Section DHS 109.13 - SeniorCare benefits and services(1) CONDITIONS FOR RECEIVING SENIORCARE BENEFITS AND SERVICES. A person who meets the eligibility requirements under s. DHS 109.11 (1) may receive SeniorCare benefits or services, subject to the conditions under this section. Except during a period of program suspension under s. 49.688(7) (b), Stats., SeniorCare benefits and services shall be available only for prescription drugs prescribed for the eligible person and dispensed with a date of service during the eligible person's benefit period.(2) PRESCRIPTION BENEFIT. (a)Income category applicability. A person may receive the prescription benefit in par. (b) under any of the following conditions: 1. The person is a member of a fiscal test group with an annual income less than or equal to 160% of the poverty line for a family the size of the fiscal test group.2. The person is a member of a fiscal test group with an annual income greater than 160% but not in excess of 240% of the poverty line for a family the size of the fiscal test group and has met the deductible as described in sub. (3) (d) during the current benefit period.3. The person is a member of a fiscal test group with an annual income greater than 240% of the poverty line for a family the size of the fiscal test group and has met both of the following thresholds during the current benefit period, in the following order: a. The spend-down as described in sub. (4) (c).b. The deductible as described in sub. (3) (d).(b)Copayment. Except as provided under sub. (3) (e), a person receiving the SeniorCare prescription benefit may purchase prescription drugs from participating SeniorCare providers for one of the following copayment amounts: 1. A copayment of $5 for each prescription drug that bears only a generic name.2. A copayment of $15 for each prescription drug that does not bear only a generic name.(bm)Exclusion of copayment. A copayment is not required for a vaccine or vaccine administration.(c)Exclusion for drugs. If a drug is covered by a third party and the participant makes a copayment to the SeniorCare provider, the department is not responsible for refunding the copayment amount to the participant.(d)Exclusion for vaccines and vaccine administration. The department will not cover reimbursement of a vaccine or vaccine administration in any of the following circumstances: 1. A vaccine is not on the federal centers for disease control and prevention's advisory committee on immunization practices list of vaccines recommended for immunization to adults.2. A vaccine is not administered by a SeniorCare provider in an allowed place of service.(e)Exclusion for vaccines. The department will not cover reimbursement of a vaccination when the vaccine is allocated through the federal government at no cost to the provider.(3) DEDUCTIBLE BENEFIT AND SERVICES. (a)Income category applicability. A person may receive the SeniorCare benefit and services under par. (b) under any of the following conditions: 1. The person is a member of a fiscal test group with an annual income greater than 160%, but not in excess of 240% of the poverty line for a family the size of the fiscal test group.2. The person is a member of a fiscal test group with an annual income greater than 240% of the federal poverty line for a family the size of the fiscal test group, but only for the remainder of the benefit period after he or she has met the spend-down as described in sub. (4) (c).(b)Benefit and services. 1. Except as provided under sub. (4) (d), a person receiving the SeniorCare deductible benefit and services may purchase prescription drugs from participating SeniorCare providers at the program payment rate.2. The department shall maintain a record of the prescription drug purchases of each person receiving the SeniorCare deductible services and shall inform participating SeniorCare providers when the person receiving the SeniorCare deductible benefits and services has met the deductible within the benefit period as described in par. (d).(c)Amount. The amount of the SeniorCare deductible is based on a fiscal test group's income as a percentage of the federal poverty line for a family the size of the fiscal test group, as follows: 1. If the fiscal test group's income is more than 160% of the federal poverty line, but not more than 200%, the deductible is $500.2. If the fiscal test group's income is more than 200% of the federal poverty line, the deductible is $850.(d)Meeting the deductible. The deductible is considered met and the person shall receive the prescription benefit under sub. (2) (b) when, under the following conditions, the person has spent the dollar amount specified in par. (c) in purchasing prescription drugs: 1. Only purchases of prescription drugs prescribed for the eligible individual count toward meeting the deductible.2. Each spouse has a deductible. When both persons in a 2-person fiscal test group are eligible for SeniorCare, each person's purchases of prescription drugs shall only be counted toward meeting the deductible of the person for whom the drugs are prescribed.3. Only prescription drugs dispensed with a date of service during the current benefit period described in s. DHS 109.14 may count toward meeting the deductible.4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person's other available coverage may count toward meeting the deductible.5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied toward meeting the deductible.6. Only claims submitted by a SeniorCare provider shall be considered in determining whether or not the participant has met the deductible.