Amendment SSA1-AB133

AB133-SSA1,605,19 46.286 Family care benefit. (1) Eligibility. Except as provided in sub. (1m), 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 infirmities of aging, as defined in s. 55.01 (3); and meets all of the following criteria:

AB133-SSA1,605,21 (a) Functional eligibility. A person is functionally eligible if any of the following applies, as determined by the department or its designee:

AB133-SSA1,605,22 1. The person's functional capacity is at either of the following levels:

AB133-SSA1,605,25 a. The comprehensive 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.

AB133-SSA1,606,4 b. The intermediate 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.

AB133-SSA1,606,10 2. 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, on the date that the family care benefit became available in the person's county of residence, the person was a resident in a nursing home or had been receiving for at least 60 days, under a written plan of care, long-term care services, as specified by the department, which were funded under any of the following:

AB133-SSA1,606,11 a. The long-term support community options program under s. 46.27.

AB133-SSA1,606,13 b. Home and community-based waiver programs under 42 USC 1396n (c), including community integration program under s. 46.275, 46.277 or 46.278.

AB133-SSA1,606,14 c. The Alzheimer's family caregiver support program under s. 46.87.

AB133-SSA1,606,16 d. Community aids under s. 46.40, if documented by the county under a method prescribed by the department.

AB133-SSA1,606,18 e. County funding, if documented by the county under a method prescribed by the department.

AB133-SSA1,606,20 (b) Financial eligibility. A person is financially eligible if all of the following apply:

AB133-SSA1,606,22 1. As determined by the department or its designee, either of the following applies:

AB133-SSA1,607,2 a. 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.

AB133-SSA1,607,3 b. The person is eligible under ch. 49 for medical assistance.

AB133-SSA1,607,5 2. If subd. 1. b. applies, the person accepts medical assistance unless he or she is exempt from the acceptance under rules promulgated by the department.

AB133-SSA1,607,10 (1m) Eligibility exception. A person whose primary disabling condition is developmental disability is eligible for the family care benefit if the person is a resident of a county or is a member of a tribe or band that has operated, before July 1, 2001, a care management organization under s. 46.281 (1) (d) and meets all other eligibility criteria under this subsection.

AB133-SSA1,607,15 (2) Cost sharing. (a) A person who is determined to be financially eligible under sub. (1) (b) shall contribute to the cost of his or her care an amount that is calculated by the department or its designee after subtracting from the person's gross income, plus one-twelfth of countable assets, the deductions and allowances permitted by the department by rule.

AB133-SSA1,607,17 (b) Funds received under par. (a) shall be used by a care management organization to pay for services under the family care benefit.

AB133-SSA1,607,21 (c) A person who is required to contribute to the cost of his or her care but who fails to make the required contributions is ineligible for the family care benefit unless he or she is exempt from the requirement under rules promulgated by the department.

AB133-SSA1,608,2 (3) Entitlement. (a) Subject to pars. (c) and (d), a person is entitled to and may receive the family care benefit through enrollment in a care management organization if he or she meets the requirements of sub. (1) (intro.), is financially eligible, fulfills any applicable cost-sharing requirements and meets any of the following criteria:

AB133-SSA1,608,3 1. Is functionally eligible at the comprehensive level.

AB133-SSA1,608,5 2. Is functionally eligible at the intermediate level and is eligible under sub. (1) (b) 1. b.

AB133-SSA1,608,8 3. Is functionally eligible at the intermediate level and is determined by an agency under s. 46.90 (2) or specified in s. 55.05 (1t) to be in need of protective services under s. 55.05 or protective placement under s. 55.06.

AB133-SSA1,608,9 4. Is functionally eligible under sub. (1) (a) 2.

AB133-SSA1,608,10 5. Is eligible under sub. (1m).

AB133-SSA1,608,12 (b) An entitled individual who is enrolled in a care management organization may not be involuntarily disenrolled except as follows:

AB133-SSA1,608,13 1. For cause, subject to the requirements of s. 46.284 (4) (a).

