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Welcome  » March 29, 2024 4:40 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Personal Care
03/29/2024  

Covered and Noncovered Services : Covered Services and Requirements

Topic #2478

Accompanying the Member to Medical Appointments

Wisconsin Medicaid and BadgerCare Plus cover personal care services in which the PCW accompanies the member to obtain a medical diagnosis and treatment at a facility where the member receives covered services. The purpose of covering a PCW to accompany the member to medical appointments is not to transport (drive) the member to medical appointments, but to assist the member with ADL and delegated nursing tasks (e.g., assistance with toileting, dressing/undressing, transferring, and if delegated, tasks such as medication administration).

The physician's orders for personal care services should clearly support the medical necessity for accompanying the member to appointments for medical diagnosis and treatment. If the member needs assistance from a PCW with prior authorized ADL and/or delegated nursing tasks to be provided in the home, then those personal care services also might be covered outside the home when the member is obtaining medical diagnosis and treatment.

Also, personal care covered services do not include providing surrogates for the guardian or legal representative. If the member is unable to speak for themselves or to understand information conveyed during the medical appointment, the member's guardian or legal representative should communicate directly with the medical professional diagnosing or treating the member. Regardless of the relationship between the PCW and the member, personal care services do not include the PCW accompanying the member to communicate with the physician. As appropriate, the PCW's nurse supervisor should speak directly with the member's physician to determine if the physician's orders have been changed and the POC needs to be modified.

Topic #2477

Assistance with Activities of Daily Living

Assistance with ADLs include the following tasks:

  • Assistance with getting in and out of bed
  • Toileting, including use and care of bedpan, urinal, commode, or toilet
  • Assistance with bathing
  • Assistance with feeding
  • Teeth, mouth, denture, and hair care
  • Assistance with dressing and undressing
  • Care of eyeglasses and hearing aids
  • Assistance with mobility and ambulation, including use of walker, cane, or crutches
  • Simple transfers, including bed-to-chair or wheelchair and reverse
  • Skin care, excluding wound care

Supervision, cueing, or prompting of a member, when that is the only service provided, is not separately reimbursable.

Topic #2475

Assistance with Medically Oriented Tasks

Medically oriented tasks generally are those tasks supportive of nursing care that require special medical knowledge or skill. These tasks are covered personal care services and must meet the following conditions according to Wis. Admin. Code § DHS 107.112(2)(b):

  • The tasks are safely delegated to the PCW by an RN.
  • The PCW is trained and supervised by the provider to provide the tasks.
  • The member, parent, or responsible person is permitted to participate in the training and supervision of the PCW.
Topic #2476

Assistance with Services Incidental to Activities of Daily Living

No more than one-third of the total weekly time spent by a PCW may be in performing services incidental to ADL for the member according to Wis. Admin. Code § DHS 107.112(3)(e). More information regarding limits to services incidental to ADL is available. To be reimbursed by Wisconsin Medicaid, the services must be incidental to medically oriented covered tasks or ADL. The following are covered personal care services:

  • Changing the member's bed and laundering the bed linens and the member's personal clothing.
  • Light cleaning in essential areas of the home used during personal care service activities including cleaning medical equipment.
  • Meal preparation, food purchasing, meal serving, and cleaning member's dishes. Wisconsin Medicaid reimburses for the time it takes a PCW to go to and from the member's home for groceries and supplies. The time spent for this is considered a personal care service, not travel time, for PA and billing purposes.

These services may not be provided for the benefit of any other member of the household, even if some of the time authorized for services incidental to ADLs and to MOTs remains.

Topic #2474

Care in Group Settings

Members may reside in alternate group living settings, such as CBRFs, RCACs, and AFHs. Any personal care service provided in a CBRF with more than 20 beds is not covered under the personal care benefit.

Alternate living facilities often provide some personal care as part of their contract with the member's county. This care often includes housekeeping, meal preparation, grocery shopping, and laundry.

Medically necessary personal care over and above that provided by the alternate living facility may be covered. Personal care providers are responsible for coordinating services to avoid duplication of those services the facility is required to provide under its licensure and contract with the county. Duplicative care will be monitored through audits.

Care provided in group settings is required to meet all requirements, including RN supervision.

