Section DHS 109.03 - Definitions Unless otherwise defined in this chapter, the definitions in s. DHS 101.03 apply to this chapter. In addition, in this chapter:
(1) "Deductible benefits and services" means both of the following:(a) The prescription drugs which may be purchased by a SeniorCare participant with income over 160% of the poverty line for amounts no greater than the program payment rate.(b) The department's tracking of prescription drug purchases by a SeniorCare participant with income over 160% of the poverty line so SeniorCare providers know when the participant may receive the SeniorCare prescription benefit.(2) "Department" means the department of health services, or its agent.(3) "Fiscal test group" means the person or persons in a household whose income and need is included in determining which SeniorCare benefits or services an applicant may receive.(4) "Generic name" has the meaning given in s. 450.12(1) (b), Stats.(5) "Innovator multiple-source drug" means a multiple source drug that was originally marketed under an original new drug application approved by the U.S. food and drug administration.(6) "Lock-in provider" means a single, SeniorCare-certified provider, selected by the participant or designated by the department in the event the participant is unwilling or unable to identify a provider, who is responsible for either personally providing all non-emergency care received by the participant under the MA program, or referring the participant to a specific provider for such needed non-emergency care.(7) "Participant" means a person who has applied for SeniorCare and meets the eligibility criteria under s. DHS 109.11 (1) and may receive benefits and services during the benefit period under s. DHS 109.14.(8) "Pharmacist" has the meaning given in s. 450.01(15), Stats.(9) "Prescription benefit" means the prescription drugs that may be purchased with a $5 or $15 payment by a SeniorCare participant with low income or who has spent at least the dollar amount specified in s. DHS 109.13 (3) on the purchase of prescription drugs during the current benefit period.(10) "Prescription drug" or "drug" means any of the following:(a) A drug under s. 450.01(20), Stats., that is included in the drugs specified under s. 49.46(2) (b) 6 h., Stats., and s. DHS 109.31 and is manufactured by a drug manufacturer that enters into a rebate agreement in force under s. DHS 109.71.(b) A vaccine recommended and approved for administration to adults by the federal centers for disease control and prevention's advisory committee on immunization practices.(11) "Prescription order" has the meaning given in s. 450.01(21), Stats.(12) "Program payment rate" means the rate of payment made for the identical drug specified under s. 49.46(2) (b) 6 h., Stats., plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46(2) (b) 6 h., Stats.(13) "Retail price" means the provider's charge for providing the same service to private paying customers.(14) "SeniorCare" means the program of prescription drug assistance for eligible elderly persons under s. 49.688, Stats.(15) "SeniorCare provider" means an MA certified pharmacist, pharmacy or dispensing physician.(16) "Spend-down" means the amount of money a SeniorCare participant must spend on prescription drugs before the participant becomes eligible for SeniorCare deductible and copayment benefits and services.(17) "Spend-down services" means the department's monitoring of participant prescription drug purchases to determine when the participant's SeniorCare fiscal test group's purchases have equaled the difference between the fiscal test group's annual income and 240% of the poverty line for a family the size of the fiscal test group.(18) "U.S. national" means any of the following: (a) A person born in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), America Samoa, Swain's Island or the Northern Mariana Islands.(b) A person born outside of the United States to at least one U.S. citizen parent.(c) A naturalized U.S. citizen.Wis. Admin. Code Department of Health Services DHS 109.03
CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (9) Register October 2004 No. 586, eff. 11-1-04; corrections in (intro.) and (2) made under s. 13.92(4) (b) 6 and 7., Stats., Register December 2008 No. 636.Amended by, CR 20-039: am. (12) Register October 2021 No. 790, eff. 11/1/2021Amended by, CR 22-046: renum. (10) to (10) (intro.) and am., cr. (10) (a), (b) Register June 2023 No. 810, eff. 7/1/2023