Subchapter V — Protection of Applicant, Eligible Person and Enrollee Rights
Continuation of services.
Cooperation with advocates.
Subchapter VI — Recovery of Paid Benefits
Recovery of incorrectly paid benefits.
Recovery of correctly paid benefits.
Subchapter VII — Assuring Timely Long-term Care Consultation
Certification by secretary of availability of resource center.
Information and referral requirements for long-term care facilities.
Requirements for resource centers.
Ch. DHS 10 Note
Chapter HFS 10 was created as an emergency rule effective February 1, 2000.
Chapter HFS 10 was renumbered to chapter DHS 10 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635
Authority and purpose.
This chapter is promulgated under the authority of ss. 46.286 (4)
, 46.287 (2) (a) 1. (intro.)
, 50.02 (2) (d)
, and 227.11 (2) (a)
, Stats., to implement a program called family care that is designed to help families arrange for appropriate long-term care services for older family members and for adults with physical or developmental disabilities. The chapter does all the following:
Establishes functional and financial eligibility criteria, entitlement criteria and cost sharing requirements for the family care benefit, including divestment of assets, treatment of trusts and spousal impoverishment protections.
Establishes the procedures for applying for the family care benefit.
Establishes standards for the performance of aging and disability resource centers.
Establishes certification standards and standards for performance by care management organizations.
Provides for the protection of applicants for the family care benefit and enrollees in care management organizations through complaint, grievance and fair hearing procedures.
Provides for the recovery of correctly and incorrectly paid family care benefits.
Establishes requirements for the provision of information about the family care program to prospective residents of long-term care facilities and for referrals to resource centers by hospitals and long-term care facilities.
DHS 10.11 History
Cr. Register, October, 2000, No. 538
, eff. 11-1-00; correction in (intro.) made under s. 13.92 (4) (b) 7.
, Stats., Register November 2008 No. 635
This chapter applies to all of the following:
County agencies designated by the department to determine financial eligibility for the family care benefit.
All organizations seeking or holding contracts with the department to operate an aging and disability resource center or a care management organization.
All persons applying to receive the family care benefit.
All persons found eligible to receive the family care benefit.
All enrollees in a care management organization.
Certain private pay individuals who may purchase certain services from a care management organization.
Hospitals, nursing homes, community-based residential facilities, residential care apartment complexes and adult family homes that are required to provide information to patients, residents and prospective residents and make certain referrals to an aging and disability resource center.
DHS 10.12 History
Cr. Register, October, 2000, No. 538
, eff. 11-1-00.
In this chapter:
Any of the following acts taken by an aging and disability resource center or county economic support unit:
Any of the following acts taken by a care management organization:
The denial or limited authorization of a requested service, including the type or level of service.
The reduction, suspension, or termination of a previously authorized service.
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.
The failure to act in a timely manner as specified in subchapter V of this chapter to resolve grievances or appeals.
The development of an individualized service plan that is unacceptable to the member because any of the following apply:
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.
The plan does not provide sufficient care, treatment, or support to meet the enrollee's needs and identified family care outcomes.
The plan requires the enrollee to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the enrollee.
Termination of the family care benefit or involuntary disenrollment from a CMO.
“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.
“Adult protective services" means protective services for individuals with intellectual disabilities and other developmental disabilities, for individuals with infirmities of aging, for individuals with chronic mental illness, and for individuals with other like incapacities incurred at any age as defined in s. 55.02
“Appeal" means a request for review of an action.
“Applicant" means a person who directly or through a representative makes application for the family care benefit.
“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.
“Assistance" means cueing, supervision or partial or complete hands-on assistance from another person.
“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.
“Client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.
“Community-based residential facility" or “CBRF" has the meaning specified in s. 50.01 (1g)
“Community spouse" means an individual who is legally married as recognized under state law to a family care spouse.
“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.
“Countable assets" means assets that are used in calculating financial eligibility and cost sharing requirements for the family care benefit.
“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.
“Department" means the Wisconsin department of health services.
“Developmental disability" means a disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, intellectual disability, or another neurological condition closely related to intellectual disability or requiring treatment similar to that required for intellectual disability, 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.
“Eligible person" means a person who has been determined under ss. DHS 10.31
to meet all eligibility criteria under s. 46.286 (1)
, Stats., and this chapter.
“Enrollee" means a person who is enrolled in a care management organization to receive the family care benefit.
“Exceptional payments" means the state supplement to federal supplemental security income authorized under s. 49.77 (3s)
“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.
“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.
“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.
“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)
, Stats., and ss. DHS 10.32
“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.
“Functional capacity" means the skill to perform activities in an acceptable manner.
“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
“Grievance" means an expression of dissatisfaction about any matter that is not an action.
“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.
“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.