Topic #2473

Care to Multiple Members at a Single Location

When personal care services are provided to more than one member at a single location, providers are required to consolidate care for tasks such as cleaning, laundry, travel time, and meal preparation.

Topic #44

Definition of Covered Services

A covered service is a service, item, or supply for which reimbursement is available when all program requirements are met. Wis. Admin. Code § DHS 101.03(35) and ch. DHS 107 contain more information about covered services.
Topic #2472

Personal Care Services

As specified in Wis. Admin. Code § DHS 107.112, covered personal care services are medically-oriented activities related to assisting a member with ADL necessary to maintain the member in their place of residence in the community.

Personal care services are covered when provided by a Medicaid-enrolled personal care provider to a member enrolled in BadgerCare Plus or Medicaid according to policies and procedures.

Covered services are required to have written orders of a physician and a written POC. All covered personal care services provided must be supervised by a RN supervisor. The services must be medically necessary and be provided by individuals who are trained in a manner that is in compliance with licensing and certification requirements.

Providers are reminded that all nursing acts delegated to a PCW by a RN must be documented in the physician orders. If the PCW is to provide MOTs, then orders for nursing acts delegated to the PCW need to clearly spell out the delegated nursing acts to be provided.

Written orders examples:

Example 1

PCW: Up to 4 hrs/day, 7 days/week for assistance with bathing, dressing and undressing, grooming, toileting, incontinence cares PRN, applying orthotics daily, suprapubic catheter cares BID, assist with changing suprapubic catheter every two weeks and PRN, and services incidental to ADL and MOTs (including laundry, grocery shopping, and meal preparation).

Example 2

PCW: 2 hrs/day, 6 days/week for assistance with bathing, grooming, dressing, and glucometer checks daily (call RN supervisor if blood glucose <70 or >200).

Topic #2471

Delegation of Medically Oriented Tasks

Medically oriented tasks are covered personal care services when delegated by an RN under Wis. Admin. Code § DHS 107.112(2)(b) and ch. N 6.

Criteria for Delegation of Medically Oriented Tasks

According to Wis. Admin. Code § DHS 107.112(2)(b), a PCW of a Medicaid-enrolled personal care agency may perform a medically oriented task under the delegation of an RN according to Wis. Admin. Code ch. N 6 and the guidelines of the Board of Nursing. When delegating medically oriented tasks, the following conditions should be met:

  1. The agency has policies and procedures designed to provide for safe and accurate performance of the delegated tasks. These policies shall be followed by personnel assigned to perform these tasks.
  2. The RN provides written delegation of the nursing act.
  3. Documentation supports the educational preparation of the caregiver who performs delegated tasks.
  4. For medication administration, documentation should also include the name of the medication, the dose, the route of administration, the time of administration, and identification of the person administering the medication.
  5. Teaching and supervisory oversight is provided by the RN.
  6. Members are informed, prior to the delivery of service, that unlicensed personnel will administer their medications and other treatments/procedures.
  7. The supervision and direction of the delegated nursing act meets the requirements of Wis. Admin. Code ch. N 6.
  8. The member, parent, or responsible person is permitted to participate in the training and supervision of the PCW.

To assure that services are competently and safely provided, and the needs of the member are being met, an RN must provide the following supervision and direction of the delegated nursing acts:

  • Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised
  • Provide direction and assistance to those supervised
  • Observe and monitor the activities of those supervised
  • Evaluate the effectiveness of acts performed under supervision

The supervising RN must document that the above requirements are met when medically oriented tasks are delegated to PCWs. Documentation must include that the PCW has been appropriately trained to provide the medically oriented task safely for the specific member and competency has been evaluated.

Responsibility for Delegation

Though agencies may suggest which nursing acts should be delegated, it is the supervising RN who makes the decision on whether and under what circumstances the delegation occurs. When an RN delegates another person to perform a task, the RN assumes responsibility and liability under their license for the proper performance of that task. The RN should only delegate tasks that can be performed appropriately or safely by the PCW.

The PCW is not required to accept a delegated act. However, the PCW should immediately inform the RN supervisor if he or she refuses to accept the delegation.

