(c) Implement internal quality improvement and quality assurance processes that meet standards prescribed by the department.
(d) Cooperate with any review by an external advocacy organization.
(e) Within 6 months after the family care benefit is available to all eligible persons in the area of the resource center, provide information about the services of the resource center, including the services specified in sub. (3) (d), about assessments under s. 46.284 (4) (b) and care plans under s. 46.284 (4) (c) and about the family care benefit to all older persons and persons with a physical disability who are residents of nursing homes, community-based residential facilities, adult family homes and residential care apartment complexes in the area of the resource center.
(f) Provide a functional and financial screen to any resident, as specified in par. (e), who requests a screen and assist any resident who is eligible and chooses to enroll in a care management organization to do so.
(g) Provide a functional and financial screen to any person seeking admission to a nursing home, community-based residential facility, residential care apartment complex or adult family home if the secretary has certified that the resource center is available to the person and the facility and the person is determined by the resource center to have a condition that is expected to last at least 90 days that would require care, assistance or supervision.
(h) Provide access to services under s. 46.90 and ch. 55 to a person who is eligible for the services, through cooperation with the county agency or agencies that provide the services.
(i) Assure that emergency calls to the resource center are responded to promptly, 24 hours per day.
(5) FUNDING. From the appropriation accounts under s. 20.435 (4) (b), (bm) and (pa) and (7) (b), (bd) and (md), the department may contract with organizations that meet standards under sub. (3) for performance of the duties under sub. (4) and shall distribute funds for services provided by resource centers.
(6) GOVERNING BOARD. A resource center shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the resource center. At least one-fourth of the members of the governing board shall be older persons or persons with physical or developmental disabilities or their family members, guardians or other advocates.
(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:
(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.
(b) Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.06 (17) (c), 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.
SECTION 1075. 46.284 of the statutes is created to read:
46.284 Care management organizations. (1) APPLICATION FOR CONTRACT. (a) After considering recommendations of the local long-term care council under s. 46.282 (3) (a) 1., 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:
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.
2. Whether to create a family care district to apply to the department for a contract to operate a care management organization.
(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.
(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.
(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.
(2) CONTRACTS. (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.
(b) Within each county, the department shall initially contract to operate a care management organization with the county or a family care district if the county elects to operate a care management organization and the care management organization meets the requirements of sub. (3) and performance standards prescribed by the department. A county that contracts under this paragraph may operate the care management organization for all of the target groups or for a selected group or groups. With respect to contracts exclusively with counties to operate a care management organization, all of the following apply:
1. Before January 1, 2003, the department may not contract with an organization other than the county to operate a care management organization in the county unless any of the following applies:
a. The county and the local long-term care council agree in writing that at least one additional care management organization is necessary or desirable.
b. The governing body of a tribe or band or the Great Lakes inter-tribal council, inc., elects to operate a care management organization within the area and is certified under sub. (3).
2. After December 31, 2002, and before January 1, 2004, the department may not contract with an organization other than the county to operate a care management organization in the county unless any of the following applies:
a. Subdivision 1. a. or b. applies.
b. The county fails to meet requirements of sub. (3) and performance standards prescribed by the department.
c. The county does not have the capacity to serve all county residents who are entitled to the family care benefit in the client group or groups that the county serves and cannot develop the capacity. If this subd. 2. c. applies, the department may contract with an organization in addition to the county.
3. After December 31, 2003, the department may contract with counties, family 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 nonprofit 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, after consulting with the local long-term care council for the county or counties, 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.
(3) CERTIFICATION; REQUIREMENTS. (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. An application shall include comments about the applicant and recommendations about the application that are provided by the appropriate local long-term care council, as specified under s. 46.282 (3) (a) 3.
(b) To be certified as a care management organization, an applicant shall demonstrate or ensure all of the following:
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.
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.
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.
4. Adequate availability of residential and day services that are geographically accessible to proposed enrollees' homes, families or friends.
5. Adequate supported living arrangements of the types and sizes that meet proposed enrollees' preference and needs.
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.
7. Thorough knowledge of local long-term care and other community resources.
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.
9. Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into a service or care plan.
10. Coverage for a geographic area specified by the department.
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.
12. Adequate and competent staffing by qualified personnel to perform all of the functions that the applicant proposes to undertake.
(4) DUTIES. A care management organization shall, in addition to meeting all contract requirements, do all of the following:
(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.
(b) Conduct a comprehensive assessment for each enrollee, including an in-person interview with the enrollee, using a standard format developed by the department.
(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.
(d) Provide or contract for the provision of necessary services and monitor the provided or contracted services.
(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 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.
(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.
(g) Meet all performance standards required by the federal government or promulgated by the department by rule.
(h) Submit to the department reports and data required or requested by the department.
(i) Implement internal quality improvement and assurance processes that meet standards prescribed by the department by rule.
(j) Cooperate with external quality assurance reviews.
(k) Meet departmental requirements for protection of solvency.
(L) Annually submit to the department an independent financial audit that meets federal requirements.
(5) FUNDING AND RISK-SHARING. (a) From the appropriation accounts under s. 20.435 (4) (b), (g) and (o) and (7) (b) and (bd), 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.
(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.
(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.
(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:
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.
2. The requirement that interest accruing to the risk reserve remain in the escrow account for the risk reserve.
3. Limitations on the distribution of funds from the risk reserve.
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.
(e) 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.
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.
(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 older persons or persons with physical or developmental disabilities or their family members, guardians or other advocates who are representative of the care management organization's enrollee.
(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:
(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.
(b) Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.06 (17) (c), 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.
SECTION 1077. 46.285 of the statutes is created to read:
46.285 Operation of resource center and care management organization. (1) 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 family 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:
(a) For a pilot project established under s. 46.281 (1) (d) 2., 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.
(b) The department may approve separation of the functions of a resource center from those of a care management organization by a means other than those specified in sub. (2).
(2) Except as provided in sub. (1), all of the following apply to operation of both a resource center and a care management organization:
(a) 1. If a county board of supervisors and, if applicable, a county executive or a county administrator, elect to apply to the department for a contract to operate a resource center, the county board of supervisors may create a family care district to apply to the department for a contract to operate a care management organization.
2. If a county board of supervisors and, if applicable, a county executive or a county administrator, elect to apply to the department for a contract to operate a care management organization, the county board of supervisors may create a family care district to apply to the department to operate a resource center.
(b) 1. If the governing body of a tribe or band elects to apply to the department for a contract directly to operate a resource center, tribal or band members may form a separate corporation to apply to the department for a contract to operate a care management organization. No members of the governing board of the corporation may be members of the tribal or band governing body.
2. If the governing body of a tribe or band elects to apply to the department for a contract directly to operate a care management organization, tribal or band members may form a separate corporation to apply to the department for a contract to operate a resource center. No members of the governing board of the corporation may be members of the tribal or band governing body.
(c) Any county or family care district that seeks to operate jointly with a tribe or band or tribal or band corporation a care management organization or resource center shall submit jointly with the tribe or band or tribal or band corporation an application to the department to operate the care management organization or resource center.
SECTION 1078. 46.286 of the statutes is created to read:
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:
(a) Functional eligibility. A person is functionally eligible if any of the following applies, as determined by the department or its designee:
1. The person's functional capacity is at either of the following levels:
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.
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.
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:
a. The long-term support community options program under s. 46.27.
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.
