DHS 10.56(2m) (2m) Exemption from right to continuation. If the sole issue is a federal or state law requiring an automatic change adversely affecting some or all enrollees and the enrollee does not dispute that he or she falls within the category of enrollees to be affected by the change, the enrollee does not have the right to continuation of services pending the outcome of the enrollee's grievance under s. DHS 10.53 (2), department review under s. DHS 10.54, or fair hearing under s. DHS 10.55. A CMO will not receive a monthly capitated payment for such an individual and is not required to continue services in such circumstances.
DHS 10.56(3) (3) Liability for continuation of services. The enrollee shall be liable for the cost of services provided during the period in which services have been continued under this section if the outcome of the grievance, department review or fair hearing is unfavorable to the enrollee. The CMO shall notify in writing an enrollee who requests continuation of services under this section of the potential for liability under this subsection and the time period during which the enrollee will be liable. If the department or its designee determines that the person would incur a significant and substantial financial hardship as a result of repaying the cost of the services provided, the department may waive or reduce the enrollee's liability under this subsection.
DHS 10.56 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 09-003: am. (2), cr. (2m) Register November 2009 No. 647, eff. 12-1-09.
DHS 10.57 DHS 10.57 Cooperation with advocates.
DHS 10.57(1)(1)Definitions. In this section:
DHS 10.57(1)(a) (a) “Advocate" means an individual or organization whom a client has chosen to assist him or her in articulating the client's preferences, needs and decisions.
DHS 10.57(1)(b) (b) “Cooperate" means:
DHS 10.57(1)(b)1. 1. To provide any information related to the client's eligibility, entitlement, cost sharing, care planning, care management, services or service providers to the extent that the information is pertinent to matters in which the client has requested the advocate's assistance.
DHS 10.57(1)(b)2. 2. To assure that a client who requests assistance from an advocate is not subject to any form of retribution for doing so.
DHS 10.57(2) (2) Cooperation with advocates. The department and each resource center and CMO shall cooperate with any advocate selected by a client. Nothing in this section allows the unauthorized release of client information or abridges a client's right to confidentiality.
DHS 10.57 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00.
subch. VI of ch. DHS 10 Subchapter VI — Recovery of Paid Benefits
DHS 10.61 DHS 10.61 Recovery of incorrectly paid benefits. County agencies, on behalf of the department, shall recover benefits incorrectly paid under the family care benefit, whether paid on behalf of individuals eligible for medical assistance or not, according to provisions of s. 49.497, Stats., s. DHS 108.03 (3) and policies established by the department or by the department of workforce development. The amount to be recovered is the amount actually paid by a CMO on behalf of a family care enrollee.
DHS 10.61 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
DHS 10.62 DHS 10.62 Recovery of correctly paid benefits.
DHS 10.62(1)(1)Recovery from the estate of an enrollee. The department shall file a claim against the estate of an enrollee to recover for the costs of the family care benefits provided under s. 46.286, Stats., on and after January 1, 2000. Recoveries from the estates of all family care enrollees shall be made in accordance with the provisions in ss. 49.496 (1), (3), (6m), and (7), and 49.849, Stats., and s. DHS 108.02 (11) and (12), except as follows:
DHS 10.62(1)(a) (a) The amount to be recovered under this section shall be the actual cost of services received by an enrollee through the family care benefit as reported to the department by the CMO in which the person was enrolled.
DHS 10.62(1)(b) (b) Recovery under this section from the estate of an enrollee who was not found eligible under s. 46.286 (1) (b) 2m. a., Stats., and who did not receive services that are recoverable under s. 46.27 (7g), 49.496 (3) or 49.682, Stats., shall be treated as follows:
DHS 10.62(1)(b)1. 1. Except as provided in subd. 2., an amount of the liquid assets owned by the enrollee on the date of death, equal to the amount of countable assets that were disregarded under s. DHS 10.34 (3) (b) 2. b. or c. at the enrollee's initial eligibility determination for the family care benefit, shall be unavailable to pay the department's claim to the extent that the amount of liquid assets exceeds the amount of claims paid having a higher priority than the department's claim under s. 859.25, Stats.