Questions Regarding Delegation

The Wisconsin DSPS standards in Wis. Admin. Code ch. N 6 define a nurse's responsibility when delegating nursing acts. Further questions regarding the interpretation of this code and the delegation of nursing acts, should be directed to:

Department of Safety and Professional Services
Board of Nursing
PO Box 8935
Madison WI 53708-8935
608-266-0145
Topic #2154

Disposable Medical Supplies Included in the Home Care Reimbursement Rate

DMS are medically necessary items that have a limited life expectancy and are consumable, expendable, disposable, or nondurable.

The cost of routine DMS used by home health providers, personal care providers, and NIP while caring for the member, including routine DMS mandated by OSHA, is covered in the reimbursement rate for the service provided. Home health providers, personal care providers, and NIP are expected to provide these supplies only during the billable hours in which they provide covered services. Providers are not expected to provide members with supplies for use when they are not directly providing covered services.

Note: None of the DMS covered in the reimbursement rate are separately reimbursable.

When DMS is included in the reimbursement rate, providers may not do any of the following:

  • Charge the member for the cost of DMS.
  • Use supplies obtained by the member and paid for by Wisconsin Medicaid.
  • Submit claims to ForwardHealth for the cost of the supplies.

DMS included in the home care reimbursement rate include, but are not limited to, those listed in the following table.

Procedure Code Modifier Description
A4244 Alcohol or peroxide, per pint
A4402 Lubricant per ounce
A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per ounce
A4456 Adhesive remover, wipes, any type, each
A4927 Gloves, non-sterile, per 100
Topic #2498

Duties of Registered Nurse Supervisor

The RN supervisor performs several roles. As the title suggests, the RN supervisor performs duties related to supervising the member's PCW. The RN supervisor's duties also include activities related to the medically necessary personal care services provided to the member.

Duties for Personnel and Service Delivery

The supervisory role applies to the PCW and to the delivery of personal care services. Supervision, according to Wis. Admin. Code § DHS 101.03(173), is defined as intermittent face-to-face contact between the supervisor and assistant and a regular review of the assistant's work by the supervisor.

According to Wis. Admin. Code § DHS 107.112, RN supervisory duties include the following:

  • Assign PCW to specific members giving full consideration to the member's preference for choice of PCW
  • Assign specific tasks to the PCW giving full consideration to the member's preference for service arrangements
  • Assure the PCW is trained for the specific tasks the PCW is assigned to provide to the member
  • Set standards for the assigned personal care activities
  • Review the PCW's daily written record
  • Supervise the PCW according to a written POC and, at least every 60 days, provide a supervisory review of the PCW providing personal care service(s) in the member's home
  • Comply with additional requirements for prior authorized services that are specifically listed in Wis. Admin. Code § DHS 107.11(2)(b).

Duties for Physician Orders and Plans of Care

Personal care services are covered only if they are ordered by the member's physician, included in the POC, and meet all other program requirements. Home health agencies providing personal care services are required also to meet the POC requirements under Wis. Admin. Code § DHS 133.20.

According to Wis. Admin. Code § DHS 107.02(2m)(b), the physician orders must be in writing and signed and dated. Wis. Admin. Code § DHS 105.17(2)(b) requires the RN supervisor to obtain the orders for personal care and to renew the orders once every three months unless the physician specifies orders covering a period of time up to a year or when the member's needs change, whichever occurs first.

As part of the POC review, the RN supervisor is required to visit the member's home. Also, according to Wis. Admin. Code § DHS 107.112, the following are RN supervisor duties applicable to the member and the POC for the member:

  • Assess the member's environment (social and physical), functional level, and pertinent cultural factors
  • Review and interpret the physician's orders
  • Develop a written POC for the purposes of providing necessary and appropriate services
  • At least every 60 days, review the POC, evaluate the member's condition, and discuss with the physician any necessary changes in the POC
Topic #85

Emergencies

Certain program requirements and reimbursement procedures are modified in emergency situations. Emergency services are defined in Wis. Admin. Code § DHS 101.03(52), as "those services that are necessary to prevent the death or serious impairment of the health of the individual." Emergency services are not reimbursed unless they are covered services.

Additional definitions and procedures for emergencies exist in other situations, such as dental and mental health.

