46.283(6)(a)3. 3. An individual who has a financial interest in, or serves on the governing board of, a care management organization or an organization that administers a program described under s. 46.2805 (1) (a) or (b) or a managed care program under s. 49.45 for individuals who are eligible to receive supplemental security income under 42 USC 1381 to 1383c, which serves any geographic area also served by a resource center, and the individual's family members, may not serve as members of the governing board of the resource center.
46.283(6)(b) (b) The governing board of a resource center shall do all of the following:
46.283(6)(b)1. 1. Determine the structure, policies, and procedures of, and oversee the operations of, the resource center. The operations of a resource center that is operated by a county are subject to the county's ordinances and budget.
46.283(6)(b)2. 2. Annually gather information from consumers and providers of long-term care services and other interested persons concerning the adequacy of long-term care services offered in the area served by the resource center. The board shall provide well-advertised opportunities for persons to participate in the board's information gathering activities conducted under this subdivision.
46.283(6)(b)3. 3. Identify any gaps in services, living arrangements, and community resources needed by individuals belonging to the client groups served by the resource center, especially those with long-term care needs.
46.283(6)(b)4. 4. Report findings made under subds. 2. and 3. to the applicable regional long-term care advisory committee.
46.283(6)(b)5. 5. Recommend strategies for building local capacity to serve older persons and persons with physical or developmental disabilities, as appropriate, to local elected officials, the regional long-term care advisory committee, or the department.
46.283(6)(b)6. 6. Identify potential new sources of community resources and funding for needed services for individuals belonging to the client groups served by the resource center.
46.283(6)(b)7. 7. Appoint members to the regional long-term care advisory committee, as provided under s. 46.2825 (1).
46.283(6)(b)8. 8. Annually review interagency agreements between the resource center and care management organizations that provide services in the area served by the resource center and make recommendations, as appropriate, on the interaction between the resource center and the care management organizations to assure coordination between or among them and to assure access to and timeliness in provision of services by the resource center and the care management organizations.
46.283(6)(b)9. 9. Review the number and types of grievances and appeals concerning the long-term care system in the area served by the resource center, to determine if a need exists for system changes, and recommend system or other changes if appropriate.
46.283(6)(b)10. 10. If directed to do so by the county board, assume the duties of the county long-term community support planning committee as specified under s. 46.27 (4) for a county served by the resource center.
46.283(7) (7)Confidentiality; exchange of information. No record, as defined in s. 19.32 (2), of a resource center that contains personally identifiable information, as defined in s. 19.62 (5), concerning an individual who receives services from the resource center may be disclosed by the resource center without the individual's informed consent, except as follows:
46.283(7)(a) (a) A resource center may provide information as required to comply with s. 16.009 (2) (p) or 49.45 (4) or as necessary for the department to administer the program under ss. 46.2805 to 46.2895.
46.283(7)(b) (b) Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.22 (3), 146.82, 252.11 (7), 253.07 (3) (c) and 938.78 (2) (a), a resource center acting under this section may exchange confidential information about a client, as defined in s. 46.287 (1), without the informed consent of the client, under s. 46.21 (2m) (c), 46.215 (1m), 46.22 (1) (dm), 46.23 (3) (e), 46.284 (7), 46.2895 (10), 51.42 (3) (e) or 51.437 (4r) (b) in the county of the resource center, if necessary to enable the resource center to perform its duties or to coordinate the delivery of services to the client.
46.284 46.284 Care management organizations.
46.284(1) (1) Application for contract.
46.284(1)(a)(a) A county board of supervisors and, in a county with a county executive or a county administrator, the county executive or county administrator, may decide all of the following:
46.284(1)(a)1. 1. Whether to authorize one or more county departments under s. 46.21, 46.215, 46.22 or 46.23 or an aging unit under s. 46.82 (1) (a) 1. or 2. to apply to the department for a contract to operate a care management organization and, if so, which to authorize and what client group to serve.
46.284(1)(a)2. 2. Whether to create a long-term care district to apply to the department for a contract to operate a care management organization.
46.284(1)(b) (b) The governing body of a tribe or band or of the Great Lakes Inter-Tribal Council, Inc., may decide whether to authorize a tribal agency to apply to the department for a contract to operate a care management organization for tribal members and, if so, which client group to serve.
46.284(1)(c) (c) Under the requirements of par. (a), a county board of supervisors may decide to apply to the department for a contract to operate a multicounty care management organization in conjunction with the county board or boards of one or more other counties or a county-tribal care management organization in conjunction with the governing body of a tribe or band or the Great Lakes Inter-Tribal Council, Inc.
