Covered and Noncovered Services : Nonmedically Necessary Noncovered Services

Nonmedically Necessary Noncovered Services

Personal Needs Allowance

The member may be financially responsible for certain noncovered items and nonmedically necessary services. A portion of a resident's funds, as prescribed in 42 C.F.R. § 483.10, is available for a living allowance or personal needs allowance. The member may choose to apply this allowance to obtain certain noncovered services and items, such as personal comfort items, that are not included in the nursing home's daily rate.

A member's personal funds cannot be used without the prior written consent of the member. The personal needs allowance is set by Wis. Stat. § 49.45(7)(a) and is currently $45.00 per month.

Private Rooms

Private rooms are not a covered service in a nursing home's daily rate, except for medically necessary isolation precautions. However, if a member, or a member's legal representative, chooses to have a private room with the full knowledge and acceptance of the financial liability, the member may reimburse the nursing home for a private room when all of the following conditions are met:

• The member or legal representative is informed of the personal financial liability for having a private room.
• Pursuant to Wis. Admin. Code § DHS 132.31(1)(d), the member or a legal representative documents the private room choice in writing.
• The member or a legal representative is personally liable for no more than the difference between the nursing home's private-pay rate for a semi-private room and the private-pay, private room rate.
• If at any time this differential rate changes, the member or a legal representative must be notified by the nursing home administrator within 15 days and a new consent agreement must be reached.

When isolation precautions are medically necessary and a private room is prior authorized, the provider may receive additional reimbursement from Wisconsin Medicaid for the private room. The member or legal representative may not, in this case, be held responsible for the additional cost of a private room since it is a covered service.

Note: In instances where the facility does not have any semi-private rooms, additional reimbursement will not be paid.