Program requirements and reimbursement procedures may be modified in the following ways:

  • PA or other program requirements may be waived in emergency situations.
  • Non-U.S. citizens may be eligible for covered services in emergency situations.
Topic #2468

Informal Support Systems

BadgerCare Plus and Medicaid supplement the personal care services provided by informal support systems, including other members of a member's household. Wisconsin Medicaid will not reimburse services furnished by the provider when family and other household members provide the medically necessary services without reimbursement. However, this informal participation is not a condition of coverage.

In assessing the member's needs for supplemental personal care, the provider is required to:

  • Ask members of the household about the extent to which they are willing and able to provide medically necessary covered services for the member and document the answers in the member's medical record.
  • List the care family members can provide.
  • Document if no member of the household can provide care. A COP assessment or narrative reflecting possible informal support systems meets this requirement.
  • Indicate all care, formal and informal, when applying for PA.
Topic #22917

Interpretive Services

ForwardHealth reimburses interpretive services provided to BadgerCare Plus and Medicaid members who are deaf or hard of hearing or who have LEP. A member with LEP is someone who does not speak English as their primary language and who has a limited ability to read, speak, write, or understand English.

Interpretive services are defined as the provision of spoken or signed language communication by an interpreter to convey a message from the language of the original speaker into the language of the listener in real time (synchronous) with the member present. This task requires the language interpreter to reflect both the tone and the meaning of the message.

Only services provided by interpreters of the spoken word or sign language will be covered with the HCPCS procedure code T1013 (Sign language or oral interpretive services, per 15 minutes). Translation services for written language are not reimbursable with T1013, including services provided by professionals trained to interpret written text.

Covered Interpretive Services

ForwardHealth covers interpretive services for deaf or hard of hearing members or members with LEP when the interpretive service and the medical service are provided to the member on the same DOS and during the same time as the medical service. A Medicaid-enrolled provider must submit for interpretive services on the same claim as the medical service, and the DOS they are provided to the member must match. Interpretive services cannot be billed by HMOs and MCOs. Providers should follow CPT and HCPCS coding guidance to appropriately document and report procedure codes related to interpretive and medical services on the applicable claim form. Time billed for interpretive services should reflect time spent providing interpretation to the member. At least three people must be present for the services to be covered: the provider, the member, and the interpreter.

Interpreters may provide services either in-person or via telehealth. Services provided via telehealth must be functionally equivalent to an in-person visit, meaning that the transmission of information must be of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

Billing time for documentation of interpretive services will be considered part of the service performed. BadgerCare Plus and Wisconsin Medicaid have adopted the federal "Documentation Guidelines for Evaluation and Management Services" (CMS 2021 and 2023) in combination with BadgerCare Plus and Medicaid policy for E&M Services.

Most Medicaid-enrolled providers, including border-status or out-of-state providers, are able to submit claims for interpretive services.

Standard ForwardHealth policy applies to the reimbursement for interpretive services for out-of-state providers, including PA requirements.

Interpretive Services Provided Via Telehealth for Out-of-State Providers

ForwardHealth requirements for services provided via telehealth by out-of-state providers are the same as the ForwardHealth policy for services provided in-person by out-of-state providers. Requirements for out-of-state providers for interpretive services are the same whether the service is provided via telehealth or in-person. Out-of-state providers who are not enrolled as either border-status or telehealth-only border-status providers are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members. The PA would indicate that interpretive services are needed.

Documentation

While not required for submitting a claim for interpretive services, providers must include the following information in the member's file:

  • The interpreter's name and/or company
  • The date and time of interpretation
  • The duration of the interpretive service (time in and time out or total duration)
  • The amount submitted by the medical provider for interpretive services reimbursement
  • The type of interpretive service provided (foreign language or sign language)
  • The type of covered service(s) the provider is billing for

Third-Party Vendors and In-House Interpreters

Providers may be reimbursed for the use of third-party vendors or in-house interpreters supplying interpretive services.

Providers are reminded that HIPAA confidentiality requirements apply to interpretive services. When a covered entity or provider utilizes interpretive services that involve PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate measures for their situation.

Limitations

There are no limitations for how often members may utilize interpretive services when the interpretive service is tied to another billable medical service for the member for the same DOS.