DHS 10.62(1)(b)2. 2. Assets that come to an enrollee's estate from an independence account under s. DHS 10.34 (3) (d) are available to pay the department's claim.
DHS 10.62(2) (2) Liens on the homes of nursing home residents and inpatients at hospitals. The department may obtain a lien on an enrollee's home if the enrollee resides in a hospital and is required to contribute to the cost of care, or if the enrollee resides in a nursing home, and the enrollee cannot reasonably be expected to be discharged from the hospital or nursing home and return home. The department shall obtain liens under this subsection in accordance with the provisions in s. 49.496 (1) and (2), Stats. The lien is for the amount that is recoverable under sub. (1) and for costs that are recoverable under ss. 49.496 and 49.849, Stats.
DHS 10.62(3) (3) Use of funds. The department shall deposit amounts recovered under this section as follows:
DHS 10.62(3)(a) (a) Amounts that are recovered for MA eligible enrollees shall be paid to the appropriation under s. 20.435 (4) (im), Stats.
DHS 10.62(3)(b) (b) Amounts that are recovered for non-MA eligible enrollees shall be paid to the appropriation under s. 20.435 (4) (im), Stats.
DHS 10.62(4) (4) Hearing rights. An enrollee's exclusive administrative hearing rights are those specified in s. 49.496 (2), Stats., and ch. HA 3 for liens and in s. DHS 108.02 (12) for hardship waivers.
DHS 10.62 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; corrections in (1) (intro.), (b) (intro.) and (4) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; correction in (1) (b) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register November 2009 No. 647; corrections in (1), (2) made under s. 13.92 (4) (b) 7., Stats., Register December 2013 No. 696; corrections in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2015 No. 719.
subch. VII of ch. DHS 10 Subchapter VII — Assuring Timely Long-term Care Consultation
DHS 10.71 DHS 10.71 Certification by secretary of availability of resource center. When the secretary determines that a resource center is prepared to receive referrals from hospitals and long-term care facilities under ss. DHS 10.72 and 10.73, the secretary shall certify to each county, hospital and long-term care facility that serves residents of the geographic area served by the resource center the date on which the resource center is first available to provide pre-admission consultation and functional and financial screens for the family care benefit. To facilitate phase-in of services of resource centers, the secretary may certify that the resource center is available for a specified target population or for specified facilities in the area of the resource center. The secretary may make more than one certification for a resource center during the time that it phases in its services.
DHS 10.71 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00.
DHS 10.73 DHS 10.73 Information and referral requirements for long-term care facilities.
DHS 10.73(1)(1)Purpose. This section implements ss. 50.034 (5m) to (5p) and (8), 50.035 (4m) to (4p) and (11) and 50.04 (2g) to (2i), Stats., which establish requirements for adult family homes, residential care apartment complexes, community-based residential facilities and nursing homes to provide information to prospective residents and to refer certain prospective or newly admitted residents to a resource center and establish penalties for non-compliance.
DHS 10.73(2) (2) Applicability. Except as otherwise specified, this section applies to a long-term care facility only to the extent that the secretary has certified under s. DHS 10.71 that one or more resource centers are available for referrals from the facility for one or more specified target groups.
DHS 10.73(3) (3) Provision of information required. Subject to sub. (2), the long-term care facility shall give to each prospective resident, the resident's guardian, or a representative designated by the resident written information about the services of a resource center, the family care benefit and the availability of screening to determine the prospective resident's eligibility for the family care benefit. The facility shall provide the information at the time it first provides, in response to a request from the person or his or her representative, any written information about the facility, its services or potential admission, or at the time that it accepts an application for admission from the person, whichever is first. The written information shall be provided to the facility by the department or by the resource center that is the subject of the information.
DHS 10.73(4) (4) Required referral.
DHS 10.73(4)(a)(a) Subject to sub. (2), a long-term care facility shall refer a person seeking admission to the facility to the resource center serving the county in which the person resides or intends to reside, if the person has a disability or condition expected to last at least 90 days and is at least 65 years or age or has a developmental or physical disability. The facility shall make the referral when it first provides an assessment of the person's needs for nursing or residential services, or at the time that it accepts an application for admission from the person. The facility is not required to make the referral if any of the following applies:
DHS 10.73(4)(a)1. 1. The person is under the age of 17 years and 9 months.