AB133-SSA1,608,18 2. If the contract between the care management organization and the department is canceled or not renewed. If this circumstance occurs, the department shall assure that enrollees continue to receive needed services through another care management organization or through the medical assistance fee-for-service system or any of the programs specified under sub. (1) (a) 2. a. to d.

AB133-SSA1,608,20 3. The department or its designee determines that the person no longer meets eligibility criteria under sub. (1).

AB133-SSA1,609,2 (c) Within each county and for each client group, par. (a) shall first apply on the effective date of a contract under which a care management organization accepts a per person per month payment to provide services under the family care benefit to eligible persons in that client group in the county. Within 24 months after this date, the department shall assure that sufficient capacity exists within one or more care management organizations to provide the family care benefit to all entitled persons in that client group in the county.

AB133-SSA1,609,5 (d) The department shall determine the date, which shall not be later than July 1, 2000, on which par. (a) shall first apply to persons who are not eligible for medical assistance under ch. 49.

AB133-SSA1,609,8 (4) Divestment; rules. The department shall promulgate rules relating to prohibitions on divestment of assets of persons who receive the family care benefit, that are substantially similar to applicable provisions under s. 49.453.

AB133-SSA1,609,11 (5) Treatment of trust amounts; rules. The department shall promulgate rules relating to treatment of trust amounts of persons who receive the family care benefit, that are substantially similar to applicable provisions under s. 49.454.

AB133-SSA1,609,16 (6) Protection of income and resources of couple for maintenance of community spouse; rules. The department shall promulgate rules relating to protection of income and resources of couples for the maintenance of the spouse in the community with regard to persons who receive the family care benefit, that are substantially similar to applicable provisions under s. 49.455.

AB133-SSA1,609,21 (7) Recovery of family care benefit payments; rules. The department shall promulgate rules relating to the recovery from persons who receive the family care benefit, including by liens and from estates, of correctly and incorrectly paid family care benefits, that are substantially similar to applicable provisions under ss. 49.496 and 49.497.

AB133-SSA1, s. 1079 Section 1079. 46.287 of the statutes is created to read:

AB133-SSA1,609,24 46.287 Hearings. (1) Definition. In this section, "client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.

AB133-SSA1,610,6 (2) Hearing. (a) 1. Except as provided in subd. 2., a client may contest any of the following applicable matters by filing, within 45 days of the failure of a resource center or care management organization to act on the contested matter within the time frames specified by rule by the department or within 45 days after receipt of notice of a decision in a contested matter, a written request for a hearing under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1):

AB133-SSA1,610,7 a. Denial of eligibility under s. 46.286 (1) or (1m).

AB133-SSA1,610,8 b. Determination of cost sharing under s. 46.286 (2).

AB133-SSA1,610,9 c. Denial of entitlement under s. 46.286 (3).

AB133-SSA1,610,11 d. Failure to provide timely services and support items that are included in the plan of care.

AB133-SSA1,610,12 e. Reduction of services or support items under the family care benefit.

AB133-SSA1,610,16 f. Development of a plan of care that is unacceptable because the plan of care requires the enrollee to live in a place that is unacceptable to the enrollee or the plan of care provides care, treatment or support items that are insufficient to meet the enrollee's needs, are unnecessarily restrictive or are unwanted by the enrollee.

AB133-SSA1,610,17 g. Termination of the family care benefit.

AB133-SSA1,610,18 h. Imposition of ineligibility for the family care benefit under s. 46.286 (4).

AB133-SSA1,610,20 i. Denial of eligibility or reduction of the amounts of the family care benefit under s. 46.286 (5).

AB133-SSA1,610,22 j. Determinations similar to those specified under s. 49.455 (8) (a), made under s. 46.286 (6).

AB133-SSA1,610,23 k. Recovery of family care benefit payments under s. 46.286 (7).

