DHS 10.13(1)(b)1.
1. The denial or limited authorization of a requested service, including the type or level of service.
DHS 10.13(1)(b)2.
2. The reduction, suspension, or termination of a previously authorized service.
DHS 10.13(1)(b)4.
4. The failure to provide services and support items included in the individualized service plan in a timely manner, as defined in the health and community services contract.
DHS 10.13(1)(b)5.
5. The failure to act in a timely manner as specified in subchapter
V of this chapter to resolve grievances or appeals.
DHS 10.13(1)(b)6.
6. The development of an individualized service plan that is unacceptable to the member because any of the following apply:
DHS 10.13(1)(b)6.a.
a. The plan is contrary to an enrollee's wishes insofar as it requires the enrollee to live in a place that is unacceptable to the enrollee.
DHS 10.13(1)(b)6.b.
b. The plan does not provide sufficient care, treatment, or support to meet the enrollee's needs and identified family care outcomes.
DHS 10.13(1)(b)6.c.
c. The plan requires the enrollee to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the enrollee.
DHS 10.13(1)(b)7.
7. Termination of the family care benefit or involuntary disenrollment from a CMO.
DHS 10.13(1m)
(1m) "Activities of daily living" or "ADLs" means bathing, dressing, eating, mobility, transferring from one surface to another such as bed to chair and using the toilet.
DHS 10.13(3)
(3) "Adult protective services" means protective services for mentally retarded and other developmentally disabled persons, for aged infirm persons, for chronically mentally ill persons and for persons with other like incapacities incurred at any age as defined in s.
55.02, Stats.
DHS 10.13(3m)
(3m) "Appeal" means a request for review of an action.
DHS 10.13(4)
(4) "Applicant" means a person who directly or through a representative makes application for the family care benefit.
DHS 10.13(5)
(5) "Assets" means any interest in real or personal property that can be used for support and maintenance. "Assets" includes motor vehicles, cash on hand, amounts in checking and savings accounts, certificates of deposit, money market accounts, marketable securities, other financial instruments and cash value of life insurance.
DHS 10.13(6)
(6) "Assistance" means cueing, supervision or partial or complete hands-on assistance from another person.
DHS 10.13(8)
(8) "Care management organization" or "CMO" means an entity that is certified as meeting the requirements for a care management organization under s.
46.284 (3), Stats., and this chapter and that has a contract under s.
46.284 (2), Stats., and
s. DHS 10.42. "Care management organization" does not include an entity that contracts with the department to operate a PACE or Wisconsin partnership program.
DHS 10.13(9)
(9) "Client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.
DHS 10.13(10)
(10) "Community-based residential facility" or "CBRF" has the meaning specified in s.
50.01 (1g), Stats.
DHS 10.13(11)
(11) "Community spouse" means an individual who is legally married as recognized under state law to a family care spouse.
DHS 10.13(12)
(12) "Complaint" means any communication made to the department, a resource center, a care management organization or a service provider by or on behalf of a client expressing dissatisfaction with any aspect of the operations, activities or behaviors of the department, resource center, care management organization or service provider related to access to or delivery of the family care benefit, regardless of whether the communication requests any remedial action.
DHS 10.13(13)
(13) "Countable assets" means assets that are used in calculating financial eligibility and cost sharing requirements for the family care benefit.
DHS 10.13(14)
(14) "County agency" means a county department of aging, social services or human services, an aging and disability resource center, a family care district or a tribal agency, that has been designated by the department to determine financial eligibility and cost sharing requirements for the family care benefit.
DHS 10.13(15)
(15) "Department" means the Wisconsin department of health services.
DHS 10.13(16)
(16) "Developmental disability" means a disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, mental retardation, or another neurological condition closely related to mental retardation or requiring treatment similar to that required for mental retardation, that has continued or can be expected to continue indefinitely and constitutes a substantial handicap to the afflicted individual. "Developmental disability" does not include senility that is primarily caused by the process of aging or the infirmities of aging.