Claims Submission

To receive reimbursement, providers may bill for interpretive services on one of the following claim forms:

  • 1500 Health Insurance Claim Form (for dental, professional, and professional crossover claims)
  • Institutional UB-04 (CMS 1450) claim form (for outpatient crossover claims and home health/personal care claims)

Noncovered Services

The following will not be eligible for reimbursement with procedure code T1013:

  • Interpretive services provided in conjunction with a noncovered, non-reimbursable, or excluded service
  • Interpretive services provided by the member's family member, such as a parent, spouse, sibling, or child
  • The interpreter's waiting time and transportation costs, including travel time and mileage reimbursement, for interpreters to get to or from appointments
  • The technology and equipment needed to conduct interpretive services
  • Interpretive services provided directly by the HMOs and MCOs are not billable to ForwardHealth for reimbursement via procedure code T1013

Cancellations or No Shows

Providers cannot submit a claim for interpretive services if an appointment is cancelled, the member or the interpreter is a no-show (is not present), or the interpreter is unable to perform the interpretation needed to complete the appointment successfully.

Procedure Code and Modifiers

Providers must submit claims for interpretive services and the medical service provided to the member on separate details on the same claim.

Procedure code T1013 is a time-based code, with 15-minute increments. Rounding up to the 15-minute mark is allowable if at least eight minutes of interpretation were provided.

Providers should use the following rounding guidelines for procedure code T1013.

Time (Minutes) Number of Interpretation Units Billed
8–22 minutes 1.0 unit
23–37 minutes 2.0 units
38–52 minutes 3.0 units
53–67 minutes 4.0 units
68–82 minutes 5.0 units
83–97 minutes 6.0 units

Claims for interpretive services must include HCPCS procedure code T1013 and the appropriate modifier(s):

  • U1 (Spoken language)
  • U3 (Sign Language)
  • GT (Via interactive audio and video telecommunication systems)
  • 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system)

Providers should refer to the interactive maximum allowable fee schedules for the reimbursement rate, covered provider types and specialties, modifiers, and the allowable POS codes for procedure code T1013.

Delivery Method of Interpretive Services Definition for Sign Language and Foreign Language Interpreters Modifiers
In person
(foreign language and sign language)
When the interpreter is physically present with the member and provider U1 or U3
Telehealth*
(foreign language and sign language)
When the member is located at an originating site and the interpreter is available remotely (via audio-visual or audio only) at a distant site U1 or U3

and

GT or 93
 
Phone
(foreign language only)
When the interpreter is not physically present with the member and the provider and interprets via audio-only through the phone
U1 and 93
 
Interactive video
(foreign language and sign language)
When the interpreter is not physically present with the member and the provider and interprets on interactive video
U1 or U3

and

GT

*Any telehealth service must be provided using HIPAA-compliant software or delivered via an app or service that includes all the necessary privacy and security safeguards to meet the requirements of HIPAA.

Dental Providers

Dental providers submitting claims for interpretive services are not required to include a modifier with procedure code T1013. Dental providers should retain documentation of the interpretive service in the member's records.

Allowable Places of Service

Claims for interpretive services must include a valid POS code where the interpretive services are being provided.

Federally Qualified Health Centers

Non-tribal FQHCs, also known as CHCs, (POS code 50), will not receive direct reimbursement for interpretive services as these are indirect services assumed to be already included in the FQHC's bundled PPS rate. However, CHCs can still bill the T1013 code as an indirect procedure code when providing interpretive services. This billing process is similar to that of other indirect services provided by non-tribal FQHCs. This will enable DHS to better track how FQHCs provide these services and process any future change in scope adjustment to increase their PPS rate that includes providing interpretive services.

Rural Health Clinics

RHCs (POS code 72) receives direct reimbursement for interpretive services. Procedure code T1013 should be billed when providing interpretive services.

Interpreter Qualifications

The two types of allowable interpreters include:

  • Sign language interpreters—Professionals who facilitate the communication between a hearing individual and a person who is deaf or hard of hearing and uses sign language to communicate.
  • Foreign language interpreters—Professionals who are fluent in both English and another language and listen to a communication in one language and convert it to another language while retaining the same meaning.