46.284(1)(d) (d) Under the requirements of par. (b), the governing body of a tribe or band may decide to apply to the department for a contract to operate a care management organization in conjunction with the governing body or governing bodies of one or more other tribes or bands or the Great Lakes Inter-Tribal Council, Inc., or with a county board of supervisors.
46.284(2) (2)Contracts.
46.284(2)(a)(a) The department may contract for operation of a care management organization only with an entity that is certified as meeting the requirements under sub. (3). No entity may operate as a care management organization under the requirements of this section unless so certified and under contract with the department.
46.284(2)(bm) (bm) The department may contract with counties, long-term care districts, the governing body of a tribe or band or the Great Lakes inter-tribal council, inc., or under a joint application of any of these, or with a private organization that has no significant connection to an entity that operates a resource center. Proposals for contracts under this subdivision shall be solicited under a competitive sealed proposal process under s. 16.75 (2m) and the department shall evaluate the proposals primarily as to the quality of care that is proposed to be provided, certify those applicants that meet the requirements specified in sub. (3) (a), select certified applicants for contract and contract with the selected applicants.
46.284(2)(c) (c) The department shall require, as a term of any contract with a care management organization under this section, that the care management organization contract for the provision of services that are covered under the family care benefit with any community-based residential facility under s. 50.01 (1g), residential care apartment complex under s. 50.01 (6d), nursing home under s. 50.01 (3), intermediate care facility for persons with an intellectual disability under s. 50.14 (1) (b), community rehabilitation program, home health agency under s. 50.49 (1) (a), provider of day services, or provider of personal care, as defined in s. 50.01 (4o), that agrees to accept the reimbursement rate that the care management organization pays under contract to similar providers for the same service and that satisfies any applicable quality of care, utilization, or other criteria that the care management organization requires of other providers with which it contracts to provide the same service.
46.284(2)(d) (d) As a term of a contract with a care management organization under this section, the department shall prohibit a care management organization from including a provision that requires a provider to return any funding for residential services, prevocational services, or supported employment services that exceeds the cost of those services to the care management organization in a contract for services covered by the family care benefit.
46.284(3) (3)Certification; requirements.
46.284(3)(a)(a) If an entity meets the requirements under par. (b) and applicable rules of the department and submits to the department an application for initial certification or certification renewal, the department shall certify that the entity meets the requirements for a care management organization.
46.284(3)(b) (b) To be certified as a care management organization, an applicant shall demonstrate or ensure all of the following:
46.284(3)(b)1. 1. Adequate availability of providers with the expertise and ability to provide services that are responsive to the disabilities or conditions of all of the applicant's proposed enrollees and sufficient representation of programmatic philosophies and cultural orientations to accommodate a variety of enrollee preferences and needs.
46.284(3)(b)2. 2. Adequate availability of providers that can meet the preferences and needs of its proposed service recipients for services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.
46.284(3)(b)3. 3. Adequate availability of providers that are able and willing to perform all of the tasks that are likely to be identified in proposed enrollees' service and care plans.
46.284(3)(b)4. 4. Adequate availability of residential and day services that are geographically accessible to proposed enrollees' homes, families or friends.
46.284(3)(b)5. 5. Adequate supported living arrangements of the types and sizes that meet proposed enrollees' preference and needs.
46.284(3)(b)6. 6. Expertise in determining and meeting the needs of every target population that the applicant proposes to serve and connections to the appropriate service providers.
46.284(3)(b)7. 7. Thorough knowledge of local long-term care and other community resources.
46.284(3)(b)8. 8. The ability to manage and deliver, either directly or through subcontracts or partnerships with other organizations, the full range of benefits to be included in the monthly payment amount.
46.284(3)(b)9. 9. Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into a service or care plan.
46.284(3)(b)10. 10. Coverage for a geographic area specified by the department.
46.284(3)(b)11. 11. The ability to develop strong linkages with systems and services that are not directly within the scope of the applicant's responsibility but that are important to the target group that it proposes to serve, including primary and acute health care services.
46.284(3)(b)12. 12. Adequate and competent staffing by qualified personnel to perform all of the functions that the applicant proposes to undertake.
46.284(3m) (3m)Permit required. A care management organization that is described under s. 600.01 (1) (b) 10. a., to which s. 600.01 (1) (b) 10. b. does not apply and that is certified under sub. (3) shall apply for a permit with the office of the commissioner of insurance under ch. 648.