DHS 10.13(17)
(17) "Eligible person" means a person who has been determined under
ss. DHS 10.31 and
10.32 to meet all eligibility criteria under s.
46.286 (1), Stats., and this chapter.
DHS 10.13(18)
(18) "Enrollee" means a person who is enrolled in a care management organization to receive the family care benefit.
DHS 10.13(19)
(19) "Exceptional payments" means the state supplement to federal supplemental security income authorized under s.
49.77 (3s), Stats.
DHS 10.13(20)
(20) "Fair hearing" means a de novo proceeding under
ch. HA 3 before an impartial administrative law judge in which the petitioner or the petitioner's representative presents the reasons why an action or inaction by the department, a county agency, a resource center or a CMO in the petitioner's case should be corrected.
DHS 10.13(21)
(21) "Family care benefit" has the meaning given in s.
46.2805 (4), Stats., namely, financial assistance for long-term care and support items for an enrollee.
DHS 10.13(23)
(23) "Family care spouse" means an individual who is a family care applicant or enrollee and is legally married as recognized under state law to an individual who does not reside in a medical institution or a nursing facility.
DHS 10.13(24)
(24) "Financial eligibility and cost-sharing screening" means a uniform screening tool prescribed by the department that is used to determine financial eligibility and cost-sharing under s.
46.286 (1) (b) and
(2), Stats., and
ss. DHS 10.32 and
10.34.
DHS 10.13(25m)
(25m) "Frail elder" means an individual aged 65 or older who has a physical disability, or an irreversible dementia, that restricts the individual's ability to perform normal daily tasks or that threatens the capacity of the individual to live independently.
DHS 10.13(26)
(26) "Functional capacity" means the skill to perform activities in an acceptable manner.
DHS 10.13(27)
(27) "Functional screening" means a uniform screening tool prescribed by the department that is used to determine functional eligibility under s.
46.286 (1) (a), Stats., and
ss. DHS 10.32 and
10.33.
DHS 10.13(28)
(28) "Grievance" means an expression of dissatisfaction about any matter that is not an action.
DHS 10.13(29)
(29) "Home" means a place of abode and lands used or operated in connection with the place of abode.
DHS 10.13 Note
Note: Note: In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead.
DHS 10.13(32)
(32) "Instrumental activities of daily living" or "IADLs" means management of medications and treatments, meal preparation and nutrition, money management, using the telephone, arranging and using transportation and the ability to function at a job site.
DHS 10.13(34)
(34) "Long-term care facility" means a nursing home, adult family home, community-based residential facility or residential care apartment complex.
DHS 10.13(36)
(36) "Medical institution" means a facility that meets all of the following conditions:
DHS 10.13(36)(a)
(a) Is organized to provide medical care, including nursing and convalescent care.
DHS 10.13(36)(b)
(b) Has the necessary professional personnel, equipment and facilities to manage the medical, nursing and other health care needs of patients on a continuing basis in accordance with accepted professional standards.
DHS 10.13(36)(d)
(d) Is staffed by professional personnel who are responsible for professional medical and nursing services. The professional medical and nursing services include adequate and continual medical care and supervision by a physician, registered nurse or licensed practical nurse supervision and services and nurses' aide services sufficient to meet nursing care needs and a physician's guidance on the professional aspects of operating the institution.
DHS 10.13(38)
(38) "Older person" means a person who is at least 65 years of age.
DHS 10.13(40)
(40) "Physical disability" means a physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, that results from injury, disease or congenital disorder and that significantly interferes with or significantly limits at least one major life activity of a person. In the context of physical disability, "major life activity" means self-care, performance of manual tasks unrelated to gainful employment, walking, receptive and expressive language, breathing, working, participating in educational programs, mobility other than walking and capacity for independent living.
DHS 10.13(41)
(41) "Residential care apartment complex" or "RCAC" has the meaning specified in s.
50.01 (1d), Stats.
DHS 10.13(42)
(42) "Resource center" or "aging and disability resource center" means an entity that meets the standards for operation and is under contract with the department to provide services under s.
