(1) CALCULATION. A participant's liability to
contribute toward the cost of treatment shall be calculated in accordance with
subs. (2) to (4). If there are 2 or more participants in the same family, the
family's liability shall be limited to the liability of one member of the
family.
(2) INCOME DEDUCTIBLE. A
participant whose estimated total family income in the current year is at or
above 200% of the federal poverty guidelines shall obligate or expend the
following percentage of that income to pay the cost of medical treatment for
the condition before the hemophilia home care program will provide assistance
in paying for the cost of treatment:
(a) When
total family income is from 200% to 250% of the federal poverty guidelines,
0.50% of that income.
(b) When
total family income is more than 250% but not more than 275% of the federal
poverty guidelines, 0.75% of that income.
(c) When total family income is more than
275%, but not more than 300% of the federal poverty guidelines, 1.0% of that
income.
(d) When total family
income is more than 300% but not more than 325% of the federal poverty
guidelines, 1.25% of that income.
(e) When total family income is more than
325% but not more than 350% of the federal poverty guidelines, 2.0% of that
income.
(f) When total family
income is more than 350% but not more than 375% of the federal poverty
guidelines, 2.75% of that income.
(g) When total family income is more than
375% but not more than 400% of the federal poverty guidelines, 3.5% of that
income.
(h) When total family
income is more than 400% of the federal poverty guidelines, 4.5% of that
income.
(3) PARTICIPANT
COINSURANCE.
(a) A participant shall pay a
coinsurance amount to cover part of the cost of blood products and home care
supplies.
(b) A participant's
coinsurance amount shall be determined at the time the patient is certified for
eligibility and annually thereafter.
(c) The amount of a participant's coinsurance
shall be related to family size and to family income rounded to the nearest
whole dollar, in accordance with the schedule in Table 153.07.
(d) The amount that a patient pays in
coinsurance annually may not exceed the following applicable percentage of the
family's income, rounded to the nearest whole dollar:
1. For an income of up to $10,000,
3%;
2. For an income of $10,001 to
$20,000, 4%;
3. For an income of
$20,001 to $40,000, 5%;
4. For an
income of $40,001 to $60,000, 6%;
5. For an income of $60,001 to $80,000,
7%;
6. For an income of $80,001 to
$100,000, 9%; and
7. For an income
of $100,001 and over, 10%.
(4) PARTICIPANT COPAYMENT. When a pharmacy
directly bills the hemophilia home care program for a prescription received by
a program participant, the participant is responsible for a $7.50 copayment
amount for each generic drug and a $15.00 copayment amount for each brand name
drug.
(5) ESTATE RECOVERY.
(a) An heir or beneficiary of the estate of a
participant or a participant's surviving spouse may apply to the department for
a waiver of an estate claim filed by the department pursuant to s.
49.682 or
49.849,
Stats. The criteria for granting waivers in s.
DHS 108.02(12) (b) shall apply to
applications under this subsection. All of the procedures and rights in s.
DHS 108.02(12) (b) to (e) shall apply to
this subsection.
(b) For purposes
of applying s.
DHS 108.02(12) (b) to (e) to this
subsection the following definitions apply:
1. "Beneficiary" means any person nominated
in a will to receive an interest in property other than in a fiduciary
capacity;
2. "Decedent" means a
deceased participant or the deceased surviving spouse of a participant who
received benefits that are subject to recovery under s.
49.682 or
49.849,
Stats.;
3. "Heir" means any person
who is entitled under the statutes of intestate succession, ch. 852, Stats., to
an interest in property of a decedent;
4. "Recipient" means a participant who
received reimbursement under s.
49.685,
Stats.; and
5. "Waiver applicant"
means a beneficiary or heir of a decedent who requests the department to waive
an estate claim filed by the department pursuant to s.
49.682 or
49.849,
Stats.
(c) The
department may make adjustments to and settle estate claims filed under s.