(e)Carryover of deductible. When the cost of a prescription applied towards meeting the deductible under par. (d) exceeds the remaining deductible amount, the excess prescription costs shall be applied to the prescription benefit. No participant may be required to pay the copayment under sub. (2) (b) for that prescription.(4) SPEND-DOWN SERVICES. (a)Income category applicability. 1. A person may receive the SeniorCare spend-down services under this subsection when he or she is in a fiscal test group with an annual income that exceeds 240% of the poverty line for a family the size of the fiscal test group.2. The department shall maintain an accounting of the prescription drug purchases of each person receiving the SeniorCare spend-down services and shall inform participating SeniorCare providers when he or she has met the spend-down within the benefit period as described in par. (c).(b)Amount. The amount of a person's SeniorCare spend-down is the difference between the SeniorCare fiscal test group's annual income and 240% of the poverty line for a family the size of the fiscal test group.(c)Meeting a spend-down. A SeniorCare spend-down shall be met and the person's subsequent prescription purchases shall count toward meeting the deductible under sub. (3) (c) and (d) when the member or members of the fiscal test group, under the following conditions, have spent the amount of the spend-down in purchasing prescription drugs at the retail price: 1. When only one person is an eligible member of the SeniorCare fiscal test group in a calendar month, only purchases of prescription drugs prescribed for that person may be counted toward meeting the spend-down in that calendar month.2. When 2 spouses are both eligible members of the same SeniorCare fiscal test group in a calendar month, purchases of prescription drugs prescribed for either person may be counted toward meeting the spend-down in that month.3. Only prescription drugs dispensed with a date of service during the benefit period described in s. DHS 109.14 may count toward meeting the spend-down.4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person's other available coverage may be counted toward meeting the spend-down.5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied to meeting the spend-down.6. Only claims submitted by a SeniorCare provider may be considered in determining whether the participant has met the spend-down.(d)Carryover of spend-down. When the cost of a prescription applied towards meeting the spend-down under par. (c) exceeds the remaining spend-down amount, the excess prescription costs shall be applied towards meeting the deductible under sub. (3) (d). The program payment rate may not apply to that portion of the prescription counted for the deductible.(5) REVIEW OF BENEFITS. After the department learns of an error or omission in the information on the application form or other information provided by the recipient used to determine the benefits and services, the department shall promptly redetermine which SeniorCare benefits and services a participant may receive under this section. The benefits and services may only be changed if the error or omission is of factual information available to the recipient at the time he or she filed the application.(6) CORRECTION OF BENEFITS. The department shall correct in the following ways the benefits and services received in error under this section:(a) For underpayment errors caused by the department, benefits will be corrected back to the beginning of the benefit period.(b) For underpayment errors caused by the recipient when the recipient reports the error within 45 days after the date of the initial eligibility notice, benefits will be corrected back to the beginning of the benefit period.(c) For underpayment errors caused by the recipient when the recipient reports the error more than 45 days after the date of the initial eligibility notice, benefits will be corrected back to the first of the month in which the error was reported.(d) For overpayment errors, benefits will be corrected beginning the first of the month following the issuance by the department of a timely notice of decision under s. DHS 109.11 (5) (b). Recovery of benefits issued in error shall be in accordance with s. DHS 109.62.Wis. Admin. Code Department of Health Services DHS 109.13
CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (3) (c) and (d) (intro) and 2. Register October 2004 No. 586, eff. 11-1-04.Amended by, CR 22-046: cr. (2) (bm), am. (2) (c) (title), cr. (2) (d), (e) Register June 2023 No. 810, eff. 7-1-23; correction in (2) (d) (intro.), 1. made under s. 35.17, Stats., Register June 2023 No. 810, eff. 7/1/2023