46.284(4) (4)Duties. A care management organization shall, in addition to meeting all contract requirements, do all of the following:
46.284(4)(a) (a) Accept requested enrollment of any person who is entitled to the family care benefit and of any person who is eligible for the family care benefit and for whom funding is available. No care management organization may disenroll any enrollee, except under circumstances specified by the department by contract. No care management organization may encourage any enrollee to disenroll in order to obtain long-term care services under the medical assistance fee-for-service system. No involuntary disenrollment is effective unless the department has reviewed and approved it.
46.284(4)(b) (b) Conduct a comprehensive assessment for each enrollee, including an in-person interview with the enrollee, using a standard format developed by the department.
46.284(4)(c) (c) With the enrollee and the enrollee's family or guardian, if appropriate, develop a comprehensive care plan that reflects the enrollee's values and preferences.
46.284(4)(d) (d) Provide or contract for the provision of necessary services and monitor the provided or contracted services.
46.284(4)(e) (e) Provide, within guidelines established by the department, a mechanism by which an enrollee may arrange for, manage, and monitor his or her family care benefit directly or with the assistance of another person chosen by the enrollee. The care management organization shall provide each enrollee with a form on which the enrollee shall indicate whether he or she has been offered the option under this paragraph and whether he or she has accepted or declined the option. If the enrollee accepts the option, the care management organization shall monitor the enrollee's use of a fixed budget for purchase of services or support items from any qualified provider, monitor the health and safety of the enrollee, and provide assistance in management of the enrollee's budget and services at a level tailored to the enrollee's need and desire for the assistance.
46.284(4)(f) (f) Provide, on a fee-for-service basis, case management services to persons who are functionally eligible but not financially eligible for the family care benefit.
46.284(4)(g) (g) Meet all performance standards required by the federal government or promulgated by the department by rule.
46.284(4)(h) (h) Submit to the department reports and data required or requested by the department.
46.284(4)(i) (i) Implement internal quality improvement and assurance processes that meet standards prescribed by the department by rule.
46.284(4)(j) (j) Cooperate with external quality assurance reviews.
46.284(4)(k) (k) Meet departmental requirements for protection of solvency.
46.284(4)(L) (L) Annually submit to the department an independent financial audit that meets federal requirements.
46.284(5) (5)Funding and risk-sharing.
46.284(5)(a)(a) From the appropriation accounts under s. 20.435 (4) (b), (g), (gm), (im), (o), and (w) and (7) (b), (bd), and (g), the department shall provide funding on a capitated payment basis for the provision of services under this section. Notwithstanding s. 46.036 (3) and (5m), a care management organization that is under contract with the department may expend the funds, consistent with this section, including providing payment, on a capitated basis, to providers of services under the family care benefit.
46.284(5)(b) (b) If the expenditures by a care management organization under par. (a) exceed payments received from the department under par. (a), as determined by the department by contract, the department may share the loss with the care management organization, within the limits prescribed under the contract with the department.
46.284(5)(c) (c) If the payments received from the department under par. (a) exceed the expenditures by a care management organization under par. (a), as determined by the department by contract, the care management organization may retain a portion of the excess payments, within the limits prescribed under the contract with the department, and shall return the remainder to the department.
46.284(5)(d) (d) The department may, by contract, impose solvency protections that the department determines are reasonable and necessary to retain federal financial participation. These protections may include all of the following:
46.284(5)(d)1. 1. The requirement that a care management organization segregate a risk reserve from other funds of the care management organization or the authorizing body for the care management organization.
46.284(5)(d)2. 2. The requirement that interest accruing to the risk reserve remain in the escrow account for the risk reserve.
46.284(5)(d)3. 3. Limitations on the distribution of funds from the risk reserve.
46.284(5)(d)4. 4. The requirement that a care management organization place funds in a risk reserve and maintain the risk reserve in an interest-bearing escrow account with a financial institution, as defined in s. 69.30 (1) (b), or invest funds as specified in s. 46.2895 (4) (j) 2. or 3. Moneys in the risk reserve or invested as specified in this subdivision may be expended only for the provision of services under this section. If a care management organization ceases participation under this section, the funds in the risk reserve or invested as specified in this subdivision, minus any contribution of moneys other than those specified in par. (c), shall be returned to the department. The department shall expend the moneys for the payment of outstanding debts to providers of family care benefit services and for the continuation of family care benefit services to enrollees.