49.682 or
49.849,
Stats., to obtain the fullest amount practicable.
Table 153.07
Patient Coinsurance Liability for the Direct Cost of
Treatment -
|
Annual Family Income
|
Percent of Charges for Which Patient is
Liable, by Family Size
|
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10+
|
|
$0-7,000
|
1%
|
0%
|
0%
|
0%
|
0%
|
0%
|
0%
|
0%
|
0%
|
0%
|
|
7,001-10,000
|
2
|
1
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
|
10,001-15,000
|
3
|
2
|
1
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
|
15,001-20,000
|
4
|
3
|
2
|
1
|
0
|
0
|
0
|
0
|
0
|
0
|
|
20,001-25,000
|
5
|
4
|
3
|
2
|
1
|
0
|
0
|
0
|
0
|
0
|
|
25,001-30,000
|
14
|
5
|
4
|
3
|
2
|
1
|
0
|
0
|
0
|
0
|
|
30,001-35,000
|
17
|
13
|
5
|
4
|
3
|
2
|
1
|
0
|
0
|
0
|
|
35,001-40,000
|
20
|
16
|
6
|
5
|
4
|
3
|
2
|
1
|
0
|
0
|
|
40,001-45,000
|
24
|
19
|
15
|
6
|
5
|
4
|
3
|
2
|
1
|
0
|
|
45,001-50,000
|
29
|
24
|
20
|
17
|
6
|
5
|
4
|
3
|
2
|
1
|
|
50,001-55,000
|
34
|
29
|
25
|
21
|
7
|
6
|
5
|
4
|
3
|
2
|
|
55,001-60,000
|
39
|
34
|
29
|
25
|
23
|
7
|
6
|
5
|
4
|
3
|
|
60,001-65,000
|
44
|
39
|
34
|
30
|
28
|
25
|
7
|
6
|
5
|
4
|
|
65,001-70,000
|
49
|
44
|
39
|
35
|
32
|
29
|
8
|
7
|
6
|
5
|
|
70,001-75,000
|
55
|
49
|
44
|
40
|
37
|
34
|
32
|
8
|
7
|
6
|
|
75,001-80,000
|
61
|
55
|
50
|
46
|
43
|
40
|
37
|
35
|
7
|
6
|
|
80,001-85,000
|
67
|
61
|
56
|
52
|
49
|
46
|
43
|
40
|
7
|
6
|
|
85,001-90,000
|
74
|
68
|
63
|
59
|
56
|
53
|
50
|
47
|
45
|
6
|
|
90,001-95,000
|
81
|
75
|
70
|
66
|
63
|
60
|
57
|
55
|
53
|
51
|
|
95,001-100,000
|
88
|
82
|
77
|
73
|
70
|
67
|
64
|
62
|
60
|
58
|
|
$ 100,000+
|
97
|
91
|
86
|
82
|
79
|
76
|
73
|
71
|
69
|
67
|
Notes
Wis. Admin. Code Department of Health Services
DHS 153.07
Cr. Register, December,
1994, No. 468, eff. 1-1-95; emerg. cr. (5), eff. 11-1-95; cr. (5), Register,
April, 1996, No. 484, eff. 5-1-96; CR 02-070: am. (4) Register October 2002 No.
562, eff. 11-1-02; CR 04-051: am. (2) and (4), cr. (2) (f) to (h) Register
November 2004 No. 587, eff. 12-1-04; corrections in (5) (a) and (b) (intro.)
made under s.
13.92(4) (b) 7, Stats., Register January 2009 No. 637;
corrections in (5) (a), (b) 2., 5., (c) made under s.
13.92(4) (b) 7, Stats., Register December 2014 No.
696.
To illustrate how a patient's coinsurance liability is
calculated, assume that the family has 2 members and an annual income of
$38,000, and that a bill has been received for treatment in the amount of $600.
The patient would be liable for 16% of that bill, or $96.