46.283 (3), Stats., and this chapter or, if under contract to provide a portion of the services specified under s.
46.283 (3), Stats., meets the standards for operation with respect to those services.
DHS 10.13(43)
(43) "Respite care" means temporary placement in a long-term care facility for maintenance of care, treatment or services, as established by the person's primary care provider, in addition to room and board, for no more than 28 consecutive days at a time.
DHS 10.13(44)
(44) "Secretary" means the secretary of the department.
DHS 10.13(45)
(45) "Supplemental security income" means the supplemental security income program authorized under
42 USC 1381.
DHS 10.13(46)
(46) "Target population" means any of the following groups that a resource center or a care management organization has contracted with the department to serve:
DHS 10.13(47)
(47) "Wisconsin partnership program" means a demonstration program known by this name under contract with the department to provide health and long-term care services under a federal waiver authorized under
42 USC 1315.
DHS 10.13 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: renum. (1) to be (1m), cr. (1), (3m), and (25m), am. (24) and (27), r. and recr. (28), r. (31)
Register November 2004 No. 587, eff. 12-1-04; correction in (17) made under s. 13.93 (2m) (b) 7., Stats.,
Register November 2004 No. 587; corrections in (15) and (35) made under s. 13.92 (4) (b) 6. and 7., Stats.,
Register November 2008 No. 635;
CR 08-109: cr. (16m)
Register June 2009 No. 642, eff. 7-1-09; corrections and renum. of (33) to be (40m) made under s. 13.92 (4) (b) 1., 6. and 7., Stats.,
Register November 2009 No. 647.
DHS 10.21(1)(1) The department may contract for resource center operation only with entities that do all of the following:
DHS 10.21(2)
(2) The department's contracts with organizations operating resource centers shall specify sanctions that may be taken if certain contract requirements are not met, including the withholding or deduction of funds.
DHS 10.21(3)
(3) The department shall use standard contract provisions for contracting with resource centers, except as provided in this subsection. The provisions of the standard contract shall comply with all applicable state and federal laws and may be modified only in accordance with those laws and after consideration of the advice of all of the following:
DHS 10.21(3)(b)
(b) The regional long-term care advisory committee appointed under s.
46.2825 (1), Stats., serving the area in which an organization operates, or proposes to operate, a resource center.
DHS 10.21(4)
(4) The department shall annually provide to the members of the council on long-term care copies of the standard resource center contract the department proposes to use in the next contract period and seek the advice of the council regarding the contract's provisions. The department shall consider any recommendations of the council and may make revisions, as appropriate, based on those recommendations. If the department proposes to modify the terms of the standard contract, including adding or deleting provisions, in contracting with one or more organizations, the department shall seek the advice of the council and consider any recommendations of the council before making the modifications.
DHS 10.21(5)
(5) Whenever the department considers an application from an organization for a contract to operate a resource center, the department shall provide a copy of the standard resource center contract to the regional long-term care advisory committee serving the area in which an organization operates, or proposes to operate, the resource center. If the department proposes to modify the contract, including adding or deleting provisions, the department shall seek the advice of the committee and consider any recommendations of the committee prior to signing the modified contract.
DHS 10.21(6)
(6) Prior to receiving funds to operate a resource center, an organization shall agree to the terms of the standard contract.
DHS 10.21 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (3) (a)
Register November 2004 No. 587, eff. 12-1-04; corrections in (3) (b) and (5) made under s.
13.92 (4) (b) 6. and
7., Stats.,
Register November 2009 No. 647.
DHS 10.22(1)
(1)
Target population. Each contract for operation of a resource center shall specify the target population that the resource center will serve. The target population to be served by the resource center includes all members of the specified group who reside in the geographic area served by the resource center regardless of whether they need or are seeking family care or other long-term care services or programs.
DHS 10.22(2)(a)(a) A resource center shall have a name that is appropriate to its target population and includes any of the following phrases:
