case management may not be billed separately to Wisconsin Medicaid for individuals enrolled in these programs:

·         Children Come First (CCF);

·         Community Care for the Elderly;

·         Community Health Partnership;

·         Community Living Alliance;

·         Elder Care Options; and

·         Wraparound Milwaukee(WAM).

DHFS establishes contracted hourly rates for all covered services provided by certified case management agencies.  The contracted hourly rates are based on various factors, including a review of budgetary constraints and other relevant economic limitations.

Providers are required to bill their usual and customary charge.  For providers using a sliding fee scale, the usual and customary charge is the median of the provider’s charge for the service when provided to non-Medicaid patients.

For each covered service, DHFS pays the federal Medicaid share of the contracted hourly rate.  Medicaid reimbursement, less appropriate copayments and payments by other insurers will be considered payment in full.

Providers are reimbursed by Medicaid only for that portion of allowable costs for which federal financial participation (FFP) is available.  The State share shall come from non-federal funds available to case management agencies.

Transportation by ambulance, specialized medical vehicle (SMV) or county-approved or tribe-approved common carrier is covered.

Many transportation services require prior authorization.

DHFS establishes maximum allowable fees for certified transportation providers.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.

Covered services provided by a certified nurse midwife may include the care of mothers and their babies throughout the maternity cycle, including pregnancy, labor, normal childbirth, and the immediate post-partum period and other services within the nurse midwife’s scope of practice.

Covered Nurse Practitioner services are medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a medical setting, or the recipient’s home or elsewhere provided with the Nurse Practitioner’s scope of practice.

Coverage for nurse-midwife services for management and care of the mother and newborn child shall end after the sixth week of postpartum care.

Services provided by a Nurse Practitioner must be delegated by a physician through a written protocol developed with the NP, or a collaborative practice agreement as required for advanced practice nurse prescribers.  These written or oral orders must include arrangements for communication of the physician’s directions, consultation with the physician, assistance with medical emergencies, patient referrals and other provisions relating to medical procedures and treatment.

DHFS establishes maximum allowable fees for certified nurse midwives and nurse practitioners.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.  Nurse Practitioners receive the same reimbursement as physicians for covered services.  Nurse midwives receive 90% of the physician’s maximum fee.

The following services are covered under the “Prenatal Care Coordination” program:

·         Nutritional counseling;

·         Health education;

·         Outreach;

·         Risk assessment; and

·         Care planning.

Services must be provided by an agency certified by DHFS or by a qualified person under contract with an agency certified by DHFS.

Prenatal care coordination services are available to recipients from the beginning of pregnancy up to the 61^st day after delivery, and who are at high risk for adverse pregnancy outcomes.

Reimbursement for prenatal care coordination services is limited to a maximum amount per pregnancy.

Ambulatory prenatal services are covered, and include treatment of conditions or complications that are caused by, exist or are exacerbated by a pregnant woman’s pregnant condition.

An ambulatory prenatal service may be subject to a prior authorization requirement, when appropriate.

Ambulatory prenatal services are reimbursed only if the recipient has been determined to have presumptive Medicaid eligibility by a qualified provider.

DHFS establishes maximum allowable fees for certified prenatal care providers.

DHFS pays the lesser of a provider’s usual and customary charges or a maximum rate established by DHFS.  The maximum allowable fee is based on various factors, including a review of usual and customary charges submitted to the Wisconsin Medicaid program, the Wisconsin State Legislature’s Medicaid budgetary constraints, and other relevant economic limitations.