46.284(5)(e)1.1. Subject to subd. 2., a care management organization may enter into contracts with providers of family care benefit services and may limit profits of the providers under the contracts.
46.284(5)(e)2. 2. The department shall review the contracts in subd. 1., including rates for the provision of service, to ensure that the contract terms protect services access by enrollees and financial viability of the care management organization, and may require contract revision.
46.284(6) (6)Governing board. A care management organization shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the care management organization. At least one-fourth of the members of the governing board shall be representative of the client group or groups whom the care management organization is contracted to serve or those clients' family members, guardians, or other advocates.
46.284(7) (7)Confidentiality; exchange of information. No record, as defined in s. 19.32 (2), of a care management organization that contains personally identifiable information, as defined in s. 19.62 (5), concerning an individual who receives services from the care management organization may be disclosed by the care management organization without the individual's informed consent, except as follows:
46.284(7)(a) (a) A care management organization may provide information as required to comply with s. 16.009 (2) (p) or 49.45 (4) or as necessary for the department to administer the program under ss. 46.2805 to 46.2895.
46.284(7)(b) (b) Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.22 (3), 146.82, 252.11 (7), 253.07 (3) (c) and 938.78 (2) (a), a care management organization acting under this section may exchange confidential information about a client, as defined in s. 46.287 (1), without the informed consent of the client, under s. 46.21 (2m) (c), 46.215 (1m), 46.22 (1) (dm), 46.23 (3) (e), 46.283 (7), 46.2895 (10), 51.42 (3) (e) or 51.437 (4r) (b) in the county of the care management organization, if necessary to enable the care management organization to perform its duties or to coordinate the delivery of services to the client.
46.285 46.285 Operation of resource center and care management organization. In order to meet federal requirements and assure federal financial participation in funding of the family care benefit, a county, a tribe or band, a long-term care district or an organization, including a private, nonprofit corporation, may not directly operate both a resource center and a care management organization, except as follows:
46.285(1) (1) For an entity with which the department has contracted under s. 46.281 (1) (e) 1., 2005 stats., provision of the services specified under s. 46.283 (3) (b), (e), (f) and (g) shall be structurally separate from the provision of services of the care management organization by January 1, 2001.
46.285(2) (2) The department may approve separation of the functions of a resource center from those of a care management organization by a means other than creating a long-term care district under s. 46.2895 to serve either as a resource center or as a care management organization.
46.285 History History: 1999 a. 9; 2005 a. 386; 2007 a. 20.
46.286 46.286 Family care benefit.
46.286(1) (1) Eligibility. A person is eligible for, but not necessarily entitled to, the family care benefit if the person is at least 18 years of age; has a physical disability, as defined in s. 15.197 (4) (a) 2., or a developmental disability, as defined in s. 51.01 (5) (a), or is a frail elder; and meets all of the following criteria:
46.286(1)(a) (a) Functional eligibility. A person is functionally eligible if the person's level of care need, as determined by the department or its designee, is either of the following:
46.286(1)(a)1m. 1m. The nursing home level, if the person has a long-term or irreversible condition, expected to last at least 90 days or result in death within one year of the date of application, and requires ongoing care, assistance or supervision.
46.286(1)(a)2m. 2m. The non-nursing home level, if the person has a condition that is expected to last at least 90 days or result in death within 12 months after the date of application, and is at risk of losing his or her independence or functional capacity unless he or she receives assistance from others.
46.286(1)(b) (b) Financial eligibility.
46.286(1)(b)1c.1c. In this paragraph, "medical assistance" does not include coverage of the benefits under s. 49.471 (11).
46.286(1)(b)2m. 2m. A person is financially eligible if any of the following apply:
46.286(1)(b)2m.a. a. The person is eligible under ch. 49 for medical assistance and, unless he or she is exempt from acceptance under rules promulgated by the department, accepts medical assistance.
46.286(1)(b)2m.b. b. The person was receiving the family care benefit on October 27, 2007, the person would qualify for medical assistance except for financial or disability criteria, and the projected cost of the person's care plan, as calculated by the department or its designee, exceeds the person's gross monthly income, plus one-twelfth of his or her countable assets, less deductions and allowances permitted by rule by the department.
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2011-12 Wisconsin Statutes updated through 2013 Wis. Act 380 and all Supreme Court Orders entered before Dec. 13, 2014. Published and certified under s. 35.18. Changes effective after Dec. 13, 2014 are designated by NOTES. (Published 12-13-14)