AB133-SSA1,611,3 2. An applicant for or recipient of medical assistance is not entitled to a hearing concerning the identical dispute or matter under both this section and 42 CFR 431.200 to 431.246.

AB133-SSA1,611,10 (b) An enrollee may contest a decision, omission or action of a care management organization other than those specified in par. (a), or may contest the choice of service provider. In these instances, the enrollee shall first send a written request for review by the unit of the department that monitors care management organization contracts. This unit shall review and attempt to resolve the dispute. If the dispute is not resolved to the satisfaction of the enrollee, he or she may request a hearing under the procedures specified in par. (a) 1. (intro.).

AB133-SSA1,611,14 (c) Information regarding the availability of advocacy services and notice of adverse actions taken and appeal rights shall be provided to a client by the resource center or care management organization in a form and manner that is prescribed by the department by rule.

AB133-SSA1, s. 1080 Section 1080. 46.288 of the statutes is created to read:

AB133-SSA1,611,17 46.288 Rule-making. The department shall promulgate as rules all of the following:

AB133-SSA1,611,20 (1) Standards for performance by resource centers and for certification of care management organizations, including requirements for maintaining quality assurance and quality improvement.

AB133-SSA1,612,2 (2) Criteria and procedures for determining functional eligibility under s. 46.286 (1) (a), financial eligibility under s. 46.286 (1) (b), cost sharing under s. 46.286 (2) (a) and entitlement under s. 46.286 (3). The rules for determining functional eligibility under s. 46.286 (1) (a) 1. a. shall be substantially similar to eligibility criteria for receipt of the long-term support community options program under s. 46.27. Rules under this subsection shall include definitions of the following terms applicable to s. 46.286:

AB133-SSA1,612,3 (a) "Primary disabling condition".

AB133-SSA1,612,4 (b) "Mental illness".

AB133-SSA1,612,5 (c) "Substance abuse".

AB133-SSA1,612,6 (d) "Long-term or irreversible".

AB133-SSA1,612,7 (e) "Requires ongoing care, assistance or supervision".

AB133-SSA1,612,9 (f) "Condition that is expected to last at least 90 days or result in death within one year".

AB133-SSA1,612,10 (g) "At risk of losing independence or functional capacity".

AB133-SSA1,612,11 (h) "Gross monthly income".

AB133-SSA1,612,12 (i) "Deductions and allowances".

AB133-SSA1,612,13 (j) "Countable assets".

AB133-SSA1,612,16 (3) Procedures and standards for procedures for s. 46.287 (2), including time frames for action by a resource center or a care management organization on a contested matter.

AB133-SSA1, s. 1081 Section 1081. 46.289 of the statutes is created to read:

AB133-SSA1,612,24 46.289 Transition. In order to facilitate the transition to the long-term care system specified in ss. 46.2805 to 46.2895, within the limits of applicable federal statutes and regulations and if the secretary of health and family services finds it necessary, he or she may grant a county limited waivers to or exemptions from ss. 46.27 (3) (e) (intro.), 1. and 2. and (f), (5) (d) and (e), (6) (a) 1., 2. and 3. and (b) (intro.), 1. and 2., (6r) (c), (7) (b), (cj) and (cm) and (11) (c) 5m. (intro.) and 6. and 46.277 (3) (a), (4) (a) and (5) (d) 1m., 1n. and 2. and rules promulgated under those provisions.

AB133-SSA1, s. 1082 Section 1082. 46.2895 of the statutes is created to read:

AB133-SSA1,613,6 46.2895 Family care district. (1) Creation. (a) After considering recommendations of the local long-term care council under s. 46.282 (3) (a) 1., a county board of supervisors may create a special purpose district that is termed a "family care district", that is a local unit of government, that is separate and distinct from, and independent of, the state and the county, and that has the powers and duties specified in this section, if the county board does all of the following:

AB133-SSA1,613,7 1. Adopts an enabling resolution that does all of the following:

AB133-SSA1,613,8 a. Declares the need for establishing the family care district.