DHS 10.73(4)(a)2. 2. A functional screen under s. DHS 10.33 has been completed for the person within the previous 6 months.
DHS 10.73(4)(a)3. 3. The person is seeking admission to the long-term care facility only for respite care.
DHS 10.73(4)(a)4. 4. The person is an enrollee of a care management organization.
DHS 10.73(4)(a)5. 5. The long-term care facility has been notified that the person was referred to the resource center by another entity within the previous 30 days.
DHS 10.73(4)(b) (b) If the long-term care facility admits a person without referral because the person's disability or condition is not expected to last at least 90 days, the facility shall later refer the person to the resource center if the person's disability or condition is later expected to last at least 90 days. The facility shall refer the person within three business days of determining that the person's disability or condition is likely to last longer than was expected at the time of admission.
DHS 10.73(4)(c) (c) A person seeking admission or about to be admitted to a long-term care facility on a private pay basis who is referred to a resource center need not provide financial information to a resource center or county agency, unless the person is expected to be eligible for medical assistance within 6 months or unless the person wishes to apply for the family care benefit.
DHS 10.73(5) (5) Penalties for rcacs and cbrfs.
DHS 10.73(5)(a) (a) Forfeiture. If the department finds that a residential care apartment complex or a community-based residential facility has not complied with the requirements of this section, it may directly impose a forfeiture of not more than $500 for each violation. If the department determines that a forfeiture should be assessed for a particular violation, the department shall send a notice of assessment to the facility. The notice shall specify the amount of the forfeiture assessed, the violation and the statute or rule alleged to have been violated, and shall inform the facility of the right to a hearing under par. (b).
DHS 10.73(5)(b) (b) Right to hearing. A residential care apartment complex or a community-based residential facility may contest an assessment of a forfeiture by sending, within 10 days after receipt of notice under par. (a), a written request for a hearing under s. 227.44, Stats., to the division of hearings and appeals in the department of administration. A hearing request shall be considered filed on the date of actual receipt by the division of hearings and appeals, or the date of the postmark, whichever is earlier. A request filed by facsimile is complete upon transmission. If the request is filed by facsimile transmission and such transmission is completed between 5 p.m. and midnight, one day shall be added to the prescribed period. The hearing shall be scheduled and conducted in accordance with the requirements of ss. 50.034 (8) (c) and 50.035 (11) (c), Stats.
DHS 10.73 Note Note: A hearing request should be addressed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707. Hearing requests may be delivered in person to that office at 5005 University Avenue, Room 201, Madison, WI.
DHS 10.73(5)(c) (c) Payment of forfeitures. All forfeitures shall be paid to the department within 10 days after receipt of notice of assessment or, if the forfeiture is contested under par. (b), within 10 days after receipt of the final decision after exhaustion of administrative review, unless the final decision is appealed and the order is stayed by court order. The department shall remit all forfeitures paid to the state treasurer for deposit in the school fund.
DHS 10.73(6) (6) Penalties for nursing homes. Failure to comply with the requirements of s. 50.04 (2g) and (2h), Stats., and this section is a class “C" violation under s. 50.04 (4) (b) 3., Stats.
DHS 10.73 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
DHS 10.74 DHS 10.74 Requirements for resource centers. The department shall establish, through its contracts with resource centers, minimum timeliness requirements for completion of resource center duties related to responding to referrals from hospitals and long-term care facilities. Minimum timeliness requirements shall specify that the resource center initiate contact with the person who was referred or the person's designated representative as soon as practical following receipt of a request or referral for the screen or for long-term care services. The resource center's initial contact is for the purpose of informing the person about the family care benefit and the availability of functional and financial eligibility and cost-sharing screens and long-term care options consultation, and for setting an appointment to provide further consultation and to conduct the screen. The consultation provided by the resource center shall meet the requirements for long-term care options counseling under s. DHS 10.23 (2) (b) and shall be provided in conjunction with performance of the functional and financial eligibility and cost-sharing screens or at another mutually agreed upon time.
DHS 10.74 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.