46.286(3)(b)
(b) An entitled individual who is enrolled in a care management organization may not be involuntarily disenrolled except as follows:
46.286(3)(b)2.
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 following programs:
46.286(3)(b)2.d.
d. Community aids under
s. 46.40, if documented by the county under a method prescribed by the department.
46.286(3)(b)2.e.
e. County funding, if documented by the county under a method prescribed by the department.
46.286(3)(b)3.
3. The department or its designee determines that the person no longer meets eligibility criteria under
sub. (1).
46.286(3)(c)
(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 36 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.
46.286(3m)
(3m) Information about enrollees. The department shall obtain and share information about family care enrollees as provided in
s. 49.475.
46.286(4)
(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.
46.286(5)
(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.
46.286(6)
(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.
46.286(7)
(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.
46.286 Cross-reference
Cross-reference: See also ch.
DHS 10, Wis. adm. code.
46.287(1)(1)
Definition. In this section, "client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.
46.287(2)(a)1.1. 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):
46.287(2)(a)1.d.
d. Failure to provide timely services and support items that are included in the plan of care.
46.287(2)(a)1.e.
e. Reduction of services or support items under the family care benefit.
46.287(2)(a)1.f.
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.
46.287(2)(a)2.
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.
46.287(2)(b)
(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.).
46.287(2)(c)
(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.
46.287 History
History: 1999 a. 9;
2003 a. 33.
46.288
46.288
Rule-making. The department shall promulgate as rules all of the following:
46.288(1)
(1) Standards for performance by resource centers and for certification of care management organizations, including requirements for maintaining quality assurance and quality improvement.
46.288(2)
(2) Criteria and procedures for determining functional eligibility under
s. 46.286 (1) (a), financial eligibility under
s. 46.286 (1) (b), and cost sharing under
s. 46.286 (2) (a). The rules for determining functional eligibility under
s. 46.286 (1) (a) 1m. 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:
46.288(2)(e)
(e) "Requires ongoing care, assistance or supervision".
46.288(2)(f)
(f) "Condition that is expected to last at least 90 days or result in death within one year".
46.288(2)(g)
(g) "At risk of losing independence or functional capacity".
46.288(3)
(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.
46.288 History
History: 1999 a. 9;
2007 a. 20;
2009 a. 28.
46.2895
46.2895
Long-term care district. 46.2895(1)(a)(a) A county, a tribe or band, or any combination of counties or tribes or bands, may create a special purpose district that is termed a "long-term care district", that is a local unit of government, that is separate and distinct from, and independent of, the state and the county or tribe or band that created it, and that has the powers and duties specified in this section, if each county or tribe or band that participates in creating the district does all of the following:
46.2895(1)(a)1.
1. Adopts an enabling resolution that does all of the following:
46.2895(1)(a)1.b.
b. Specifies the long-term care district's primary purpose, which shall be to operate, under contract with the department, a resource center under
s. 46.283, a care management organization under
s. 46.284, or a program described under
s. 46.2805 (1) (a) or
(b).
46.2895(1)(a)1.c.
c. Specifies the number of individuals who shall be appointed as members of the long-term care district board, the length of their terms, and, if the long-term care district is created by more than one county or tribe or band, how many members shall be appointed by each county or tribe or band.
46.2895(1)(a)2.
2. Files copies of the enabling resolution with the secretary of administration, the secretary of health services and the secretary of revenue.
46.2895(1)(c)
(c) A long-term care district may not operate a care management organization under
s. 46.284 or a program described under
s. 46.2805 (1) (a) or
(b) if the district operates a resource center under
s. 46.283.
46.2895(1)(d)
(d) A county or tribe or band may create more than one long-term care district.
46.2895(1)(e)
(e) A long-term care district may change its primary purpose specified under
par. (a) 1. b. if all the counties or tribes or bands that created the district and that have not withdrawn or been removed from the district under
sub. (14), adopt a resolution approving the change in primary purpose and if the change in purpose does not violate
par. (c) or any provision of a contract between the department and the district.
46.2895(2)
(2) Jurisdiction. A long-term care district's jurisdiction is the geographical area of the county or counties that created the long-term care district and the geographic area of the reservation of, or lands held in trust for, any tribe or band that created the long-term care district.
46.2895(3)(a)(a) 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 long-term care district board members whom the county is allotted, by resolutions adopted under
sub. (1) (a) 1. c., to appoint.
46.2895(3)(b)1.1. At least one-fourth of the members of a long-term care district board shall be representative of the client group or groups whom it is the long-term care district's primary purpose to serve or those clients' family members, guardians, or other advocates.
46.2895(3)(b)3.
3. Membership of a long-term care district board shall reflect the ethnic and economic diversity in the jurisdiction of the long-term care district.
46.2895(3)(b)4.
4. No member of a long-term care district board may have a private financial interest in or profit directly or indirectly from any contract or other business of the long-term care district.
46.2895(3)(b)5.
5. Only individuals who reside within the jurisdiction of a long-term care district may serve as members of the long-term care district board.
46.2895(3)(d)
(d) As soon as possible after the appointment of the initial members of the long-term 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. Unless specified otherwise in a bylaw adopted by the board, the board may act based on the affirmative vote of a majority of a quorum.
46.2895(4)
(4) Powers. Subject to
sub. (1) (c), a long-term 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 long-term care district may do all of the following:
46.2895(4)(a)
(a) Adopt and alter, at pleasure, an official seal.
46.2895(4)(b)
(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. 46.2805 to
46.2895 and, if the long-term care district contracts with the department under
par. (d) or
(dm), with the terms of that contract.
46.2895(4)(d)
(d) Negotiate and enter into leases or contracts, including a contract with the department to operate either a resource center or a portion of its functions under
s. 46.283 or a care management organization under
s. 46.284, but not both a resource center or its functions and a care management organization.
46.2895(4)(dm)
(dm) Subject to
sub. (1) (c), enter into a contract with the department to operate a program described under
s. 46.2805 (1) (a) or
(b) and provide services related to the contracted services.
46.2895(4)(e)
(e) Provide services related to services available under the family care benefit, to older persons and persons with disabilities, in addition to the services funded under the contract with the department that is specified under
par. (d).
46.2895(4)(f)
(f) Acquire, construct, equip, maintain, improve or manage a resource center under
s. 46.283 or a care management organization under
s. 46.284, but not both.
46.2895(4)(g)
(g) Subject to
sub. (8), employ any agent, employee, or special adviser that the long-term care district finds necessary, fix and regulate his or her compensation and provide, either directly or subject to an agreement under
s. 66.0301 as a participant in a benefit plan of another governmental entity, any employee benefits, including an employee pension plan.
46.2895(4)(h)
(h) Mortgage, pledge or otherwise encumber the long-term care district's property or funds.
46.2895(4)(i)
(i) Buy, sell or lease property, including real estate, and maintain or dispose of the property.
46.2895(4)(j)
(j) Invest any funds not required for immediate disbursement in any of the following:
46.2895(4)(j)2.
2. Time deposits in any financial institution, as defined in
s. 69.30 (1) (b), if the time deposits mature in not more than 2 years.
46.2895(4)(j)3.
3. Bonds or securities issued or guaranteed as to principal and interest by the federal government or by a commission, board or other instrumentality of the federal government.
46.2895(4)(k)
(k) Create a risk reserve or other special reserve as the long-term care district board desires or as the department requires under the contract with the department that is specified under
par. (d).