AB133-SSA1,613,11 b. Specifies the family care district's primary purpose, which shall be to operate, under contract with the department, either a resource center under s. 46.283 or a care management organization under s. 46.284, but not both.

AB133-SSA1,613,13 2. Files copies of the enabling resolution with the secretary of administration, the secretary of health and family services and the secretary of revenue.

AB133-SSA1,613,17 (b) The county boards of supervisors of 2 or more counties may together create a family care district with the attributes specified in par. (a) (intro.) on a multicounty basis within the counties if the county boards of supervisors comply with the requirements of par. (a) 1. and 2.

AB133-SSA1,613,20 (2) Jurisdiction. A family care district's jurisdiction is the geographical area of the county or counties of the county board or boards of supervisors who created the family care district.

AB133-SSA1,613,25 (3) Family care district board. (a) 1. The county board of supervisors of a county or, in a county with a county administrator or county executive, the county administrator or county executive shall appoint the members of the family care district board, which is the governing board of a family care district under sub. (1) (a).

AB133-SSA1,614,5 2. The county boards of supervisors of 2 or more counties shall appoint the members of the family care district board, which is the governing board of the family care district under sub. (1) (b). Each county board shall appoint members in the same proportion that the county's population represents to the total population of all of the counties that constitute the jurisdiction of the family care district.

AB133-SSA1,614,10 (b) 1. The family care district board appointed under par. (a) 1. shall consist of 15 persons who are residents of the area of jurisdiction of the family care district. At least one-fourth of the members shall be representative of the client group or groups whom it is the family care district's primary purpose to serve or those clients' family members, guardians or other advocates.

AB133-SSA1,614,16 2. The family care district board appointed under par. (a) 2. shall consist of an odd number of members that is at least 15 but not more than 21 persons, all of whom are residents of the area of jurisdiction of the family care district. At least one-fourth of the members shall be representative of the client group or groups whom it is the family care district's primary purpose to serve or those clients' family members, guardians or other advocates.

AB133-SSA1,614,22 3. Membership of the family care district board under subd. 1. or 2. shall reflect the ethnic and economic diversity of the area of jurisdiction of the family care district. Up to one-fourth of the members of the board may be elected or appointed officials or employes of the county or counties that created the family care district. No member of the board may have a private financial interest in or profit directly or indirectly from any contract or other business of the family care district.

AB133-SSA1,615,3 (c) The members of the family care district board appointed under par. (a) shall serve 3-year terms. No member may serve more than 2 consecutive terms. Of the members first appointed, 5 shall be appointed for 3 years; 5 shall be appointed for 4 years; and 5 or, in the case of a board appointed under par. (b) 2., the remainder, shall be appointed for 5 years. A member shall serve until his or her successor is appointed, unless removed for cause under s. 17.13.

AB133-SSA1,615,10 (d) As soon as possible after the appointment of the initial members of the family care district board, the board shall organize for the transaction of business and elect a chairperson and other necessary officers. Each chairperson shall be elected by the board from time to time for the term of that chairperson's office as a member of the board or for the term of 3 years, whichever is shorter, and shall be eligible for reelection. A majority of the board shall constitute a quorum. The board may act based on the affirmative vote of a majority of a quorum.

AB133-SSA1,615,14 (4) Powers. Subject to sub. (1) (a) 1. b., a family care district has all the powers necessary or convenient to carry out the purposes and provisions of ss. 46.2805 to 46.2895. In addition to all these powers, a family care district may do all of the following:

AB133-SSA1,615,15 (a) Adopt and alter, at pleasure, an official seal.

AB133-SSA1,615,19 (b) Adopt bylaws and policies and procedures for the regulation of its affairs and the conduct of its business. The bylaws, policies and procedures shall be consistent with ss. 46.2085 to 46.2895 and, if the family care district contracts with the department under par. (d), with the terms of that contract.

AB133-SSA1,615,20 (c) Sue and be sued.