Qualifications for Sign Language Interpreters

For Medicaid-enrolled providers to receive reimbursement, sign language interpreters must be licensed in Wisconsin under Wis. Stat. § 440.032 and must follow the specific requirements regarding education, training, and locations where they are able to interpret. The billing provider is responsible for determining the sign language interpreter's licensure and must retain all documentation supporting it.

Qualifications for Foreign Language Interpreters

There is not a licensing process in Wisconsin for foreign language interpreters. However, Wisconsin Medicaid strongly recommends that providers work through professional agencies that can verify the qualifications and skills of their foreign language interpreters.

A competent foreign language interpreter should:

  • Be at least 18 years of age.
  • Be able to interpret effectively, accurately, and impartially, both receptively and expressively, using necessary specialized vocabulary.
  • Demonstrate proficiency in English and another language and have knowledge of the relevant specialized terms and concepts in both languages.
  • Be guided by the standards developed by the National Council on Interpreting Health Care.
  • Demonstrate cultural responsiveness regarding the LEP language group being served including values, beliefs, practices, languages, and terminology.
Topic #84

Medical Necessity

Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.

Topic #86

Member Payment for Covered Services

Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.

If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.

Topic #2467

Personal Care Services

According to Wis. Admin. Code § DHS 107.112(1)(b), Wisconsin Medicaid will reimburse a personal care provider for the following medically necessary services:

  • Assistance with ADL
  • Assistance with housekeeping activities
  • Accompanying the member to medical appointments
  • Assistance with medically oriented tasks
  • Travel time

Personal care services must be performed under the supervision of an RN by a PCW who meets Wisconsin Medicaid qualifications and who is employed by or under contract with a Medicaid-enrolled provider. Licensed home health agencies should also refer to the Home Health service area for further information.

Topic #2466

Place of Service

Although the member does not need to be confined to the home to receive personal care services, the services must be provided in the home (which is the place where the member lives and sleeps). Authorization for services in a member's temporary residence is handled on a case-by-case basis through PA. The only exceptions to services provided in the home allow the PCW reasonable time to:

  • Accompany the member to medical appointments for diagnosis and treatment.
  • Leave the home to purchase groceries and medical supplies or prescriptions for a member who is unable to perform these activities. The member does not accompany the PCW on these trips.
Topic #66

Program Requirements

For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including—but not limited to—medical necessity, PA, claims submission, prescription, and documentation requirements.

Topic #824

Services That Do Not Meet Program Requirements

As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.

Examples of covered services that do not meet program requirements include the following:

  • Services for which records or other documentation were not prepared or maintained
  • Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
  • Services that fail to comply with requirements or state and federal statutes, rules, and regulations
  • Services that the Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
  • Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
  • Services provided by a provider who fails or refuses to provide access to records
  • Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS
Topic #4819

Transportation to Medical Appointments When Accompanied by a Personal Care Worker

Coverage for most personal care services is limited to services provided in the member's home. Accompanying a member to obtain medical diagnosis and treatment allows for coverage of medically necessary personal care services outside the home when the member is seeking BadgerCare Plus-covered diagnosis and treatment services. If a member needs transportation services, providers can refer to the ForwardHealth Portal for more information about covered transportation services.

If an attendant is needed to accompany a member for medical diagnosis and treatment that is other than routine (such as during transportation to receive a service that is available only in another county or state) per Wis. Admin. Code § DHS 107.23(1)(d)4., the provider should seek authorization for coverage of the attendant under BadgerCare Plus transportation services, not under BadgerCare Plus personal care services.

Topic #2461

Two Caregivers Providing Care for a Member at the Same Time

When it is medically necessary, Wisconsin Medicaid may reimburse a PCW to assist an RN, LPN, home health aide, or another PCW to provide care simultaneously to a member when a primary caregiver is not available. If two providers are caring for a member simultaneously, one provider must be a PCW.

The situations in which a PCW may assist are:

  • Periodic changing of the entire tracheotomy tube.
  • Periodic transfer or repositioning of a member when a two-person transfer is required because all other transfer devices have failed.

The RN supervisor is required to document on the POC the reason that two caregivers are required.

 
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